Human and Organizational Performance [HOP]

in Safety System Engineering

Disampaikan pada Webinar K3 Nasional, 8 Maret 2023
"People, Technical, And Organizational Aspect In Safety Implementation"
Perspektif Engineering Dalam Sistem Keselamatan

Presented by:
Dr. Adithya Sudiarno, ST., MT., IPM, ASEAN Eng., MIIRSM.
Industrial and Systems Engineering Department – ITS
Komisi III, Dewan K3 Provinsi Jawa Timur.
Working Experiences
▪ Lecturer in Industrial and System Eng.
CV Dr. Ir. Adithya Sudiarno, ST, MT, IPM, ASEAN Eng, MIIRSM
Dept., Sepuluh Nopember Institute of Technology (ITS) Industrial Partnership Experiences
▪ Coordinator of the expert team formulating competency
standards for human factors, Indonesian Ministry of Manpower
▪ Member of the Safety Council of East Java Province (Dewan K3
Jawa Timur), commission III.
▪ Expert Staff of the Indonesian Young Scientist Association (IYSA)
Current (on-going) Education
▪ International Diploma for Occupational Safety & Health
Management Professionals, NEBOSH, UK
Certifications
▪ General OHS Expert ▪ BNSP Assessor of Competency
▪ OHSMS Auditor ▪ Senior Professional Engineer
Affiliate Membership
Awards
▪ Silver Medal, WWIEA, South Korea, 2018.
▪ Special Award, APIR, Poland, 2019.
▪ Special Award, TIA, Taiwan, 2019.
▪ Gold Medal, WIIPA, Taiwan, 2020.
▪ Mención De Honor, EXPOCYTAR, Argentina, 2020.
▪ Gold Medal, ASIE, Virginia-USA, 2021.
▪ Silver Medal, KIDE, Kaohsiung-Taiwan, 2021
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 HOP-Based Safety
Culture Assessment
04
Todd Conklin’s 5 HOP
Principles
Human and Organizational
Performance [HOP]
02 05 Conlussion
01
03 HOP & SC
Connection
 Human & Organizational Performance [HOP] Leaders & Evolution
HOP is a systems-based approach that originated with safety thought leaders
like Todd Conklin, Sidney Dekker, Erik Hollnagel, and James Reason.

James Reason Erik Hollnagel Sidney Dekker Todd

Todd Conklin
Conklin
“Human Error” “Human Reliability Analysis” “Drift Into Failure” “Pre-Accident Investigations”
“Managing the Risks “Safety I and Safety II” “The Safety Anarchist” “5 Principles of Human
of Organizational Accidents” Performance”
“Swiss Cheese Model”

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Organization That Have Been Working With HOP

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https://www.youtube.com/watch?v=mdLfDLjIqXE&ab_channel=SecuriteIndustrielle

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 HOP Backgrounds and Rationale [#1]
How many people
go to work and want Are there people
to come home purposely coming to
safely? work to fail?

100% No one
“Mistakes arise directly from
the way the mind handles
information, NOT through
stupidity or carelessness.”
- Dr. Edward de Bono
Humans are fallible but they also
contribute a lot to safety, they
are capable of adapting to
unexpected situations, and they
are aware when the risk
increases
(Charles Major ; Wes Harvard ; ICSI)

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 HOP Backgrounds and Rationale [#2]
How Work Really Happens : Drift And Accumulation
Expectations: Work As Planned (Imagined)
“Continuous improvement/
innovation”

Complex
Adaptive SUCCESS!
Behavior Task end
Task start
Worker become :
“violation” “master of the blue line”
Conklin / Fisher
Reality: Work As Performed (Done)

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 Human & Organizational Performance [HOP] Definition
Another Way [New View] to Think About Safety
HOP is a science-based approach to looking at HOP is a contemporary perspective on how we can
mistakes so we can address them more effectively. It improve work. It focuses on understanding the
builds an understanding of how humans perform and context and conditions of work, recognizing the
how we can build systems that are more error- complex interactions between people and systems.
tolerant (SAIF’s leadership project). HOP helps us to understand how humans perform
and gives us a framework for building more
HOP is a science-based approach to understanding RESILIENT organizations. HOP is a tool that helps
how and why people make these mistakes or errors safety practitioners answer the question: how can
and what you can do about them either as an we do safety differently? (HOP LAB, Southpac
organization or as an individual (Rob Fisher, 2019). Int’l Group ; Andrea Baker).

