1. Human & Organizational
Performance – H.O.P.
Bob Edwards, M.Eng.

2. The Complex Adaptive Environment
The more complex our organization or process is, the more error prone it is and the less tolerant of error it becomes. (Conklin, 2012)

3. H.O.P. helps us improve our operational learning …
… it’s not like a traditional program . . .

4. H.O.P. improves our traditional programs by increasing our collaboration & operational learning.

5. Works hand in hand with our Safety and Quality Management System’s approach:
VPP (4 Elements)
ANSI Z10 (PDCA)
OHSAS (Risk Based & OE)
Upcoming ISO (Similar to Z10)
Internal System (i.e. Framework)
ISO 9001 (Quality).

6. interested in learning!
Our Goal with H.O.P.
. . . is to become a lot less surprised by human error and failure . . .
. . . and instead, become a lot more
interested in learning!

7. Reliable and Resilient!
Through improved operational learning,
our organizations are becoming more
Reliable and Resilient!

8. History of Human Performance

9. Nuclear Power Plants

10. Aviation Safety

11. Automotive Safety

12. General Industry

13. The Principles of Human Performance
People make errors
Error-likely situations are predictable
Individual behaviors are influenced
Operational upsets can be avoided
Our response to failure matters.

14. Todd Conklin, Ph.D.

15. Implementation Process
Leadership Commitment
Selected & Trained Pilot Sites
Implemented Learning Teams
Developed Advocates / Coaches
Created Centers of Excellence
Shared Success Stories

16. HOP - GE Businesses

17. HOP – Other Companies

18. The Principles of Human Performance
People make errors
Error-likely situations are predictable
Individual behaviors are influenced
Operational upsets can be avoided
Our response to failure matters

19. Was this Kenny’s FAULT?

20. What about an injured firefighter?

21. To err is human . . .
. . . to forgive is Divine.
(Alexander Pope, )
…and neither are Marine Corps Policy!

22. Free Billy!

23. Blame
is very common
but
not helpful at all!

24. The Principles of Human Performance
People make errors
Error-likely situations are predictable
Individual behaviors are influenced
Operational upsets can be avoided
Our response to failure matters

25. “Mistakes arise directly from the way the mind handles information, not through stupidity or carelessness.”
(Edward de Bono PhD)

26. Error Frequencies Simple math error with self-check: 3 in 100
(P.L. Clemens, 2002)

27. Error Frequencies Inspector oversight of operator: 1 in 10
(P.L. Clemens, 2002)

28. Error Frequencies High stress / dangerous activity: 3 in 10
(P.L. Clemens, 2002)

29. Error Tolerance is Strongly Situational
A batting average of .330 is worthy of
Hall of Fame . . .
. . . would that be acceptable …
. . . for a concert pianist?
(P.L. Clemens, 2002)

30. Operational Errors
Immediate results

31. Organizational Errors
Delayed results

32. Robots vs. Humans

33. Error is not a Choice…
Error is not Violation.

34. Deviation Types Intentional Deviation (Rule Breaking)
Unintentional Deviation (Error)
Normalized Deviation (Common)

35. HOP is NOT the absence of rules or discipline
HOP is the notion that if you depend on a person doing something 100% right 100% of the time…
…you will be disappointed...
…A LOT
(Baker, 2014)

36. The Texting Trash Hauler

37. HOP Terminology Error Traps Provocative Error Traps Trigger
Latent Conditions

39. Error Trap

41. Provocative Error Trap

42. Workers don’t cause failures
Worker’s “trigger” latent conditions that lie dormant in our organizations
Errors are consequences not causes.
(Conklin, 2012 / Dekker, 2006)

43. Being surprised by it doesn’t make things better.
Error
is common . . .
Being surprised by it doesn’t make things better.

