human and

organizational
performance
pocket guide

work systems culture

process equipment

improving systems
improving outcomes
1
 purpose

chevron human and

organizational
performance

Provides value to the organization by

capturing innovation and key learnings
from the field to accelerate continuous
improvement through increased safety,
reliability, productivity, and reduced
waste.

22
 contents
2 Role of HOP
4 HOP defined
6 HOP principles
8 HOP concepts
10 Error is normal
12 Error traps
14 Error traps examples
18 E-Colours personality tendencies
20 HOP in managing safe work
22 Systems influence behaviour
24 Resilient systems
26 Blame fixes nothing
27 Learning and improving is essential
28 How we learn and improve
29 Response matters
30 HOP in managing work
31 A day in the life
32 Three way communication
33 Speak, Point & Check
35 Pre-task brief
36 Post-job review
38 Normal variability of work
40 Save your life actions-start work
checks
42 HOP discussion questions
46 Resources
48 Notes
50 OE tenets

3
 human and
organizational
performance

What is Human and

Organizational Performance?
• is a philosophical shift in thinking
• is a journey that takes time
• redefines safety… not the absence
of incidents, but the presence of
safeguards
• expands our thinking from “why” to
include “how”
• builds error tolerant defenses and
systems
• builds on our OE success and
targets serious incident reduction
and fatality prevention

Human and Organizational

Performance is not:
• a program, single process or
standard
• the one and only solution

4
5
 human and
organizational
performance
principles

1 error is normal

systems influence
2 behavior

3 blame fixes nothing

learning and
4 improving is
essential

5 response matters

6
7
 the role of human
and organizational
performance
is the way work systems, culture,
processes and equipment
interact as a system.

work systems culture

process equipment

8
Focuses
Focuseson reducing the the
on reducing seriousness andand
seriousness
frequency of human failures and resulting
frequency of human failures and resulting
outcomes by:
outcomes by:
Improving the interaction between
Improving the interaction between
individuals and critical systems
individuals and critical systems
Recognizing error-likely
Recognizing error-likely
situations and applying tools to reduce the
situations and applying tools to reduce the
likelihood of error
likelihood of error

“HOP makes it easier

“HOP makes it easier
to get it right and harder
to get it right and harder
to get it wrong”
to get it wrong”
Other important definitions:
Other important definitions:
Safeguards: Safeguards are the
Safeguards:
hardware Safeguards
and human actionsare the
designed to directly
prevent or mitigate an incident ordesigned
hardware and human actions to directly
impact. There
prevent or mitigate an incident or impact.
are two critical aspects of safeguards: establishingThere
are two critical aspects of safeguards:
safeguards and sustaining and assuring establishing
safeguards and sustaining and assuring
safeguards.
safeguards.
Latent conditions: Undetected deficiencies in
Latent conditions:
organizational processes,Undetected
equipment deficiencies
or values in
that create job site conditions that either or
organizational processes, equipment values
provoke
thatorcreate
errors createjob siteinconditions
gaps that either provoke
the safeguards.
errors or create gaps in the safeguards.
For a complete glossary of terms, please visit
For a complete glossary of terms, please visit
hop.chevron.com
hop.chevron.com
99
9
 error is normal
• Error is an unintentional deviation
from an expected outcome​

• Error exists in success as well as

failure

• Errors are not choices. Error only

appears to be a choice in retrospect

• It is impossible to predict every

error, mistake or miscalculation,
so we need both preventative and
mitigative controls

• It is possible to predict error-likely

situations and we can design
preventative measures and built
error tolerant systems accordingly

• We can reduce the consequences

of errors by implementing recovery
controls

expecting humans to
be perfect is not a
reliable safeguard

10
11
 error traps

organizational
Changes
Time pressure
Inadequate training
Unclear roles and responsibilities
Organizational or peer pressure
Poor communication
Poor job planning

task demands
Vague or poorly written
guidance/procedures
High workload, multitasking
Simultaneous operations
Infrequent or first-time tasks
Inadequate job planning or design

12
additive and increase
the liklihood of errors

individual
Stress
Fatigue
Distraction
Fitness for duty
Risk tolerance
Complacency
Overconfidence

work environment
Operational upset
Inadequate labels, signs, dislays
Confusing system feedback
Poor equipment interface
Limited tool availabilty/accessibilty
Challenging peer interactions

13
 error trap
organizational factors organizational f
Pr
Change
ro

Time Pressure To

Inadequate training La

Unclear roles and responsibilities No

Bu
Organizational or peer pressure
un

Poor communication W

Poor job planning St

task demands task deman

Un
Vague or poorly written procedures
to
On
High workload, multitasking
m

Simultaneous operations Tu

Infrequent or first time task Ri

Inadequate job planning or design La

14
14
 examples
izational factors
Procedure change, departure from
routing, reorganization

