WestRock Safety Expert Explains the Benefits of HOP

Traditionally, and for most of my career, we have investigated incidents with a primary focus on who to blame and developed a subsequent plan intended to stop the mistakes from happening in the future. Many times, this has meant removing the person from the work. Unfortunately, when this is our strategy for improvement, the same conditions remain in the work environment where a similar incident is likely to occur once again.

Human and Organizational Performance (HOP) recognizes that people make mistakes, and that we need to design our systems to respond to these mistakes without catastrophic outcomes.

To unlearn our previous mindset, we must first understand human behavior, since humans are the key component in making our systems work. HOP is a philosophy that helps us begin to look at failure differently. There are five principles of HOP:

1. People Make Mistakes. No one intentionally chooses to make mistakes or errors; however, as humans, we are all fallible simply because of the way our brains process information.
2. Blame Fixes Nothing. When placing blame, humans will develop a fear to hide failure to avoid blame in the future. Our workers are not the problem, they are the problem solvers.
3. Learning & Improving is Vital. Engaging our experts, the people who do the work, allows us to learn and understand the context that led to the event.
4. Context Drives Behavior. There is never only one element that drives humans to the decisions they make. Humans are incredibly creative and adaptive and will adjust to the task-at-hand to reach success.
5. Response Matters. How we react and respond to events can create or hinder a learning environment. We must destigmatize failure so we can create innovation.

By now, you might be feeling the same way I did when I was first introduced to HOP several years ago: “This all sounds great, but it will never fly in a manufacturing environment.” I certainly do not like having to admit that I made a mistake, but in this case, I made a mistake.

It was September of 2021 when a significant incident occurred that entirely changed my mind about the way we had traditionally investigated incidents. When learning about this incident, I was quite focused on who failed and their behavior that caused the incident. However, if we solely think about who failed instead of what failed, we neglect the opportunity to learn and address the gaps in our system that fostered the unsafe behavior.

After this incident, I had the opportunity to participate in an operational learning event. Operational learning helps us understand how the work is actually done from the perspective of the experts performing the work. What about their work makes for a good day or a bad day? Where must they be creative and adaptive to achieve success?

By the time we completed the operational learning event, it was evident that, given the conditions they faced and the information they had, the tools and equipment that were available, along with the pressure they were under, that we would have made the same decision. During the information gathering process, if we had only focused on who was to blame or were looking for a single-point failure, we would not have learned about the gaps in our system and designed solutions that would allow our workers to fail safely.

I am currently the HOP lead for WestRock, with 28 years of experience in the paper industry. My background is in health care, where I served in the US Navy as a nurse. I can honestly say that teaching HOP has been the most gratifying experience of my career. Who wouldn’t want to witness mindsets make a complete 180?

We will be presenting more about operational learning at the PPSA Annual Conference June 9-12, 2024, at the Vinoy in St. Petersburg, FL. Please register at https://ppsa.memberclicks.net/ppsa2024. To learn more about HOP principles and how you can implement HOP in your organization, you can review the recent PPSA webinar series at www.ppsa.org.