HOP is a risk-based operating philosophy recognizing

that error is part of the human condition and that an
organization's processes and systems greatly influence
employee actions and choices, and consequently, their
likelihood of success (Brooks, 2021).
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 The Big-Ticket Idea Within HOP [#1]
Common Cause of Human Error
Workplace Injury
Machine & Individual
Equipment Mistakes
20% Failure 30% Organizational
Weaknesses

Human 80% 70%

Error

unlike a risk management program that works hard to eliminate, mitigate,

or substitute risk, HOP assumes that mistakes will happen. In essence,
humans try hard, but they’re not perfect. No amount of planning or
equipment can make them perfect, so perhaps through better process
systems management and analysis, organizations might lessen the effect
of human error through the promotion of defenses that reduce risk.

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 The Big-Ticket Idea Within HOP [#2]
Shift thinking from “why” . . . . . . to “how”! (Conklin ; Brooks)

HP = W (B+R) HOP = H (B+S+R)

NOTE : NOTE :
HP = Human Performance HOP = Human & Organizational Performance
W = Why H = How
B = Behaviors B = Behaviors
R = Results S = System
R = Results

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 The Task-Based System
Human and Organizational Performance SYSTEM MODEL
▪ The Task-Based System shows that on any
task at any time, the individual performing
the task is within a system. The individual is
equipment people surrounded by other People, Programs,
Processes, Work Environments,
organizations, and Equipment.
▪ The systemic drivers are dynamic, not static
and as they shift throughout the task, they
organization programs all impact each other, they all impact the
individual, and the individual must respond
to these shifts in systemic drivers. The
individual is an expert at adapting to
changes and optimizing our systems.
work enviro. processes
▪ A bad system will beat a good person every
time (Edwards Deming)

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 Todd Conklin’s 5 HOP Principles
https://www.southpacinternational.com/hop/the-five-principles-of-hop/

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 HOP Principles No. #1
Belief
People make mistakes
Emerging Behavior

▪ People are fallible, and even ▪ Designing to fail safely

the best make mistakes.
▪ Errors and poor judgment are
part of the human condition.
▪ As work gets more complex,
the number and complexity
of errors increase.
▪ Designing systems that can
withstand errors prevents
injuries.
▪ Defense testing
▪ Designing to fail safely
Tools Embraced
▪ Defense testing
▪ Essential controls
▪ Defense testing audits

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 HOP Principles No. #1 [example]
Error Frequencies

Simple math error with self-check:

3 in 100
High stress / dangerous activity: (P.L. Clemens, 2002) Inspector oversight of operator:
3 in 10 1 in 10
(P.L. Clemens, 2002) (P.L. Clemens, 2002 ; Dr. Seuss)

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 HOP Principles No. #2
Belief
Blame fixes nothing
▪ Thought leaders have long
known about the corrosive
nature of blame, yet it is still a
common first reaction to
workplace incidents.
▪ Blame is common because it is
easier to blame than improve.
▪ Blaming an individual will not
change the probability of a
similar event.
Emerging Behavior
▪ Discussion on reactive
accountability decreases
▪ Discussion on system
improvements and forward
accountability discussion
increases
▪ Designing to fail safely
Toolstesting
▪ Defense Embraced
▪ Removal of zero-tolerance policies
▪ Rewriting HR policies
▪ Bias training
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HOP Principles No. #2 [example]
Missile false alarm timeline, Saturday, January 13, 2018 :
▪ 8.05am: Workers initiate routine test of the emergency alert system.
▪ 8.07am: A worker mistakenly hits the button to send the emergency
warning.
▪ 8.10am: The head of the Emergency Management Agency, Joe Logan,
confirms with US Pacific Command that there was no missile launch.
Honolulu police are notified of the false alarm.
▪ 8.13am: The state issues a cancellation that prevents the message from
being sent to phones that hadn't previously received the alert, such as
those turned off or out of coverage range.
▪ 8.20am: The Emergency Management Agency issues public notification of
cancellation on Facebook and Twitter.
▪ 8.24am: Governor David Ige retweets the cancellation notice.
▪ 8.30am: Mr. Ige posts cancellation notice on his Facebook page.
▪ 8.45am: Cancellation of warning sent to mobile phones: "There is no
missile threat or danger to the State of Hawaii. Repeat. False Alarm." The
state said it issued the cancellation after getting authorisation to do so
from the Federal Emergency Management Agency.
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 HOP Principles No. #3
Belief
Context drives behaviour
▪ People are not all that unique - if one
person breaks a rule there is high
probability others will do the same.
▪ The environment in which work occurs
mainly determines workers' behavior and
actions.
▪ Those closest to the work understand
context the best.
▪ Context is the circumstances that form the
setting for an event, such as fatigue,
production demands, or broken
equipment.
Emerging Behavior
▪ Seeking to understand local
rationale
▪ Deviation prone rules and
normalized deviations
▪ A focus on improving systems
and processes, not individuals
Tools Embraced
▪ Learning Teams
▪ EEFA Charting
▪ Blackline/blueline meetings
▪ New employee listening sessions

