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THE H.O.P. MOVEMENT
(HUMAN & ORGANIZATIONALPERFORMANCE
Bob EdwardsVPPPA Region IV 2014 Conference
HOP is not a program.
It’s a change in how we respond and talk about failure.
Our Goal
. . . is to become a lot less surprised by human error and failure . . .
. . . and instead, become a lot more interested in learning!
• 3‐mile Island• Aviation Safety• Automotive• General Industry
History of Human Performance
How we began:
• Corporate commitment• Pilot sites selected• Trained Leadership• Implemented Learning Teams• Developed advocates & coaches • Shared across businesses
• Changes our discussion and response to failure• Improves our understanding of error & defenses• Increases employee engagement• Improves relationships with managers & employees• Give us deeper operational intelligence • Helps us build better system & process defenses• Moves us towards higher reliability• Builds a new culture . . .
Why HOP? Why Now?
HOP Principles:
• Humans are error prone• Errors are not violations• Response to failure matters• We need to learn from failure• We can build confidence and capacity
Low Familiarity with Task High
Inattention
Misinterpretation
Inaccurate Mental PictureKnowledge-Based
Rule-Based
Skill-Based
Patterns
If-Then
Auto1/1,000
1/10,000
50/501/2
Conklin, 2012
Performance Modes
• Intentional Deviation (Violation)
• Un‐intentional Deviation (Human Error)
• Normalized Deviation
Error vs. Violation
NormallySuccessful!
“Masters of the blue line”
Work as Planned vs. Work in Practice
* Starts with employee
* Makes our organization better.
* Tries to fix the employee
* Focuses on “why”
* Starts with the process
* Tells the story of “how”
* Looks for a “root cause” * Identifies “latent conditions”
* Makes employees feel guilty
* Fixes the process, builds defenses
* “Diagnose & treat” * “Crime & punishment”
How We See Events
Free Willie
• Focus on learning & provide “Soak Time”
• Focus on learning & provide “Soak Time”1
• Include those close to the work and event
• Include those close to the work and event2
• Focus on process and team solutions
• Focus on process and team solutions 3
Keys to Event Learning
Learning Team Applications• Injuries • Near Misses• Quality Events• Operational Upsets• Legal Issues• Inventory Misses• Engineering Change• New Suppliers• Challenging Designs
How Do You Start Your HOP Journey? Learn the basics Change your response to failure (Conklin) Build internal expertise (Advocates & Coaches) Hold each other accountable (Leaders) Make contacts and build a network Share best practices Read Dekker, Reason and Conklin, etc. Be willing to course correct (Ossewaarde) “Listen and Learn” (Kinkead) Attend workshops and conferences Use Learning Teams to get traction
What is HOP Success? Site management buy‐in Front line leaders owning incident investigations Focus on latent conditions and error traps Move away from root cause – RCA Focus shifts from employee to process and system A more open discussion about the issues Learning becomes the expectation Near misses are seen as learning opportunities Adopted by more than just EHS People self report errors!
Where Does HOP Lead Us?
Preoccupation with failure Reluctance to “over” simplify Sensitivity to operations Commitment to resilience Deference to expertise
. . . We become more like HROs!
WHO ELSE IN ON THISJOURNEY?
(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 MarinesPaul 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.
“Error must be accepted as a normal component of human behavior . . .
Most errors are committed inadvertently by people who are already trying to do their job
professionally and carefully. They did not intend to commit the errors.”
ICARUS Committee of the Flight Safety Foundation; Flight Safety Digest, Dec 94
RECOMMENDEDREADING
“Pre‐Accident Investigations”(Todd Conklin)
“The Field GuideTo UnderstandingHuman Error”(Sidney Dekker)
“Managing The Unexpected”
(Weick & Sutcliffe)
Email: [email protected]
