Safety By Design: Human and Organizational Performance

The first three articles in this six-part series addressed the critical nature and value of an organizational safety management system (SMS) that engages all employees and effectively mitigates risks through a developed plan for continuous improvement. This article focuses on human and organizational performance (HOP), an operational philosophy that utility organizations must incorporate into their SMS to achieve organizational safety success.

Over the years, traditional safety programs have primarily focused on managing employees, often overlooking the crucial systems designed to support them. Employees are expected to consistently make the right choices and adhere to safety rules 100% of the time, relying on the training they have received and the rules they must follow. When incidents occur, these employees may frequently be blamed; they are presumed to have been equipped with all the necessary tools and training to work safely yet opted not to utilize them. This scenario resembles a “Mission: Impossible” movie plot in which employees fail to “accept” their mission. While such a perspective is rarely accurate, many organizations continue to use a blame-centric model to tackle operational upsets, focusing on individual faults rather than improving organizational systems that empower and support employees.

HOP Overview
After discovering HOP, I was excited to learn more because it offered a fresh perspective that resonated with me. HOP enhances communication and understanding between employees and organizations, particularly in high-risk environments. It emphasizes the importance of grasping the reasons behind human errors and focuses on building resilient safety systems to support employees when they make mistakes. Rather than viewing human error as a failure to follow rules, HOP encourages us to recognize the underlying causes of mistakes and take action to address them.

The philosophy also encourages organizations to view errors as opportunities for learning and growth. Employees must recognize that mistakes are a normal part of life; this mindset helps to create safer work environments and fosters continuous improvement and innovation.

ASSP GM-Z10.100-2024, “Guidance and Implementation Manual for ANSI/ASSP Z10.0-2019 Occupational Health and Safety Management Systems,” introduces the five HOP principles and describes the importance of a learning and improving culture within a new view of safety. Here is a list of the principles, which are highlighted in Chapter 2, “Understanding the Workplace: The New View of Safety.”

1. People will make mistakes.
2. Error-likely situations are predictable.
3. All human actions are influenced by the context in which they occur.
4. Operational upsets can be avoided.
5. How we respond to failure matters.

Principle 1: People will make mistakes.
In my consulting work, I sometimes ask senior leaders if they have made mistakes. The question is usually met with chuckles and agreements that everyone makes mistakes. That is when I drive home the point, highlighting that employees regularly make decisions that directly affect them and the organizations they work for. Often, these decisions must be made during high-risk work activities under significant pressure, when a mistake can be devastating. This first HOP principle becomes easier to understand when we consider all the dynamic forces involved in decision-making and recognize that humans are inherently imperfect.

Viewing mistakes as learning opportunities is key to fostering a positive company culture that promotes individual and organizational growth. While eliminating every error may not be realistic, organizations must aim to reduce the number of mistakes that result in unacceptable consequences. This emphasizes the importance of addressing human error in risk mitigation plans, which was discussed earlier in this series.

Principle 2: Error-likely situations are predictable.
“If you had only asked me, I could have told you that would happen.” Have you heard employees in your organization make that statement? It is not uncommon for people to sense potential problems yet fail to take action to resolve and learn from them.

An “error-likely situation” refers to an environment in which the likelihood of making mistakes increases when specific actions or tasks are being performed. The concept, defined in Volume 1 of the U.S. Department of Energy’s “Human Performance Improvement Handbook,” is linked to error precursors or error traps. These conditions increase the risk of making mistakes and usually exist before any errors occur. By identifying and removing such traps, we can minimize jobsite mistakes.

While it may be tempting to stick to familiar routines – especially if your organization has not experienced any serious injuries or fatalities – leaders must recognize that employees possess valuable insights that can influence the likelihood of errors. The key is to develop operational processes designed to identify and address error traps before, during and after work. By focusing on both task-related and individual factors throughout the work process, organizations can reduce the risk of mistakes and continuously improve their ability to predict and mitigate errors.

Principle 3: All human actions are influenced by the context in which they occur.
Numerous organizations face significant challenges with this principle relative to organizational culture. One real-life example is members of a work group who adhere to safety rules when the “safety guy” is present but revert to their usual unsafe practices once he leaves. This behavior indicates that the work group’s decision-making is influenced by an organizational culture that undervalues safety, directly affecting how work is performed.

It is essential to recognize that our environment and circumstances greatly impact our behavior and decision-making processes. Organizations must proactively identify and rectify the gaps in their operational control structures that support safety processes. These gaps can severely impede employees’ ability to make timely decisions, compromising safety and productivity. By fostering a culture of safety and continuously evaluating and improving operational controls, organizations can empower their employees and enhance overall performance. Prioritizing these improvements protects the workforce and contributes to the organization’s long-term success and sustainability.

Principle 4: Operational upsets can be avoided.
The most effective way to prevent operational upsets or disruptions is to learn from the work being carried out. It is crucial to acknowledge that opportunities for learning and growth occur daily as tasks are performed during regular operations. Many organizations focus solely on incidents, missing valuable chances to improve. An organization with a strong culture is more likely to thrive when it is not constantly in crisis mode, trying to address past issues.

The second chapter of ASSP GM-Z10.100-2024 identifies the importance of learning from daily work. Potential learning events highlighted in the standard include:

• Tasks that employees mostly do well but that are not always successfully completed due to the challenges involved.
• Tasks with issues being reported by employees.
• Tasks that have gone exceptionally well.
• Tasks involving the successful implementation of new designs, processes or procedures.
• Tasks that resulted in serious injuries or fatalities.

Our industry utilizes various initiatives and tools to learn from work – such as after-action reviews, observations, job hazard analyses and learning teams – which are essential for identifying issues. However, organizations must also act when they recognize improvement opportunities. Positive action fosters cultural growth, while a lack of action can cause the existing culture to crumble.

Principle 5: How we respond to failure matters.
An organization’s responses to operational upsets can make a considerable impact on company culture. Positive responses encourage a culture of learning and improvement. They also help employees feel empowered to grow in their commitment to safety. Negative or punishing responses cause fear and anxiety, potentially stifling employee creativity and growth. This kind of environment can erode trust and lower morale, ultimately pushing an organization’s strong culture toward possible extinction.

Some companies face challenges in deciding how to respond, often delaying the process for weeks or even years. Remember that a lack of response or a delayed response can be just as devastating as punishing behavior, preventing any opportunity for improvement.

Summary
Integrating HOP principles into an SMS is essential to fostering a culture of trust, learning and continuous improvement. By shifting from a blame-focused approach to one that acknowledges and addresses the underlying factors that influence human behavior, organizations can build more resilient systems and empower employees to engage more meaningfully in safety efforts. Recognizing that mistakes are inevitable and often predictable, leaders must proactively identify risks and implement effective solutions. Ultimately, how an organization responds to failure defines its safety culture and determines its ability to grow stronger from every challenge it faces.

About the Author: Pam Tompkins, CUSP, CSP, is president and CEO of SET Solutions LLC. She is a 40-year veteran of the electric utility industry, a founding member of the Utility Safety & Ops Leadership Network and past chair of the USOLN executive board. Tompkins worked in the utility industry for over 20 years and has provided electric power safety consulting for the last 25 years. An OSHA-authorized instructor, she has supported utilities, contractors and other organizations operating electric power systems in designing and maintaining safety improvement methods and strategies for organizational excellence.