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HOP Principles No. #3 [example]

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 HOP Principles No. #4
Belief
Learning is vital
▪ A complex system cannot be
designed perfectly from the
beginning.
▪ Resilience is not an end state of
design, it is a state of continuous
learning and improvement.
▪ The whole point of analyzing
workplace injuries is to prevent
them from happening again, but
many organizations see the same
types of injuries over and over.
Emerging Behavior
▪ Operational Learning
rhythms adopted at all
levels of the organization
▪ Designing to fail safely
Tools Embraced
▪ Defense testing
▪ Learning teams
▪ Post-job/pre-job
▪ Live procedures
▪ The index card process
▪ Operational learning walks
▪ Seeking operator struggle
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HOP Principles No. #4 [example]

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 HOP Principles No. #5
Belief
Response matters
▪ The leaders’ reaction to failure builds
or breaks learning and improving
culture.
▪ Managers shapes how the organization
learns by their reaction to failure.
▪ You can blame and punish or you can
learn and improve, but you can't do
both.
▪ Every aspect of improvement is
contingent upon leadership's
deliberate decision to get better.
Emerging Behavior
▪ Solutions sets not
overridden by managers
▪ Try-storming embraced
▪ Policy changes built with
those closest to the work
▪ Empathetic communication
▪ Designing to fail safely
Tools Embraced
▪ Defense testing
▪ Advisory boards
▪ Communication reviews
▪ Soft skills training
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HOP Principles No. #5 [example]
State officials placed
former Hawaii Army National
Guard commander Bruce E.
Oliveira in charge of internally
investigating the events that
resulted in the false alert being
sent out. In his report, published
on January 30, Oliveira faulted
"insufficient management
controls, poor computer software
design, and human factors" for
the incident.

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 Human & Organizational Performance [HOP] Highlight

HOP is NOT a program….It is an OPERATING PHILOSOPHY.

To adopt the PHILOSOPHY, HOP principles need to become commonly
values ….
held values
value near misses as significant learning opportunities:
We value
▪ Look for what went well in our system’s responses and what
did not respond well
▪ Determine if we are good or if we are lucky.

(Baker ; Ferguson)
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HOP and Safety Culture : The Connection
12 core attributes of a world-class safety culture
Engaged management Safety recognition programs

Active safety committee Continuous improvement

Employee who are comfortable

Apply Behavior-Based Safety
speaking up
Human & Organizational
Dedicated resources
Performance
Consider contractors, customer,
Safety Training
and competition

Leading indicator Open communication

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HOP and Safety Culture : The Connection
Key Phases to Incorporate HOP in Safety Culture

1. Garnering Interest & Commitment

2. Developing Foundational of Understanding HOP

3. Beginning Operational Learning

4. Organizational Alignment

5. Prevention of Catastrophic Outcomes

HOP is a cultural change, a movement that needs to be

planned and fostered.
(Baker)
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HOP-BASED SAFETY CULTURE ASSESSMENT

We want to measure culture

culture change
(artifacts), so we can learn where there
is HOP progress…….

….. NOT FORCE change through

measurement.

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 CONCLUSSION

▪ HOP is another Way [New View] to Think About Safety which assumes
that mistakes will happen [error tolerant].
▪ HOP is NOT a program. It is an Operating Philosophy which principles
need to become commonly held values as part of safety culture
campaign.
▪ HOP-based safety culture assessment very dependent on the success of
the interest & commitment garner of all parties and organizational
alignment. Avoid forcing the change through measurement.

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SOME RESOURCES

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Great performance is not the absence of errors or failures…..
….. It is the presence of EXPANDING CAPACITY
….. It is the presence of DEFENCES. (Conklin)

#thank you

Presented by:
Dr. Adithya Sudiarno, ST., MT., IPM, ASEAN Eng., MIIRSM.
Industrial and Systems Engineering Department – ITS
Komisi III, Dewan K3 Provinsi Jawa Timur.
adithya.sudiarno@gmail.com / 08-123-0-123-88