Human and organizational performance

‘Even the best make mistakes’

On average, people make four to seven errors an hour, estimates John F. Kowalski. “We all make mistakes,” the owner and president of Safety Performance LLC said. “Even the best make mistakes.”

Obviously, most missteps aren’t costly or catastrophic. That goes for those in the workplace as well. A worker will make errors on any given day, but they go mostly unnoticed because they rarely result in significant consequences. For many organizations, the response to an employee’s error often depends on the outcome. For example, a worker who takes a shortcut and helps the company meet a production deadline might receive praise for efficiency. However, if that same shortcut leads to a destructive result, it’s likely to be followed by a reprimand or punishment.

Either way, the same shortcut was taken, and it’s worth reviewing the shortcut and the thought process behind it – even when an incident doesn’t occur.

Organizational response is a key principle of HOP. After an incident, it’s natural to look for someone or something to blame, or declare that “someone has to pay” for a costly incident. The cause, however, is often far more complex.

In the example given, the worker may have taken the shortcut for a number of different reasons, and organizations need to take time to understand why.

“Asking the question, ‘Why did it make perfectly good sense for the person to do what they did?’ creates the potential for strong insights,” Kowalski said. “The second question could be: ‘Would three other people with similar training and background take the same shortcut?’ “The second question helps to determine the culpability of people. Answering these two questions will get you closer to the actual cause.”

Baker said incidents usually occur because of “systems” issues and “very, very rarely” as a result of employee issues.

For example, Brooks said one of her previous employers experienced several forklift incidents within the same department that resulted in repeated, minor damage. It was discovered that the drivers had to perform certain tasks that had 2 inches of clearance on either side. In those situations, she said, “even the best are going to ding something eventually.”

Edwards said some organizations might respond to those kinds of incidents by “pulling” a forklift operator’s license, having them undergo post-incident drug testing or making them attend another training class.

None of these actions will fix the underlying issue. Instead of immediately punishing workers, organizations should take the opportunity to learn and improve.

“Managers have to take the time to understand the context in which the employees were working before they rush to judgment, condemn, discipline or take any action against the employees involved in the event,” Brooks said.

Building defenses

Understanding why a worker might take a specific action in a certain situation, learning why an incident occurred or perhaps even finding an underlying issue that hasn’t yet led to an incident – but might in the future – all are invaluable insights.

The next step is putting in defenses or “hazard mitigation controls,” Kowalski said. “If I have one good defense in place,” he added, “I might get the error, but I won’t get the injury and/or fatality. Or I won’t get the consequential error, the error that causes bad things to happen.”

One example of evolving defenses against human error is the automobile. Think of cars in the 1950s. They had no airbags, lane departure warning systems, automatic emergency braking or other such safety features. Those technologies were added over time because of a realization that people are error-prone and need certain protections.

On the flip side, forklifts don’t have the same level of defense as today’s cars, Baker noted. For example, forklifts might have protections such as roll cages or seat belts, but they don’t have a warning system for when they’re about to tip over.

“The ability to fail and fail quickly, and fail catastrophically, in a forklift is scary,” she said. “That’s just one example of hundreds of examples of things that historically we’ve spent more time trying to make drivers better.

“That same time and energy, we want to shift that to think about, well, how do we also make sure that the machinery that we have, the mechanical aspects of our system, allow us humans to fail safely when we do make those mistakes or those poor judgments, or make an error?”

A new view

Supporters of HOP emphasize that, unlike other safety initiatives, it’s not a program. It’s an operating philosophy.

Leaders can’t just invite people into a conference room, provide awareness training and that’s that. They have to integrate HOP principles into the organization’s operating systems and processes.

Because the benefits of HOP can extend far beyond safety and health, experts say it should be viewed as a companywide initiative. The principles of HOP can apply equally to safety, operations, quality control or anything else an organization does.

“It does take some learning to get all your leadership on board and start asking different questions or responding to events differently,” Brooks said.

That change doesn’t mean all of the safety practices of the past go out the window. But alterations can be made, even in the terminology used. For example, instead of “incident investigation,” the term “post-event review” is more accurate under HOP, Brooks said.

With observations, instead of giving feedback to workers on what they did or didn’t do well, Baker said one alternative is to ask them about their difficulties when executing a certain task. “It’s augmenting what we did in the past,” Baker said. “So, it doesn’t mean that we stop doing things like compliance audits or we stop doing great process safety management design. These are all things that are foundationally needed.”

One of the main HOP principles, Edwards said, is that organizational learning and improvement are essential. That learning isn’t simply an investigation. It’s about looking at work and safety in a different way.

“It’s like putting on a new pair of glasses,” Brooks said. “Once you get this, you will never look at work the same.”