44. The Principles of Human Performance
People make errors
Error-likely situations are predictable
Individual behaviors are influenced
Operational upsets can be avoided
Our response to failure matters

45. People Are As Safe As They Need To Be, Without Being Overly Safe…
In Order To Get Their Job Done.
(Conklin)

46. Drivers Are As Safe As They Need To Be, Without Being Overly Safe…
In Order To Get To Their Destination.
(Edwards)

47. Beyond the Safety Triangle
300 –
Near Misses
Injury
DAFW
Reduction Frequency Reduction Severity

48. Changing Behavior?? Behavior Modification Behavior Change
Observable
Hidden
Belief Systems (Values)
What gets rewarded –
gets repeated
(Edgar Schein)

49. Performance Modes – Error Rates
Knowledge Based
Error Rate: 1:2
Why? No knowledge or reference point
Rule Based
Error Rate: 1:1,000
Why? Misinterpretation
or bad application
Low Attention to Task High
Skill Based
Error Rate: 1:10,000
Why? Complacency.
Low Familiarity with Task High
(Jens Rasmussen)

50. Performance Modes – Error Rates
Knowledge Based
Inadequate knowledge
No knowledge
No reference point
Error Rate: 1:2
Training / demonstration
Coaching / mentoring / feedback
Rule Based
Error Rate: 1:1,000
Misapplication of good rules
Application of bad rules
Failure to apply a good rule
Procedures & control panels
Checklists / Cross - checks
Low Attention to Task High
Skill Based
Error Rate: 1:10,000
Omissions
Slips / trips / lapses
Complacency (how?)
Rumble strips / Drift Sensing
Automation / Auto Shutoffs
Low Familiarity with Task High
(Jens Rasmussen)

51. Right defense for the right mode

52. The Principles of Human Performance
People make errors
Error-likely situations are predictable
Individual behaviors are influenced
Operational upsets can be avoided
Our response to failure matters

53. Great performance is not the absence of errors. . .
. . . it’s the presence of defenses. (Conklin, 2012)

54. Procedures are important…
But they are not sufficient enough to create safety
Our organizations have become complex-webs of procedures that are incomplete and difficult. (Conklin)

55. Defenses Types of Defenses Strength of Defenses Layers of Defense
Sustainability of Defenses

56. Hierarchy of Controls ?? Elimination Substitution Engineering Controls
Administrative Controls
Behavior (Cultural)
PPE
Not so focused on it being a hierarchy
More focused on ownership and effectiveness.

57. Layers of Defenses All Procedure Steps Critical Steps
November 10, 2009
Layers of Defenses
Example: Walking near a cliff
Absence of barriers or fences
Improve technique
Taking extra care
Pay attention
Margin – proximity of treadway to edge
All Procedure Steps
Critical Steps
All Risk-Important
Actions
Main chute fails to open 0.1%
Fatality rate 0.001%
Source:

58. Strength of Defenses

59. Sustainability of Defenses
. . . and one year later . . .

60. We want to make it easier to do right
than to do wrong!

61. The Principles of Human Performance
People make errors
Error-likely situations are predictable
Individual behaviors are influenced
Operational upsets can be avoided
Our response to failure matters

62. Workers
Are Masters of
Complex Adaptive
Behavior… (Conklin)

63. Work as Planned vs. Work in Practice “Masters of the blue line”
Normally
Successful!
(Conklin, 2012)

64. Accidents are unexpected combinations of normal variability.
(Conklin)

65. combinations of normal variability.
Success is also the unexpected
combinations of normal variability.
(Conklin)

66. 3 Parts of an Event
(Conklin) 66

67. bias our judgment of the pre-event context.
3 Parts of an Event
The Challenge:
Not to let
post-event hindsight
bias our judgment of the pre-event context.
(Conklin)
How do you know…? 67

68. “Underneath every seemingly obvious, simple story of error, there is a second deeper story. A more complicated story a story about the system in which people work.” (Dekker, 2006)

69. Our traditional approach . . .
. . . looked for root cause
Linear Approach
Event 5 4 3 2 1
Root
Cause?
The problem is, the failure was not linear . . .
. . . and there almost NEVER is one root cause.

70. Start back in process . . . . . . move towards the event.
Production pressure
Fear of reporting
Latent Conditions
Inadequate defenses
Many of the things that we find that led to the failure, were not identified in traditional hazard assessments!
System Weaknesses
Event
Resource constraints
Errors
Hazards & Risks
Flawed processes
Local Factors
Normal Variability
System deficiencies
Near Misses
Design shortcomings
Poor communication
(Edwards/Baker/Howe, 2014)

71. The Pressure to Fix . . . . . . Outweighs the Desire to Learn!
Learning
Information
Best
Solutions
Response and Containment
Event
Time 71 71

72. Everybody knows . . .
Audible Alarm

73. “. . . blame is the enemy of understanding.” (Andrew Hopkins)

74. Beyond Taylorism
Break the concept that the planner is smarter than the worker
Bring the worker and planner together to create the plan
Anticipate that human error will occur
Expect operational drift
Understand why the drift occurs
Learn from “masters of the blue line”
Learn from failure
Learn from success.

