HOP & RCA

It’s AND, not OR

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Table of contents
1. Introduction 3

2. Old way = culture of blame! 4

3. Safety is more than just compliance 5

4. 5 Whys ? 6

5. Is the intent really to learn? 7

6. Sologic RCA; 5 steps, not 5 Whys 8

7. Sologic RCA - multiple causes working together 9

8. Human and organizational performance 10

9. Focus on work-as-done 11

10. Mapping HOP principles to Sologic RCA 12

11. Facilitation is key 13

12. Learning team approach: struck-by-incident 14

13. “Outside-in” or “inside-out”? 15

14. Summing it all up 16

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Introduction
D irk is a Regional Safety Manager for Schooner Construction.
Schooner specializes in heavy civil engineering projects.
The projects Schooner takes on are difficult from the start and
they involve tricky challenges concerning terrain or existing
structures. Schooner is not afraid to innovate. In fact, innovation
is required due to the unique nature of their work. Many times,
what they do has never been done before.

Dirk loves his job. He came up through the trades and, over a short time, earned
the respect of his veteran peers with toughness and pride. But he quickly found
out that others considered Safety as “…the Safety Police who keep us from
getting the job done.” From their perspective, Safety was a tax on productivity.
They believed that their knowledge and experience would protect them from
injury. They also believed that injuries were usually the result of someone
messing up. “Accountability” meant finding and punishing the guilty party.

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Old way = culture of blame!
But that wasn’t how Dirk saw it. He was standing nearby when
a close friend experienced a life-changing injury. It all happened
very quickly. They were working on a multi-story building at a
water treatment plant when a falling pipe wrench hit his friend
on the head.

He was never the same after the injury, even though he was wearing his
hard hat when he was struck. Most people blamed the guy who dropped
the wrench – it slipped while tightening a large valve. Some people quietly
blamed Dirk’s friend for being in the wrong place. As Dirk saw it, this could
have happened to anyone – it was just bad luck.

Truthfully, this sort of thing (dropping stuff) happens – not often, maybe a few
times per year. Was Dirk’s friend truly unlucky? Maybe it wasn’t his day? Hard to
know, but that didn’t stop Leadership from walking the guy who dropped the
wrench off of the site. There was zero interest in learning from what happened
– they all just went back to work, plus one story and minus one pipefitter.

Dirk decided to take a job in Safety after that.

Figure 1: The classic model of accountability - if you mess up, you pay a price.

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 Safety is more than just
compliance
A big part of his job was to find violations and write people up
for them. He quickly learned that enforcing compliance wasn’t
an effective motivator to learning and improving. It wasn’t going
to keep people safe. But why not?

Dirk knew the answer. Workers had no problem following the rules, so long
as they didn’t get in the way of work. Workers generally didn’t see most rule
violations as particularly important. If the work got done and no one got
hurt, wasn’t that the goal? In fact, supervisors were a big part of this culture.
If people were productive and nothing bad happened, they’d let violations
slide. They didn’t realize it, but they were blinded by the notion that past
successful results guaranteed future successful performance. That’s just not
how risk works.

The thing is, they were almost always successful and they almost never got hurt.
When they did get hurt, it was chalked up to either someone’s mistake or bad
luck. And no rule was going to have much of an impact on either of those.

ENFORCING
COMPLIANCE ISN’T
A GREAT MOTIVATOR
TO IMPROVE
AND LEARN

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5-Whys?
Part of Dirk’s new job was to investigate incidents and accidents.
He was familiar with the term “root cause analysis.” In fact, he had
attended a training course that briefly discussed “RCA.” But it was
just a supplemental topic – not the focus of the course. In that
case, the attendees were told they needed to ask “why” at least
five times and then they’d get to the “root cause.”

This made sense in theory (sort of), but in practice, it didn’t work very well.
First, few people actually did the RCA unless they were specifically told to
do it. And then when they were asked, they often (not always) made the
5-why questions lead to the answers they thought leadership wanted to
hear. While the 5-Whys was sometimes useful in helping front-line workers
think a little more deeply about problems, it was often mismatched with
much more complicated events, and this never worked out well.

Figure 2: The Five Whys was intended to help evolve from the traditional “break–fix” pattern of problem-
solving. But it is too often misused for more complex problems which leads to oversimplification and/or blame.