Too much/not enough time, deadlines, goals

Lack or too much; poor quality, irrelevant

Not defined or overly ambitious expectations

Business objective conflicts, metrics and scorecards,

unintended consequences

Work instruction, language, timing, complexity

Staffing, shift changes, task timing, seasonality

sk demands
Unclear, complicated, inadequate, inaccessible,
too many procedures
On the phone and typing at the same time;
monitoring multiple gauges and switches

Turnaround, multiple work activities, tight layout

Risk assessments, inspections, tools, developing JSA

Late changes, missing or wrong information

15
15
 error trap
individual factors individual fac

Stress W

Distraction Co

Ph
Fitness for Duty
ph

Risk tolerance It

Complacency La

Overconfidence W

work environment work environm

Ch
Operational Upset
pr

Inadequate labels, signs, displays La

Confusing system feedback Inc

Poor equipment interface Co

Ac
Limited tool availability/accessibility
co

Challenging peer interactions Te

16
16
 examples
vidual factors

Work-life conflicts, family, financial, work stress

Competing priorities, working while sick, climate

Physical and cognitive ability, medication or drug use,

physical and mental health

It worked OK last time, seen others do it this way

Lack of interest/motivation, done it many times before

We always do it this way

k environment
Changes in operations; water, sand,
pressure, unplanned

Lack of or too many, complex

Incorrect, too many, alarms, broken gauges

Control panel design, equipment or task location

Access and availability of tools, unexpected

conditions, wrong tools for the job

Team dynamics/relations, diversity, hierarchy

17
17
 e-colours
personal tendencies
and error traps

• Since we are all different, how we

relate to one another is partially due
to our personal tendencies

• E-Colours help us understand

different thinking styles and
personal tendencies

• Having a particular E-Colour profile

(example: red-green) does not
mean you will display only that
profile’s traps

• We all have four E-Colours, can

display tendencies from all colours,
and one colour may be stronger in
certain circumstances

• Identifying and managing our

tendencies during work planning
helps us avoid error traps

18
doer socializer

thinker relater

Doer Socializer
The part of your The part of your
personality that helps personality that helps
you take action and you interact and
get things done. engage with others.

Thinker Relater
The part of your The part of your
personality that helps personality that helps
you plan and analyze you empathize with
information. and support others.

19
 manage your personal
tendency error traps

Traps for yourself: Tr

• Being a poor listener •
• Not needing details others want to provide •
• Thinking “I know best” •
• Doing tasks without asking for help •
Traps for others: Tr
• Not providing enough detail for others •
• Not tolerating others’ information requests •
• Taking on others’ tasks to get the job done •
• Driving others to finish the task •

Traps for yourself: Tr

• Thinking “I’m and expert” after completing •
a task once or something similar •
• Over-analyzing •
• Not involving others •
Traps for others: Tr
• Withdrawing if someone expresses confidence •
• Providing too much detail •
• Giving others overly complicated information •

Tables: Copyright © 2017 Equilibria Services, Ltd. and Fisher IT, Inc. All
rights reserved. Used with permission.

20
 by understanding
your e-colours

Traps for yourself:

• Being a selective listener, missing details
• Giving up too easily
• Choosing to overlook hazard or risk
• Skipping steps in a procedure
Traps for others:
• Delivering unstructured communication
• Not allowing time for clarification
• Providing incomplete instructions
• Not being clear and concise

Traps for yourself:

• Not questioning the unclear
• Unwilling to challenege people I respect
• Not validating details
• Focusing on understanding rather than executing
Traps for others:
• Trusting others too much
• Not speaking up about hazards and risks
• Shutting down when others seem uninterested

21
 systems influence
behavior
principle 2
• Workers do what they do for a
reason, and that reason makes
sense to them at the time

• We can manage the systems that

create known controls and barriers
designed to limit failure from an
unwanted outcome

• People adapt and make things

work, which is why we mostly
have success

• Decisions are not made without

significant system influence

• Design resilient systems to help

support better decisions

the work environment

influences workers’
behavior and actions

22
23
 resilient systems
potential and safeguards

We will never be fully

resilient because of the
normal variability of work,
but we can build resilient
potentials

resilient potentials
• Respond: When and how are we
responding?
• Monitor: What and why are we
monitoring?
• Learn: How and what are we
learning?
• Anticipate: What has not happened?
The strength of an organization’s
Resilient System is drawn from its
ability to plan and adapt continuously

24
 capacity of safeguards
in resilient systems

Integrate permanent barriers

intended to permanently
prevent error and/or the
consequences of error for a
specific critical step

Integrates temporary
barriers(s) intended to
prevent specific errors and/
or the consequence of error
for a specific step
increasing resiliency

