The Reimagining of the Human Performance Handbooks - Part One: An Introduction and Reporting Errors and Near Misses.

Human and Organizational Performance (HOP) is a safety philosophy that emerged from the Nuclear Energy Sector in North America in the recognition that human error is normal and will happen and that systems should be designed to be more resilient to these errors.

The principles of HOP were developed over time by both industry professionals and safety science academics who observed the need for a shift in traditional thinking about safety and reliability in organizations.

The author of the book "The 5 Principles of Human Performance: A Contemporary Update of the Building Blocks of Human Performance for the New View of Safety,” Todd Conklin , provides a detailed account of the development of HOP.

Todd Conklin describes the struggles for a better understanding of how work is conducted and how workers adapt in everyday work; it did not start with the introduction of Human Performance (HP) philosophies 30 years ago; it has been ongoing for much longer.

The principles of HOP have been influenced by various sources, including the INPO/DOE (Institute of Nuclear Power Operations/Department Of Energy) handbooks, and continue to evolve. These HP (Human Performance) principles have been used to create a philosophical shift in thinking about how people behave in organizations and how organizations function best with the workers in the organization.

The original HP Principles from the INP/DOE handbooks were:

1. People are fallible, and even the best people make mistakes.
2. Error-likely situations are predictable, manageable, and preventable.
3. Individual behavior is influenced by organizational processes and values.
4. People achieve high levels of performance because of the encouragement and reinforcement received from leaders, peers, and subordinates.
5. Events can be avoided through an understanding of the reasons mistakes occur and application of the lessons learned from past events (or errors).

HOP encourages operational and organizational learning and emphasizes the importance of learning from past experiences and mistakes, learning from normal everyday work, and the role of leadership in creating a safe and open environment for this learning to happen.

Human Organizational Performance “HOP" came about due to a long history of learning from past experiences, a desire to improve safety and reliability in organizations, and a shift in thinking about how people behave and how organizations function.

In this series we explore some of the concepts and tools from the handbooks and reimagine both the language and how they could be applied in todays world using a contemporary lens.

Later in the series we are hoping to pay respect to the many that contributed to the development of these handbooks, from which HOP evolved.

An Introduction to the DOE Handbooks

The purpose of the two volumes of the DOE Handbook 1028-2009 were:

Volume 1: Concepts and Principles

Volume 1 provided the foundational concepts and principles of Human Performance. It explains the key elements of human performance and their impact on events within organizations, particularly in high-risk environments. This volume emphasized that understanding human error, the anatomy of events, error precursors, and the importance of managing controls to reduce errors.

The concepts and principles were targeted toward understanding human fallibility, error-likely situations, and mental models in decision-making processes.

Volume 2: Human Performance Tools for Individuals, Work Teams, and Management

Volume 2 focused on practical tools and methods to enhance human performance. It provided techniques for anticipating, preventing, and mitigating human errors at different organizational levels, from workers to managers.

The tools in this volume were aimed to help organizations improve workplace safety by reducing active and latent errors. It was designed for use in various industries like nuclear power and aviation, applying the principles from Volume 1 to everyday practice.

The tools were grouped into three segments:

1. Human Performance Tools for Individuals
2. Human Performance Tools for Work Teams
3. Management Tools

And out of interest is also included an Organizational Safety Climate Assessment Survey tool and a Human Performance Gap Analysis Tool.

Together, these volumes offered both theoretical and practical guidance to help organizations manage human performance risks and improve safety and operational excellence.

Reporting Errors and Near Misses - The Handbook

The "Error and Near Miss Reporting" section of the DOE Handbook 1028-2009, Volume 2 focused on improving human performance by encouraging the reporting of errors and near misses.

It outlined the importance of such feedback mechanisms, the creation of a "Just Culture," the challenges and solutions in establishing an effective reporting system, and recommended practices to develop an error reporting system.

The document emphasized the need for organizations to use different feedback mechanisms to gather information on irregularities related to physical safety, facility deficiencies, equipment issues, security problems, and work processes.