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Is the intent really to learn?
The focus was on getting the investigation done, not actually
learning from it!

“Did you do that root cause analysis?”

“Yes!”

Great – problem solved! But many of the problems weren’t getting solved. It
was clear to Dirk that the culture at Schooner needed to change. Effective
problem-solving requires learning, and the learning just wasn’t taking place.

Figure 3: Even when there is a requirement to investigate, the goal can be misinterpreted as completing
the investigation and getting back to work rather than learning from the event.

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Sologic RCA;
5 steps, not 5 Whys
A year or so after he was hired into Safety, he found himself
working for a new VP. She came from the Chemical industry
where the consequences of failure could potentially sicken or
kill scores of people. She was convinced that the more advanced
processes she used in that industry could be applied to the
construction work at Schooner, so she brought in Sologic.

One thing Dirk really liked about the Sologic method was how it focused
on learning without blame. Dirk knows of several people who had been
punished or even fired because of a mistake. Sologic encouraged teams to
look beyond the error in order to understand what was going on before the
error happened

5 Steps of Sologic RCA

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Sologic RCA - multiple causes
working together
Dirk also liked how Sologic avoided the pitfalls of the Five Whys.
Sologic uses a branching logic diagram to map out the different
causes and how they relate to each other. In class, they used Dirk’s
friend’s accident as an example. The result was a simplified model
of the event that helped him see each of the different contributors.
This allowed their team to identify solutions that would keep the
problem from happening again.

Most importantly, he learned that a lot more was going on than someone
simply letting a wrench slip out of their hand. He always knew this intuitively
– but seeing it mapped out accomplished a few things:
1. It confirmed that he was right – there was more to it
2. Mapping the causes made it easier to organize and understand
3. Multiple causal pathways led to multiple solutions

Figure 4: Sologic RCA recognizes that events are the result of multiple causes acting together.

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 Human and organizational
performance
The next year, his VP wanted everyone to attend a Human and
Organizational Performance (HOP) training course. This was a
“new” way of looking at work that was supposed to help move
away from the blame culture and to embrace the hard-earned
knowledge of people working at the “sharp end” of the job – the
place with the risk of direct personal injury.

5 principles of HOP
1. Human error is normal
2. Blame fixes nothing
3. Learning is vital
4. Context drives behavior
5. How you respond to failure matters

1. HUMAN ERROR IS NORMAL

2. BLAME FIXES NOTHING
3. LEARNING IS VITAL
4. CONTEXT DRIVES BEHAVIOR
5. HOW YOU RESPOND TO FAILURE MATTERS

Based on the work of Dr. Todd Conklin. For more on this subject, you should read his book “The 5 Principles of Human
Performance: A Contemporary Update on the Building Blocks of Human Performance for the New View of Safety”

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 Focus on work-as-done
He attended a multi-day class on learning teams where the
instructor said something that, at first, didn’t make sense to Dirk.
She said that focusing on specific causes of any single event might
introduce bias and blame. For instance, in the case of Dirk’s friend
who was hit on the head, the chances of any single person being
struck by something falling are very low.

People work at different elevations daily and almost never drop anything.
And, if something is dropped, it is very unlikely that someone will be
underneath it. By focusing only on the specific causes of the event, we can
overemphasize the role of the people involved, such as the worker who
dropped the wrench – or even the person who was injured – when most of
the contributors to an event like this are always present. This leads to blame
while leaving crucial systemic contributors undiscovered or discounted.

After an adverse event has occurred, at first it makes sense to focus more on
how work is normally done rather than the specifics of the event itself. By
first keeping a broader focus, the team can better understand the “normal”
conditions and risks that workers are expected to manage on a daily basis.
This widens the initial focus to identify system-level risk contributors. By the
end of the class, Dirk could see what the instructor was getting at.

FOCUSING ON HOW
WORK IS ACTUALLY
DONE HELPS
UNCOVER SYSTEMIC
CONTRIBUTORS
TO RISK

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Mapping HOP principles to
Sologic RCA
Dirk realized that Sologic RCA & the HOP principles overlapped
in many ways:

HOP Principle From Sologic RCA

Human error is normal • Never stop at “human error”
• Go beyond “human error” to understand what
allowed the error to happen in the first place.

Blame fixes nothing • Do not use names or judgmental language.

