Human and Organizational Performance

Why good people make mistakes and how to design work that tolerates error, followed through the invented Harrowgate Foods as it adopts human and organizational performance across its plants and distribution centre in Nova Scotia after a near miss on a bakery line: the HOP principles and their roots in Rasmussen, Reason, Dekker, Hollnagel and Conklin, error types and performance modes, error traps and precursors, work as imagined and work as done and drift, error-proofing, poka-yoke, human factors and checklists, procedures people can use, learning teams, pre-job briefs and operational learning, critical controls and serious injury and fatality prevention, resilience and capacity, restorative just culture and care for the people involved, and leading, measuring and implementing HOP, with a capstone dock event.

HSE-408 12 lessons · 4 h 24 min ▶ Video lessons coming soon

Offered by HSM University · Safety Training

This is the Canadian version of this course. See the American version.

What you'll learn

Explain the five HOP principles and trace them to the work of Rasmussen, Reason, the DOE handbook, Dekker, Hollnagel and Conklin.
Classify errors by performance mode as slips, lapses, rule-based mistakes and knowledge-based mistakes, distinguish them from violations, and explain why error rates add up across long tasks.
Identify error precursors in the four TWIN categories, recognize error traps at critical steps, and decide which to design out and which to manage on the day.
Distinguish work as imagined, prescribed, disclosed and done, apply local rationality, and recognize drift toward the boundary of safe performance.
Design work that tolerates error using the error hierarchy, poka-yoke, human factors principles, short checklists, independent checks and fail-safe design.
Write, test and maintain procedures people can use, with honest levels of use, plain steps, machine-specific lockout placards and a rule for when a procedure does not fit.
Plan, facilitate and follow through on learning teams after events and on normal work, and measure their quality rather than their number.
Identify critical steps and use pre-job briefs, self-checking, peer checking, three-way communication, handovers and post-job reviews to protect them and learn from everyday work.
Build bowties, select critical controls that work despite error, write performance standards and verify controls in the field to prevent serious injuries and fatalities.
Explain resilience and capacity, apply Hollnagel's four abilities, and use utilization, pre-mortems and capacity indicators to protect margin at critical steps.
Respond to failure with restorative just culture, forward-looking accountability and peer support for people involved, while handling reckless conduct fairly.
Lead, measure and implement HOP across several sites, and apply the course's principles and tools to analyse a serious-potential event.

Course content

12 lessons · 4 h 24 min total · final exam

1 The HOP principles and where they come from 25 min · quiz
2 Error is normal: error types and performance modes 22 min · quiz
3 Error traps and precursors 21 min · quiz
4 Context drives behaviour: work as imagined, work as done and drift 22 min · quiz
5 Designing work that tolerates error 22 min · quiz
6 Procedures people can use 21 min · quiz
7 Learning teams in practice 21 min · quiz
8 Pre-job briefs, operational learning and other HOP tools 21 min · quiz
9 Critical controls and serious injury and fatality prevention 22 min · quiz
10 Resilience and capacity 21 min · quiz
11 Responding to failure: restorative just culture and second victims 23 min · quiz
12 Leading, measuring and implementing HOP: a capstone for Harrowgate 23 min · quiz
E Final exam 20 questions

Requirements

HSE-403 Incident Investigation and Root Cause Analysis

Recommended background. You can start any course at any time.