HOP, Swiss Cheese, and TapRooT® RCA
Are You Just Starting a Performance Improvement Initiative?
Before you start down the road of HOP, Swiss Cheese, Safety II, and the current plethora of other “new ideas” to approach achieving excellent human performance and high reliability, you probably should learn about the concepts that are foundational to HOP and what you should consider when starting any performance improvement program.
First, a little about my history, because I was there in the beginning in the 1980s and 1990s when the foundations were laid. After my tours in the Nuclear Navy, I started my journey to improve human performance back in the early 1980s while doing graduate studies in human factors at the University of Illinois. I had great mentors, who included Dr. Charles Hopkins and Dr. Jens Rassmussen. My early work included collaborating with INPO in the mid-1980s to develop the HPES (the Human Performance Evaluation System), working at DuPont to develop a human performance improvement initiative to improve nuclear/process safety, which included developing an initial root cause analysis tool, and as a contractor working for the NRC to develop HPIP (the Human Performance Improvement Program).
Before we started the work with the NRC, we started System Improvements and worked part-time to develop a standard root cause analysis system for all types of problems. In 1991, that system became the TapRooT System (TapRooT® is now a registered trademark).
Thus, I was there when many of the concepts behind HOP were being developed and when many critical concepts were implemented in improvement efforts that predated and continue to operate alongside HOP. I was there for discussions about cognitive engineering, resilience, precursor incidents, and normal accidents, and read the books that were published about the topics by James Reason, Jens Rassmusen, Donald Norman, Charles Perrow, and later books and papers by Sidney Decker, David Woods, and Eric Hollnagel. And we wrote several books about root cause analysis and performance improvement. Plus, I was the 85th person certified as a Professional Egonomist (human factors expert) by the Board of Certification in Professional Ergonomics.
That’s why I can help you understand the basis for Swiss Cheese and HOP and explain how TapRooT® Root Cause Analysis fits right in.
Now, before continuing, let’s look at a video (Going Beyond Swiss Cheese) and a discussion of where all this started back in the 1960s, 1970s, and 1980s.
The Video that Details the Creation of Human Performance Improvement
Here are Alex Paradies and Mark Paradies having a fairly extensive discussion (that starts to scratch the surface) of the creation of the accident and human performance models that led to the current emphasis on improving human performance. This video discusses a talk I gave back in the early 2000s about going beyond Swiss Cheese. Discussions of Reason’s models and their origins start about the 2:40 mark in the video. At the 13:10 point, the discussion turns to a different model of human performance and root cause analysis – the TapRooT® System’s model. Both are interesting and provide a valuable foundation for your improvement efforts. The video will help you understand the common underpinnings and differences of both and how TapRooT® was configured as a tool to be used by people in the field to improve human performance.
Watch it now…
That was long, but foundational. Now, on to the HOP principles…
The HOP Principles
HOP grew out of the original work described in the video above, but with an organizational factors twist.
Five standard HOP principles are generally recognized across various HOP implementations by various consultants:
- Human error is normal.
- Blame fixes nothing.
- Context drives behavior.
- Learning is vital.
- How you respond to failure matters.
To understand how HOP functions and what you may need to consider before adopting the HOP philosophy, let’s look at each of these principles.
Human Error is Normal
Certainly, this concept has been around forever. The quote:
“To err is human; to forgive is divine,”.
from the 1711 poem by Alexander Pope shows that human error and blame (lack of forgiveness) have been around a long time.
This age-old concept became the mantra of human and organizational performance consultants and seems to imply that we can’t impact people’s ability not to make errors. This is directly opposed to the application of human factors technology that focuses on engineering highly reliable and easy-to-use systems. For examples of the human factors approach, see Donald Norman’s book The Design of Everyday Things.
Thus, this statement “Human Error is Normal” should be seen as controversial, in that there is considerable variability in human error based on the system’s design. And this variability can be predicted by analysis of the system’s design. Thus, we don’t have to accept a highly error-prone system.
So, although the concept of common human errors is not new, and thus it seems that nobody currently alive can take credit for the concept that “human error is normal.” But to make “Human Error in Normal” the first principle of your improvement initiative seems a bit odd. However, that principle is being popularized by HOP.
Blame Fixes Nothing
The focus on blame in Western civilization is not new. It seems to me that it is the basis of much of our legal system. Perhaps that is why it is so common for management to ask “who did it” even before they ask “what happened” after an accident.
In 1992, Mark Paradies (then President of System Improvements, the TapRooT® RCA folks) wrote in the first Root Cause Network™ Newsletter about the problems with blame and suggested a “new” model to focus on opportunities to improve rather than blame (Beat ‘Em or Lead ‘Em). That article came from a 1990 talk that Mark Paradies gave at an American Nuclear Society meeting. The concept of reducing or eliminating blame was for most accidents became one of the basic beliefs when we created the TapRooT® Root Cause Analysis System.
In the early to mid-1990s, James Reason and David Marx developed the concept of a “Just Culture” and took the next step to guide management to avoid blame for certain types of mistakes.
However, even before that, back in the late 1970s, there was research to show that getting participation in incident and near-miss reporting was dependent on the elimination of blame for most precursor incidents. Certainly, in our experience, the potential for blame and discipline has shown a very negative impact on the willing participation by operators and mechanics in incident investigations.