Integrates safety tools that

cue individuals they are in a
hazardous area or zone

Job aids such as checklist(s),

labels, signs… that
communicate behavior
expectations at the critical step

Depends on people not

making errors regardless of
knowledge, skills and ability
Improved capacity to avoid
human error at critical steps

25
 blame fixes nothing
principle 3
• Blame makes error look like a
choice
• Workers are not the problem,
they are the problem solvers
• Blame is both emotional and
personal
• Blame misdirects resources
and strategies ​
• Blame gets in the way of learning
the “how”

If we talk about blame,

we must understand:
• Error – an action or inaction
that unintentionally results in an
undesirable outcome
• Violation - action or an inaction
that intentionally deviates from a
set of rules

with errors and violations

there is no intent to harm
blame prevents learning
about the conditions that
influenced the event
26
 learning and
improving is essential
principle 4
• Learning and improving is essential
for success
• It is how we grow, mature and build
capacity​
• When we ask better questions we
get better answers
• Learning is an investment in the
future, not a cost to the business
• Without learning we are limited to
past results and responses and are
unable to cope with the normal
variability of work

our ability to learn and

improve is dependent
on our capacity to
adapt, adjust and
develop resilient
systems

27
 how we learn and
improve

Start of
shift
Safeguard
Shift
learning
turnover
tool

Learning How do Pre-job /

team
you learn? JSA

Safeguar Pre-job
d V&V briefing

Post-job
review

• Identify learning and improvement

opportunities
• Define actions and implement
• Close actions
• Verification and validation

28
 response matters
principle 5

• If we react negatively when

mistakes happen, our workforce
will likely stop reporting them and
opportunities to learn will be lost
• Focus on the context, not the
outcome
• We shape how the organization
learns by our reaction to failure and
success
• How we respond to failure and
success will assist in restoring the
confidence and capacity of the
organization
• Talk less, listen more

we can either learn

and improve or blame
and punish, but we
cannot do both

29
 human and organizational
performance concepts

start-of-shift meeting
review:
Common understanding of plans, activities
and expectations
Critical tasks being performed today
The potential impact of simultaneous
operations

plan work

consider:
Procedure writing
Critical task analysis
Checklist development
Post-job analysis
Learning teams recommendations
Feedback from verification and
validation (V&V) coaches
Save-your-life actions
Task consequence checklist
Safety in Design

operational learning

apply:
Post-job debrief results
Learning teams recommendations
Feedback from V&V
HOP error reduction tools
30
 efficient, reliable and
safe operations

work execution

conduct:
Pre-task brief
apply:
Save-your-life actions
Start-work checks

consider:
Maintain vulnerability
Personal tendencies
Error traps

verify and validate:

Safeguards are in place
and functioning

execute:
Permitted work
Non-Permitted work

understand: leaders:
Normal variability Build trust and create
of work opportunities for
Learn from open dialogue
successful work
31
three-way communication

one person
delivers the
message

team member
repeats the
message back

first person
ensures their team
member correctly
hears the message

Reduce the likelihood and outcome of errors

Improve communication and understanding
Incorporate phonetics and hand signals
Agree upfront to use during high
consequence tasks

24
32
 speak, point and check
Stop and focus: Remove distractions
Understand the task
Speak the step and expected outcome
Point to the item/component/equipment
Check that you got the expected outcome

STOP and get help if you are concerned

33
25
 step-by-step
place-keeping
Use with procedures, SOP’s, JSA’s
Review the procedure
Follow as written
One step at a time in order
Without adding or eliminating steps
Physically mark steps in the procedure

STOP and get help if you are concerned

What tools will you use?

Three-way communication
Speak, point & check
Step-by-step place-keeping

34
26
 pre-task brief

Immediately before high-risk tasks

Always before a critical step
Always before a non-recoverable step

Commit to:
Review work instructions
Review JSA
Identify known hazards

and functioning
Review written procedure and standards
Assign roles and responsibilities
– Identify and discuss personal tendency
error traps
Discuss all four categories of error traps
Identify start/stop conditions

35
27
 post job review
Complete each job or day with a post-job
review/debrief.
Capture successes, normal variability and any
unexpected changes. Integrate learnings into
future work and planning.

Ask these questions:

What safeguards worked?
–
as expected?
Which human and organizational performance
tools did you use
What mistakes were made?
– What contributed to the mistakes
(error traps, etc.)?
–

36
28
 why a post-job review
is so important
Post-job reviews are learning opportunities
Identifies and reinforces safeguards that
successfully kept the team safe
Helps teams identify normal variability
– how the job occurred versus how it was
planned
Identifies improvements for
the next time the same job is performed
Helps to prepare you and the team for the
next job/shift

Post-job reviews do not have

to take a long time
Usually 5 minutes at the end
of each job/shift

2937
 Normal variability of work

L.O. Learning Opportunity (L.O.)