75. Knows the most about the hazards.
Sharp End
Workers
Highest
Influence
Over
System
Highest
Injury
Potential
Front-line
Supervisors
Managers
Leaders
Company
Knows the most about the hazards.
Customers
Regulators
Blunt End
(Conklin)

76. Operational Learning

77. … you want to understand why it made sense for people to do what they did … in their context (not yours!) … (Dekker, 2006)
Safe assumption – people came to do work
Michelle story – “what are you thinking?”

78. Daily Operational Learning
Possible Questions:
What went well today?
What surprised you?
What did you learn today?
What will help us tomorrow?
Pre-Job Brief
Post-Job Brief
Leads to frequent meaningful daily improvements.
Sometimes uncovers significant system problems

79. Event Response
Respond seriously and deliberately to events, near misses and good catches
Remember, events are “Information Rich!”
Promote a culture of learning & collaboration
Learn before taking action
Reduce operational complexity
Fix processes and systems – NOT people.

80. How do we do this? Pull the right people together
Give them time and space to learn and discover
Create an open dialog (Trust)
Ask meaningful questions
Listen and Learn (Be interested)
Empower the team to help solve the problems.
Talking:
You didn’t come to work today to…
Pull away from the shop – do it there, brains can’t take a rest from the job
Learn – teach the coach
Discover – 4 year old, everything is discovery – think we’ve seen it all, turn the switch back on – coupling, took at where we learned
Trust – Quiet guy – fire / Catoosa county trench work– open door policy – near misses
Tell me about the kind of work you do – trust, common ground
Common ground – we all what to be successful
Questions – that’s your goal as a coach
Interested – normally thinking about your response
Notes – don’t sanitize – all we need them to know it is complex – not a black line problem – VP/stone and sword joke, hang charts anyway
Empower – help them think it through

81. Shift the question from “why” . . . . . . to “how”. (Conklin)
Physics - Gas, spark, blew up

82. Operational Learning
Not an investigation Not worried about collusion Not focused on the “one true story” Not focused on the one “root cause?” It is the story as each person saw the event It is the story of complexity It is the story of normal variability and coupling It is the story of how work gets done.
Don’t care about event
Example: pissing contest on the phone and fork truck – buggies are old, yolks are bent
Put one true story in as last

83. The Learning Team Process
Determine need for Learning Team
1st Session – Learning Mode only
Provide “Soak Time”
2nd Session – Start in Learning Mode
Define defenses / build new ones
Tracking actions & criteria for closure
Tell the story.
Hour long
Soak time – overnight – “we couldn’t figure out how to do it…” – how many sessions
Defenses – what do you want to do different?
Crane story – crane program, not high risk – weak signal story – moving crane – put the letter in (used to be mad)
Use your same crane actions
Creates cultural confidence
Freewill vs determinism – more influence than we think

84. Learning Team Session One
. . . is to learn and discover . . .
. . . and not to fix!
Cure for cancer

85. Sample questions for Session 1 -
19 September 2018
Sample questions for Session 1 -
- How far back in the process should we start? - Tell me about your work. How hard is it to get things done? - How doable are your procedures? - Do you have the right tools? - What were the conditions leading up to the event? - What other near misses have you seen in this area? - What worked well? What failed or went wrong? - Where else could a similar event happen? - What else should I know? Who should this be shared with? - How did the employee’s actions (or inaction) make sense in their context? (not yours!) - Who else should we invite to the next session?
The second to last line comes up as two

86. Wall of Discovery
Add in Bob’s story – longest forks used in narrow aisle
Add blow up picture of George
Came from George the fork truck driver – more powerful

88. Soak Time At least overnight (if at all possible)
Allows time to process learnings
Allows time to go look
Allows time to study and research
How many times have you said – “let me sleep on it”?