The concept of blame being counterproductive was adopted as a HOP principle. It is not an original piece of thinking. However, it is good that the HOP folks adopted it because blame is deeply embedded in our culture. Why? Because changing that blame culture is needed for advanced root cause analysis and correcting human error-related incidents. A task that has been ongoing since the early 1990s.
Context Drives Behavior
Human factors and organizational rewards and punishments certainly influence human actions. I dislike the term “behavior” because I think it contributes to the blame after accidents. Why? Some people think that these behaviors are an individual’s choice rather than an organizationally driven outcome. Certainly, management doesn’t like to hear that their actions negatively impact work performed in the field. And occasionally, the individual’s “behavior” is a direct cause of an accident. People can choose to violate a well-understood, positively reinforced rule that others follow. When they do, they are violating a rule that makes work safer.
So, “context drives behavior” seems to be a very limited view of the possible reasons (dare I say root causes) of people making mistakes and causing incidents. Thus, this organizational focus seems like a very limiting approach to the broad reasons for human error and the expanse of potential corrective actions to improve human performance. And even though HOP stands for Human and Organizational Factors, the human factors part of improving human performance seems to be frequently overlooked.
Learning is Vital
This concept, too, was adopted by HOP but is common to many previous improvement efforts, including root cause analysis, Six Sigma, Deming’s Plan-Do-Check-Act cycle, and Lean improvement efforts.
The important issue here is HOW do we learn?
The concept that learning from “normal work” and that the worker is the expert on improving the job is a common fallacy. This is not to say that the workers don’t know what they are doing. They know how to do the job and some ways to improve performance. But they seldom know much about human factors and may not understand why certain safeguards are built into the system. They may not understand the engineering limits of the design or the reasons for certain procedural limitations.
Thus, we have always found that guidance in finding and fixing root causes is a necessary part of an excellent root cause analysis system and any performance improvement program. And we built that guidance – invisibly – into the TapRooT® Root Cause Analysis System.
That is one of the reasons why, in 1994, we decided we needed a place to bring professionals together to discuss human performance and root cause analysis, and sponsored the first Root Cause Analysis Conference. That conference featured Dr. Charles Hopkins as a keynote speaker, outlining how human factors could be applied to improving safety and operations. Since 1994, we have continued sponsoring these conferences (which we now call Summits) to this day. You can read about the history of the Global TapRooT® Summit HERE. Or watch the video about the Summit below…
Read about the upcoming 2027 Global TapRooT® Summit and the six Best Practice Improvement Tracks and the five Keynote Speakers … HERE.
How You Respond to Failure Matters
This really goes back to the blame problem. If management and supervision encourage reporting of problems and provide the resources that are needed to implement effective corrective actions that really make work easier and more reliable, then employees on the shop floor can become excited about performance improvement.
If management responds with blame, punishment, difficult-to-follow rules, and making the work more difficult, of course, the improvement efforts will be unpopular and ineffective.
I remember one of the most shocking experiences I had at a TapRooT® Course being held at a refinery back in the early 1990s. We arrived early to set up for the course and found that there were protestors at the refinery gate. As we slowly passed by, they handed us a piece of paper through the window. A few minutes later, the other instructor had me pull over so she could read to me what the paper said.
It seems that the week before, there was an incident, and an employee had been fired for leaving the scene of work before verifying that the operation had completely shut down. The process continued to run and dumped product for a considerable time before someone noticed the problem. The employee had violated a rule and thus was fired.
However, the union had performed a TapRooT® Root Cause Analysis and found several other Causal Factors and root causes that mitigated the employee’s mistake. The Union was protesting because they wanted management to agree to perform a TapRooT® Root Cause Analysis before any disciplinary action was taken against any employee in the future, and that the fired employee be reinstated. In other words, they wanted to have a thorough root cause analysis and thoughtful response before action was taken, thus eliminating knee-jerk reactions.
Thus, “response to failure matters” has been a core part of advanced root cause analysis long before HOP existed and is a good best practice that HOP adopted (but is not exclusive to HOP).
Response to failure is where the rubber meets the road. People in the field instanntly recognize the difference between lip service to performance improvement and actual action by management that listens to what the system is telling them and results in effective, blameless improvement. You can read aboutthe right way and the wrong way to do this in Book 1: TapRooT® Root Cause Analysis Leadership Lessons.
Your Next Step – Respond and Learn!
If you are considering using HOP or if you are already implementing HOP or other new improvement processes, perhaps you should consider learning a fundamental skill that would make any eventual application of HOP or other improvement principles more effective. A necessary skill that makes Learning Teams more effective. A skill that helps you thoughtfully respond to opportunities to learn rather than implementing knee-jerk reactions. That skill is advanced root cause analysis – the TapRooT® System.
Therefore, if you want to know more about successful ways to improve safety, human performance, quality, equipment reliability, environmental performance, operational excellence, high-reliability, and root cause analysis, attend one of our courses (see the complete list HERE and the complete list of upcoming dates and locations of our public courses HERE).
Or, for some coaching on developing a performance improvement program, talk to one of our Implementation Advisors by calling 865-539-2139 or send an e-mail by CLICKING HERE.
If you want to see the practical results of applying advanced root cause analysis (TapRooT® RCA) at industrial facilities around the world to eliminate blame, find real fixable root causes, stop fatalities and serious injuries, and other important performance improvement efforts, see the Success Stories from TapRooT® Users, HERE.
