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HOP is a Journey, Not a Destination


EWTC HSE Committee Member Lamberto Nonno, Baker Hughes

Sooner or later, all organizations face some of these questions: Why don’t employees follow the procedures? Why can’t they just follow the rules and make sure everything will go as planned? Why do we keep seeing, investigating and correcting similar incidents over and over again?

A decade ago at Baker Hughes, we realized that sometimes these simple questions deserve better than the usual simple answers; and decided to embark on a journey that would see us developing, integrating and measuring Human and Organizational efforts in our operations.

By embracing Human and Organizational Performance (HOP), we began responding to these and many more questions on how safety is created in our operations and why people do what they do. Through learning and implementing HOP, we challenged the way we viewed safety, helping to reveal new perspectives in how to find, understand and resolve safety issues, while improving the overall organizational ability to learn and create a healthier, safer and more productive workplace.

“Errare humanum est”

For years we looked at behaviours and tried to fix one person at a time. Then with Macondo, we invested heavily in Process Safety and tried to make the system more reliable instead. But it was when we paused to reflect on human factors and human performance that we saw the need to focus on where the people meet the system. And recently, at Baker Hughes OFSE, we adopted the following HOP principles:

  1. Error is normal and must be planned for.
    Does all you do go as planned and expected? We need to recognize that even the best people can make mistakes. And it’s in those that we find opportunities to learn and improve: What are the conditions that increase the likelihood of errors; and how can we plan around them to ensure that if an error occurs, consequences are contained?
  2. Context influences behavior and drives social norms.
    The work environment influences our behavior, actions and decisions. When something goes wrong, we need to understand the context that influenced our people’s decisions. Culture, peers and most importantly, leaders, are all part of the context and can have an impact on the decisions our team members make.
  3. Blame stops improvements and fixes nothing.
    Blame and punishment severely impact our learning ability. Worse, it can create negative side-effects that lead to reduced trust and less understanding of what might have influenced the decision or mistake. People achieve higher levels of performance following encouragement and positive reinforcement.
  4. Learning and improving is vital and deliberate.
    Safety is about learning. We need to not only to learn from our failures but also to learn from normal work. We have tools (Learning Teams, Walk Through Talk Through and Finding the Next Incident) today that can proactively support learning about our teams challenges, constraints and error traps.
  5. How leaders respond matters.
    More than a principle, this is what links all the principles together. How the organization sees error, context, blame and learning depends on how leaders respond to human performance. We need to create a psychologically safe environment for our teams to ensure we can understand what, how and why things go differently from the Work-As-Imagined.
“Leadership and learning are indispensable to each other”

HOP is a journey though, and adopting a set of principles doesn’t do any good to your organization if they do not become part of they way you run the business. If we really need to select key aspects that are fundamental to this journey, they definitely go around leadership and learning.

  1. Leadership
    The first step to integrating HOP into an organization is by introducing it to the leadership team and getting their buy-in. Senior leaders’ understanding and investment is crucial for the elements of HOP to be fully integrated and implemented across various levels of the organization. Leveraging leadership is at the start of every HOP journey.
  2. HOP in Learning from Failure (Events)
    HOP looks at learning from incidents in a different way. A second and important step into a HOP journey is to ensure it is part of the investigation process and any learning and improving effort. HOP aims to distinguish between “a person” problem and “a system” problem. All those affecting the “learning” process must be trained for it.
  3. HOP in Learning from Normal Work
    A third step is to begin Learning From Normal Work (LFNW). Learning From Normal Work aims at understanding how work is being done and learning from it even if accidents do not happen (or better: before they do). The following are three examples of LFNW tools that help the organization learning:
    • Walk-Through Talk-Through (WTTT):
      A Walk-Through Talk-Through session is a simple conversation with a team member demonstrating step-by-step how to carry out a task and understanding how things can go wrong and how badly things can go wrong. Conducting a WTTT is not about checking procedural discipline, but rather understanding constraints that need to be addressed to improve.
      • A lot has been written and published around Walk-Through Talk-Through and Learning Teams. A comprehensive guide can be found in the “IOGP Report 642: Learning From Normal Work” and in the books authored by Todd Conklin.
    • Learning Teams:
      A Learning Team is a facilitated session where we engage with team members to learn from everyday successful work. This includes understanding what, how and why people do things differently from the Work-As-Imagined in order to get the job done. The intent is to determine how work is conducted and its constraints, trade-offs, non-conformances and dilemmas and what the organization can learn and where defenses can be built to strengthen the system.
    • Finding the Next Incident:
      While with similar intents of Learning Teams, Finding the next incident (FTNI) is a method that doesn’t focus on a specific task or job, but leverages team members’ insights to develop scenarios for likely incidents that could lead to serious injuries or fatalities.
      • More information about Finding the Next Incident can be found in papers published on the tool, or in this video.

Walk-Through Talk-Through and Finding the Next Incident can be conducted at anytime by anyone (preferably by leaders who can sponsor the changes/ improvements) and only require simple briefings to explain the process. Learning Teams require facilitator training and cannot be conducted by a leader of the organization.

A Journey in HOP

Embracing Human and Organizational Performance requires a change in how the organization views team members and their actions: it’s not a tool that can be rolled out at a certain date, it calls for a fundamental mindset shift across the organization, at all levels.

However, at Baker Hughes we know that it works. We are continually learning from it and, of course, from ourselves. Ultimately, it is a journey, not a destination.

Lamberto Nonno, Global Regions and North America HSE Director, Baker Hughes

Lamberto Nonno, Global Regions and North America HSE Director at Baker Hughes, is a member of the IOGP Human Performance Committee and currently chairs the “Learning From Normal Work” group for the Center of Offshore Safety of the American Petroleum Institute. Lamberto supports the Energy Workforce & Technology Council efforts in Health, Safety and Environment via the EWTC HSE Committee.



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