Management was to then use this feedback to identify organizational problems and help workers learn from mistakes to improve future performance.

The primary goal is to promote learning and enhance safety by documenting and analyzing patterns of errors.

The key recommendations for establishing a robust report system was:

Creating a Just Culture:

A "Just Culture" is crucial for the success of an error reporting system. It requires management to balance the treatment of unintentional errors and willful violations. There should be zero tolerance for reckless conduct, but unintentional unsafe acts should not be punished. Management should avoid blaming individuals for honest errors and should instead focus on system improvements. This approach encourages workers to report incidents without fear of retribution.

Overcoming Barriers to Reporting:

Several challenges prevent effective reporting:

• Fear of Confession: Workers may avoid reporting mistakes due to fear of ridicule or punishment. To mitigate this, organizations can anonymize or keep error reports confidential.
• Suspicion of Negative Consequences: Workers might fear that reporting will affect their records. A policy of indemnity and separation of functions (where the group collecting reports cannot initiate disciplinary action) helps alleviate this concern.
• Skepticism About Management's Actions: Workers need reassurance that management will act on their reports. Providing timely feedback and showing how reports lead to improvements is essential.
• Effort Involved in Reporting: Writing a report may seem time-consuming. Simplifying the report format and making it easy to access can encourage reporting.

Developing a Reporting System:

The handbook suggests several practices to establish an effective reporting system:

• Communication and Coordination: Informing workers about the reporting system and its purpose helps foster understanding and participation.
• Event Report Coordinator: Designating a coordinator to track and trend reports, provide feedback, and keep management informed is essential for ensuring the system is effective.
• Ease of Reporting: Reports should be easy to complete and readily available. Organizations should provide access through workplace computers and facilitate easy submission.
• Training and Lessons Learned: Data collected from reports should be used to inform ongoing training, develop lessons learned, and identify areas of improvement.

Accountability for Incidents involving unsafe acts:

To determine accountability for incidents involving unsafe acts, management can use different methods:

1. Foresight Test: Ask if others in the workgroup would recognize the behavior as increasing the likelihood of errors.
2. Substitution Test: Ask if another person with similar skills would have behaved differently under the same circumstances.
3. Culpability Decision Tree (CDT): A logic diagram used to assess both individual and organizational culpability by evaluating the worker's intent, knowledge, and history of performance issues.

Practices to Avoid

The handbook also identified certain at-risk practices that should be avoided, such as:

• Launching a reporting system without first establishing a Just Culture.
• Failing to address primary barriers to reporting.
• Not taking action on the data acquired from error reports.
• Using input from the reporting system in unintended ways.
• Failing to provide timely feedback to workers.

The Handbook emphasized the importance of cultivating a culture of transparency and accountability through an effective error and near miss reporting system. Establishing a Just Culture, using systematic methods to determine accountability, overcoming barriers to reporting, and implementing effective communication are key to making such a system successful.

The goal was to ensure safety and continuous improvement by learning from errors rather than blaming individuals, thereby creating a safer work environment.

Reporting Errors and Near Misses - The Handbook Remagined

Contemporary View: Human Error as Systemic Outcome, Human Error as a Symptom of System Complexity.

In an updated approach, human error is seen as a natural outcomes of interactions within complex systems and human error is not a cause but an effect of deeper systemic issues and a symptom of system complexity.

Rather than focusing on individual actions, we look at how organizational policies, resource constraints, and operational contexts contribute to error and near misses. This expands the scope from individual workers to systemic structures.

Understanding that human performance variability can be a strength in adapting to complex and unpredictable environments is crucial. HOP shifts focus from preventing errors to understanding the conditions in which people work and how systems can support them.

Learning from normal operations (not just errors or near misses) is central. Insights from everyday work can help understand how risks are managed daily and how improvements can be made proactively.