Learning

Successful
Plan outcome
Workers
manage
this gap L.O.

30
38
Margin
Incident

Start of the job

Hazard

Time
learning from the blue line
y Workers are constantly adjusting and adapting
to working conditions
y Variability isn’t always obvious; it can be small
changes over time that may become the
accepted practice
y When we understand how normal work gets
done we can incorporate learnings into future
work and strengthen safeguards
y What did we learn?
– How did we perform vs. how did we
expect to perform?
– What latent conditions were present?
– What surprised us?
– What do we want to do differently next time?

39
31
 save your life actions–
start work checks
A tool that incorporates two human and
organizational performance aspects
– checklists and a peer review/check
Used in our highest-consequence
permitted work
Final check immediately before work is executed
Focuses on the critical steps or hold points and
the essential safeguards (those that must
be in place to prevent serious injuries and
fatalities during critical / non-recoverable
steps in a process or task)

32
40
 why do we need the save
your life actions?
Essential safeguards are necessary to
prevent serious injuries and fatalities. While all
safeguards are important, the life-saving actions
must be in place every time; we cannot overlook
these critical few
The start work checks help teams ensure
life saving actions are in place every time.
Persons performing work are responsible to:
– Use the start work checks immediately
before starting the task
– Get the start work checks verified by
the start work verifier

33
41
 HOP discussion
questions
• How do you know work has been
completed successfully?

• Is work always completed according

to plan? Can some examples be
given?

• How are SSE’s exposed to variability

of work?

• How does the work team manage

variability of work? What is needed
to better manage it?

• Does error always result in failure?

Why or why not?

• How are latent conditions important

in understanding the causes of
failure or errors?

• What are some preventive measures

we use to reduce error-likely
situations?​

• What is a non-recoverable step and

how do you verify safeguards are in
place?

42
• What are some recovery controls
already in place for your BU/site?​

• What are some areas/tasks where

we need more recovery controls?​

• What are some designs we have

implemented that plan for human
error?​

• Can we install permanent barriers

in a work environment to prevent
EVERY error or consequence from
occurring? Why or why not?

• What is a critical step and why is it

important to align on this definition?

• Should we focus our resilience only

on critical steps? Why?

• How can identifying and managing

our personal tendencies help us in
becoming aware of error traps for
ourselves and others?

• Is it possible to over-rely on
safeguards? Why?

• What are some of the conditions

that could trigger the safeguards in
your work?

43
 HOP discussion
questions cont.
• “Multi-tasking” – Is there a difference
between doing different tasks at the
same time or is it “multi-switching”,
going from one task to the other? Is
this a consideration in HOP? Why?

• How do you respond to a co-worker

who is not themselves today?

• How important is it to elicit

feedback? What systems, processes
and tools do we have to openly elicit
feedback and gather information in
a safe, proactive manner?

• When variability happens from a

procedure, is it important to discuss
how it happens? Why?

• How can interactions between

people and/or processes cause a
sense of threat/stress? Can that lead
to an increase in errors? Why?

• The brain is wired for either threat

or reward. What can be done to shift
a person from a sense of threat to a
sense of reward?
44
• What are ways we can acknowledge
workers to create a sense of
accomplishment in our day-to-day
work?

• What are ways to include co-

workers in the learning process?

• Is it possible to have a specific

E-Colour profile and NOT display
all the tendencies and traps of that
profile? Is it possible to display the
tendencies of other E-Colours?
Why?

45
 resources
Links
http://hop.chevron.com

Additional Reading

Todd Conklin, Pre-Accident

Investigations: An Introduction
to Organizational Safety,
CRC Press, 2012

Sidney Dekker, The Field Guide

to Understanding Human Error,
CRC Press, 2014

James Reason, Managing the Risks

of Organizational Accidents,
Ashgate, 1997

4634
Disclaimer:
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35

47
notes

48
notes

49
 chevron
tenets of operation
our work is guided by
two key principles:
1. Do it safely or not at all.
2. There is always time to do it right.

we always:
1. Operate within design and environmental
limits.
2. Operate in a safe and controlled condition.
3. Ensure safety devices are in place and
functioning.
4. Follow safe work practices and
procedures.
5. Meet or exceed customer’s requirements.
6. Maintain integrity of dedicated systems.
7. Comply with all applicable rules and
regulations.
8. Address abnormal conditions.
9. Follow written procedures for high risk
or unusual situations.
10. Involve the right people in decisions that
affect procedures and equipment.
© 2022 Chevron Canada Resources
Health, Safety, Environment & Regulatory

50