The Invisible Injury: What HOP Misses
HOP—Human and Organizational Performance—is the safety world’s shiny toy. Since its early days after Three Mile Island, it has spread faster than free ice cream on a hot day. It’s brought a lot of good ideas to the table, but like any tool, it’s not perfect. There’s one gap I call the Invisible SIF.
Fig. 1: Heinrich pyramid, first introduced by H.W. Heinrich in 1931. MASTER_SHIFU/SHUTTERSTOCK.COM
Let me be clear: HOP isn’t bad—it’s just incomplete. After decades of working with safety teams across the globe, I’ve seen what HOP gets right and what it misses. And when it comes to preventing serious injuries and fatalities (SIFs), this blind spot can be deadly.
ACCOUNTABILITY VS. BLAME
First up: accountability. HOP has done a great job steering us away from finger-pointing and toward fixing systems. But sometimes we overcorrect. I’ve seen “accountability anxiety” set in—where nobody holds anyone responsible for their choices because they’re too busy blaming the system.
Here’s the deal: systems shape behavior, but people still make decisions. That’s why I teach leaders about “accountable autonomy”—empowering workers to make good choices while holding them accountable for their actions. Rewarding positive behaviors is one of the themes I teach in my book, Green Beans & Ice Cream. Recognizing good choices isn’t just morale-boosting—it builds trust and helps workers understand the importance of safe decisions.
HEINRICH’S LEGACY
Now, about that famous Heinrich pyramid (Fig. 1). Some folks want to toss it in the trash, saying there’s no real link between minor incidents and major ones. But here’s the thing: the stats might not always line up, but the behaviors do.
A near-miss today can turn into a tragedy tomorrow if the stars align just wrong. It’s like pulling pieces out of a Jenga tower. The tower doesn’t collapse until it does—and by then, it’s too late.
Here’s the kicker: the Invisible SIF. Some of the riskiest behaviors in your workplace aren’t in procedure violations or system failures. They’re hiding in plain sight, camouflaged as “success.”
Take a real-life example of a plant maintenance crew that found a shortcut to clear jammed machinery. It wasn’t by the book, but it worked—hundreds of times. Then one day, it didn’t, and someone didn’t go home.
HOP would focus on the system that allowed the shortcut, and that’s important. But it might miss the bigger issue: success itself had masked the danger.
THE FIX: SUCCESS FORENSICS
So, what’s the fix? I call it “success forensics.” That’s just a fancy way of saying we need to study not only what goes wrong, but also what goes right. Ask questions like: What shortcuts are people taking? What hidden risks are buried in our wins?
This is where Green Beans & Ice Cream comes in: positive reinforcement helps us uncover these risks. When you celebrate safe behaviors—like following the correct procedure—you’re encouraging workers to stay on the right path. Recognizing their efforts also makes them more likely to speak up about risky shortcuts.
INTEGRATION IS KEY
The way forward isn’t to choose sides between HOP and Behavior-Based Safety (BBS). It’s about combining the best parts of both. HOP gives us a systems lens. BBS focuses on behaviors. Positive reinforcement ties it all together by encouraging safe actions and building trust.
At the end of the day, safety isn’t just about catching what’s wrong. It’s about creating a culture where folks feel valued, risks are addressed early, and everyone makes it home safe.
To do that, we’ve got to tackle the Invisible SIF. Because safety isn’t just about avoiding accidents—it’s about finding the dangers hiding in our successes and turning those green beans into ice cream.
will present the keynote address at PPSA’s 81st Annual Conference, which will be held August 24-27, 2025 in New Orleans, LA. Learn more at ppsa.org.