89. Sample questions for Session 2 -
19 September 2018
Sample questions for Session 2 -
What else did you think of since we last met?
What worked well and what did not?
What do you want to do to make it better?
How strong are our defenses?
Who owns the action items?
When should we follow up to make sure things are getting done and working better?
How can we tell the story? Who should we tell it to?
Help carry people past the “retrain” notion

90. Immediately following an event …
19 September 2018
Immediately following an event …
DO ASK
AVOID ASKING
What is the current condition of the person or people?
“Is it a recordable?”
“When will the line be running again?”
Are our operations safe and stable at this time?
“Why did this happen?”
“Who did this?”
“Were they following procedure?”
Tell me the story of how this happened
This slide give some examples of simple questions you can use to help facilitate the CET.
The question becomes, how do you know when you know enough? When you are done asking questions?
The more investigations you do using CET, the more it won’t be necessary to dictate an end point – you will know, because you have a very accurate picture of the situation and its contributing factors. But if this is one of your first times, trying using this rule of thumb: If you cannot answer question 10 from the list on this page, you probably don’t know enough yet.
The final question presupposes that you understand that humans make the best decisions they know how to in a given situation. If an employee knew a failure would occur as a result of their actions, they would not have made that decision. Assuming that an employee understands the implications of the action that led to a failure, is called hindsight bias. In light of this, you cannot fully understand the context of the event until you understand how the employee’s actions made sense to them at the time.
Although this rule of thumb can be helpful, it is not an end all be all; knowing how it made sense for the employee to turn on a sump sucker tells us very little about the event context. Remember to use all you’ve learned about human factors and organizational performance during these investigations. There is no one tool or trick that will cover every scenario.
What will it take for us to be able to show that it is safe to run again?
“Unless you can prove it’s not safe, turn it back on!”
Is this an opportunity for operational Learning to help us understand?
“What is the root cause and corrective action?”

91. When do we need to learn? Post-event (Injury/Quality/Operations)
Near Miss or Close Call
Good Catch
Interesting Successes
High Risk Operations
Challenging Design Problems
Anytime you can’t explain something. 91

92. Bias and other Obstacles
Hindsight Bias
Group Think
Confirmation Bias
Counter Factual
Similarity Bias
Need for Blame
Admission of Blame
Irrationality
Bounded Rationality
Fundamental Attribution Error
Irrational Escalation Bias (Sunk Cost)

93. Tracking Actions
Example of how it was tracked – helped with the culture
Cautious not to add bureaucracy

94. Learning Team Closure Criteria
Continue the effort with the Learning Team until the Team has implemented sufficient levels of defenses to satisfy:
The Learning Team
The affected employees
Management AND . . .
We have communicated our story.

95. We can NOT engineer out the possibility of every mistake…
…we cannot error proof the world
We CAN build layers of defenses to build in space for mistakes.

96. Learning from success . . .

97. Safety Defined Safety is not the freedom from risk …
. . . it is the freedom from unacceptable risk.
M. Bidez, 2013

98. When we believe we know the answer . . .
. . . we stop asking questions
. . . we stop listening
. . . we stop learning! 98

99. The power to ask the right questions . . .
. . . comes from acknowledging that you don’t know the right answer. 99

100. Workplaces and organizations are easier to manage than the minds of individual workers. You cannot change the human condition, but you can change the conditions under which people work.
(Dr. James Reason)
100

101. Nevada military depot mortar explosion kills seven Marines
(Reuters) - A mortar explosion at a U.S. Army munitions depot in Nevada killed seven Marines from Camp Lejeune, North Carolina, and injured seven other service members during a live-fire training exercise, military officials said on Tuesday. (March 18, 2013)
Nevada military depot mortar explosion kills seven Marines
Paul Szoldra, 9:16 a.m. Mar 19, 2013
Marines: Human error to blame for deadly blast in Nevada
Jim Michaels, USA TODAY12:34 p.m. EDT May 29, 2013
A training accident in Nevada that killed seven Marines during a live fire exercise earlier this year was caused by "human error," the Marines said in a statement Wednesday.
101

102. “I have never been especially impressed by the heroics of people convinced they are about to change the world. I am more awed by those who struggle to make one small difference.”
(Ellen Goodman)
102

103. Recommended Reading Check out Todd Conklin’s Podcasts “Pre-Accident
Investigations”
(Todd Conklin)
“The Field Guide
To Understanding
Human Error”
(Sidney Dekker)
“Managing The
Unexpected”
(Weick & Sutcliffe)
Bob Edwards / / C:
Check out Todd Conklin’s Podcasts

104. 104