• Focus on learning, not assigning blame
• Effective Solutions alter the causal environment
– blame doesn’t.

Learning is vital • Focus of the Facilitator is to help the team learn

from each other.
• Base findings on evidence, not conjecture.
• Share findings with others so they can also learn.

Context drives behavior • Find solutions that reduce or eliminate risk at the
system level.
• Multiple solutions controlling diverse
contributors are better than single solutions

How you respond to failure matters • Listen to the people who do the work and know
where the risks are.
• Be willing to learn and grow based on their input.

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Facilitation is key
In practice, Dirk found the process of facilitating a learning team to
be very similar to facilitating an RCA – in both cases, he still had to:

• Gather a diverse team of knowledgeable individuals

• Create a safe environment for people to contribute
• Make sure the quiet voices are amplified
• Make sure the “over-contributors” are respectfully attenuated
• Watch out for bias – don’t jump to conclusions or solutions
• Require that conclusions and assertions be based on evidence and facts
• Help break logjams and keep things moving forward
• Remember to order lunch 45 minutes before people are truly hungry

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Learning team approach:
struck-by-incident
Dirk considered how the learning team approach and the principles
of HOP might have been applied reactively to the incident
involving his friend.

First, they would have reviewed the HOP principles to help ensure everyone
would participate fully, without fear, and with a focus on learning.

Second, he would have widened the initial focus by asking questions like:

• “Tell me what a ‘typical’ day around here is like?”

• “How do you start your shift?”
• “How do you know what your daily goals and work assignments will be?”
• “How often do you run into ‘new’ situations, and what do you do when
that happens?”
• “How difficult is your work?”
• “What are the things you really have to watch out for, and how do you
know what those are?”
• “What are some of your frustrations?”

These kinds of “How” questions help the team tell the story of how normal
work happens at their site. They learn from each other, fill in blanks, and
maybe even constructively argue a little bit.

Third, he would have documented their conversation as it happened using

flipcharts, sticky notes, whatever. As the facilitator, he would need to ensure
nothing was missed or forgotten.

Fourth, he would have shifted the focus back to the actual event, but only
after everyone had a thorough understanding of the context.

And fifth, he would have asked the team what they wanted to do to make
the system (including the people who work in the system) better and more
resilient. He would have focused particularly on areas where errors could lead
to death, injury, or some other highly undesirable outcome.

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“Outside-in” or “inside-out”?
The Learning Team approach first examines the bigger picture.
Asking questions like “Can you please help me understand
what normally happens during your shift?” and then letting the
conversation develop can certainly feel less threatening. And
it also helps reduce bias. This allows the team to more easily
discover and explore the systemic risk elements.

This “outside-in” approach will often lead to crucial learning opportunities.

At its best, the process identifies key elements that result in success. In
every case, the focus is on learning and not blame.

Sologic uses an “inside-out” approach. It starts with the event and works from
the specific details outward to the bigger picture. It creates a model of how
an event did occur (or how an event might occur). It accommodates multiple
converging storylines. And it leads to the discovery of systemic contributors.

Figure 5: Specific causes are more directly related to the event. Systemic contributors may not be directly
related to the event, but they increase the likelihood of an event occurring.

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Summing it all up
What Dirk Learned:
• The five HOP principles are universally true for any type of
learning event.
• A diverse team of knowledgeable experts, including those who
do the actual work, is critical to discovering the unvarnished
truth about what it takes to actually get work done.
• Sometimes it makes sense to focus first on problem specifics
and then work outward toward the systemic contributors.
• Sometimes it makes sense to learn about the broader system
first and then move towards event details.
• The best facilitators are in tune with their teams and know
how to curate an effective learning experience in the moment
by using a variety of tools and techniques.

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In every case, solutions need to focus on a wide variety of causes and
contributors – not single root causes. They need to help build system
resiliency, particularly around critical steps where errors could result in
significant negative outcomes. And they need to be documented in a
manner and place that is easily accessible and shareable so that others can
learn too.

The best part about this overall experience for Dirk was that he realized
that as time moves forward, we all continue to learn and adapt. Through
his experiences of learning, applying, adjusting, and improving, he became
an active contributor to new and innovative ways to help people and
organizations learn and grow.

Hmmm – maybe he should start his own consultancy? To be continued…

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