Why the Contemporary View is Beneficial

The shift toward contemporary tools, such as Learning Teams and the 4Ds, is important when looking at error and near misses because these approaches:

1. Enhance Engagement: By involving workers in discussions about their work, safety measures become more aligned with reality. Workers become more engaged in safety practices when they feel their voices are heard and valued.
2. Promote Organizational Learning: Instead of treating errors as isolated events, organizations develop a continuous learning culture where successes and failures both contribute to improvement. Organizational resilience is built by learning how to fail safely, allowing organizations to absorb and adapt to disruptions rather than break down during crises.
3. Support Adaptive Capacity: Workers are not expected to simply follow rules but are given the tools and authority to adapt to complex and changing environments. As Conklin argues, the key to sustainable change lies in understanding that safety comes from how work is performed, not just from checking off compliance boxes.

Incorporating Learning Teams and the 4Ds Framework

The Learning Team framework provides a collaborative environment where frontline workers, who understand the complexities of the job better than anyone else, are brought into discussions about safety and improvement. This contrasts with traditional top-down investigations that may overlook critical insights from workers directly involved in operations. Learning Teams create a feedback loop where workers can share their experiences, thus contributing to system-wide learning and continuous improvement.

Application of the 4Ds Framework

The 4Ds — Dumb, Dangerous, Difficult, Different — provide a practical lens for identifying risks within operational settings. These categories allow organizations to classify near miss events and behaviors that could lead to failure, encouraging proactive learning.

1. Dumb: This refers to processes or actions that make little sense to the people doing the work, often driven by misaligned procedures or outdated protocols. For example, asking why a certain rule exists or whether it still serves a purpose allows organizations to refine procedures. Example: If workers frequently deviate from a protocol because it’s seen as impractical, the organization should investigate whether the rule is "dumb" in the context of their real-world experience.
2. Dangerous: Identifies tasks or conditions that present clear, heightened risks. By focusing on these areas, organizations can prioritize safety measures before a failure occurs. Example: Workers might identify certain machinery or processes that consistently present a risk. In a Learning Team, they can provide firsthand insight into where safety protocols should be strengthened.
3. Difficult: Complex tasks that increase cognitive load or require skills that workers may not have. The difficulty here lies in either the lack of clarity or the physical challenge of a task. Example: If a particular procedure requires a high level of skill, leading to frequent errors, it may be time to re-evaluate the training provided or simplify the task to reduce cognitive burden.
4. Different: When tasks deviate from normal operations, they introduce unpredictability. Handling "different" situations requires adaptive thinking, as standard procedures may not apply. Example: New work processes or technologies can introduce unforeseen risks, and a Learning Team can help bridge the gap by discussing how best to adapt to these changes.

Example of Learning Teams in Practice

Consider a high energy installation, where safety is paramount. Traditional safety systems might focus on compliance audits and procedural reviews. However, by incorporating Learning Teams, the organization can directly engage operators who experience the system's "sharp end" daily.

• Dumb: Operators report that certain alarms go off so frequently that they become desensitized to them, leading to reduced effectiveness. By investigating this in a Learning Team, the organization may discover that alarm thresholds are set too conservatively, prompting unnecessary alerts.
• Dangerous: Workers identify a maintenance task on heavy equipment that consistently places them in awkward, high-risk positions. The Learning Team’s insight leads to re-engineering the maintenance procedure to minimize risk.
• Difficult: A new software system for monitoring plant operations is introduced, but operators find it overly complex. A Learning Team session reveals that more intuitive interfaces or additional training could greatly enhance usability.
• Different: When a new type of plant and equipment is introduced, the operators are uncertain about its behavior under stress. Through a Learning Team, they share their concerns, leading to simulations and further testing before full deployment.

By reimagining the DOE Handbook through the lens of contemporary frameworks and tools like Learning Teams and the 4Ds, organizations can transition from reactive, compliance-driven frameworks to proactive, learning-centered systems.

This shift not only enhances safety but also empowers workers, aligns operational practices with real-world conditions, and builds a resilient organizational culture that continuously learns and adapts.

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