Adding a HOP Lens to your incident investigations

Question number 1 following my presentation on 27.07.2021 titled "Adding a HOP Lens to your incident investigations":

"Mistakes include ‘knowledge based rules’, which means that there is lack of knowledge of how to do the action safely. I’m confused as if an accident occurs due to a lack of knowledge then there is still an ‘intention’ in carrying out the action and surely it is a ‘drift’ rather than an ‘error’"

Thank you so much for this question, I'm going to try to answer it in a couple of ways.

Firstly, if your investigation does identify a lack of knowledge about how to perform a particular task, then regardless of whether an error has been made or not, trying to establish whether it was error or drift is kind of immaterial because there is obviously some organisational weakness or gap in a process which means we didn't set that individual up for success - as a responsible employer the onus is on us to ensure that individuals are given adequate instruction, supervision and training to be able to perform their duties safely. In this instance I would be looking to our recruitment, induction, onboarding and training processes to identify the drift there rather than with the worker at the jobsite.

If your question related to someone who has performed the task in a way that over time has become 'custom and practice', i.e. a routine violation and everyone does it that way, then you might still want to confirm whether or not they were EVER shown how to perform the task in the required way, but ultimately you are probably looking at drift; now - that drift might have led the individual down a route where an unpredicted error was more likely and therefore the consequence of the error might feel like a 'black-swan' event but I would still be citing organisational drift before discussing the error-likely situation that was created because of it. I hope that makes sense?

Finally I wanted to just focus in on the wording of your question to provide a bit of clarity around something we call 'Performance Modes'. Again, in my opinion I think 'performance mode' thinking is a bit out-dated thanks to the work of amazing people like Daniel Kahneman and Matthew Syed (links to their seminal works below), however. We traditionally considered three performance modes when it came to people's 'cognitive' state when they are performing a task at work. These are Skill-Based, Rule-Based and Knowledge-Based. A simple, and quite common, way of describing these is to use a driving analogy. For the majority of competent, experienced and qualified drivers, we typically get into our car and complete our journey with relative ease, particularly if we know the route, we're familiar with the car and there are fair to normal weather conditions and no major roadworks or new hazards en-route, in fact a good example is one of those journeys where you suddenly reach your destination or a known mile marker and suddenly realise you can't actually recall large parts of the journey. the "How the hell did I get here?" phenomenon which most of us will experience from time to time. This is what we call 'skill-based' performance mode. We don't need to apply much cognitive power because it is something so routine and almost mundane and habitual to us.

Now let's set out on that same journey and today there are some roadworks which have resulted in a diversion. We're not as familiar with this route so we have to focus a bit more on where we are and how we're going to get to where we're going; our lack of familiarity with the route means we have to pay more attention to the speed limits and road markings and we need to look out closely for the diversion signs. We're in a higher state of alert, requiring slightly more cognitive 'fuel', we're applying the rules that we know in order to complete our journey safely and successfully. This is rule-based mode.

Now let's imagine that your 15 year old British car (do they exist?!) is in for a service and the garage have delivered a swanky new top of the range German number as your courtesy car. You jump into the driver's seat and look for the keyhole. What no keyhole? There has to be a flipping keyhole surely? You're looking around the dashboard and you see a round button which says 'ignition'. Aha! you say, gotcha! You press the button but nothing happens. Now you are starting to get a little stressed because you should be at the end of your road by now! After ten minutes of repeatedly pressing the button, getting in and out, locking and unlocking the door you finally reach for the drivers manual and read that you have to put your foot on the brake before pressing the ignition button! Your indicator arms are on the 'wrong' side, your horn is in the middle of the steering wheel, not on the indicator arm where it should be and you just hope to god it doesn't rain because you have not got a scooby-doo where the windscreen-wiper controls are! Familiar? Welcome to Knowledge-Based mode! By the time you complete your journey you're ready to go home and back to bed. High cognitive load and you really can't perform in this mode for very long at all!

The 'aim of the game' is to try to move your workers between the three performance modes during the completion of their tasks, preferably with only very short spells of time in Knowledge-base for obvious reasons. It's not easy to do from a work planning perspective but we can convince ourselves that it is so obvious to establish the performance mode 'after' an incident. Don't fall into the trap. In my opinion, establishing the performance mode after the proverbial has hit the fan is going to be about as much use as a chocolate tea-pot in preventing recurrence!

The theory also states that the average human-being's error rate increases significantly the 'higher' up the performance modes you are, which would of course tempt you to think that the more your workers are in 'skill-based' mode the better. The problem is that, as we know there are other error-precursors that kick in when we're in skill-base, e.g. complacency, lack of situational awareness, etc. so beware of performance-modes. If this is something you want to take a deeper dive into I would highly suggest a conversation with Mr Rob Fisher at Fisher Improvement Technologies (link below). Again, in my opinion, Rob is the guy who I think explains performance modes and how they relate to the 'types' of error that occur in the best way I have ever heard!

I hope this provided some answers to your question and that you've found this useful!