Human and Organizational Performance.  HOP.

The 5 Pillars of HOP (HOP|Lab – The five principles of HOP)

    1. People make mistakes.
    2. Blame fixes nothing.
    3. Context drives behavior.
    4. Learning is vital.
    5. Response matters.

When that next bad thing does happen, it is easy for seafarers and shipping companies to fall back to the “way it has always been done.”  Namely, a retributive safety culture.

    1. Determine who is to blame.
    2. Determine how egregious was the violation of procedure.
    3. Retrain if relatively minor.
    4. Strict warning (verbal or written) if moderate.
    5. Replace if egregious.

As humans, we want to blame someone.  We want to hold them accountable.  And, if the situation warrants, we want to hold their (metaphorical) head up on a pike and demonstrate to all that the procedures are important and not to be trifled with.

But does that help keep the same incident from happening again?

An example we frequently use at the Maritime Safety Innovation Lab (MSIL) of the drawbacks to a retributive safety culture is the collision of USS Porter with a tanker in the Straits of Hormuz in 2012.  In this incident, USS Porter crossed the traffic separation scheme (TSS) and, as the give-way vessel in a crossing situation, collided with the tanker.  the impact was in the vicinity of the bridgewing and on the starboard side.  The audio recording from the bridge USS Porter is chilling and enlightening at the same time :

The captain of USS Porter was relieved of duty and received a punitive letter of reprimand.  It is said that the lessons learned from that collision are incorporated into the training of other naval officers.  Unfortunately, the collision of USS John S. McCain with a merchant vessel in 2017 was eerily reminiscent of USS Porter’s damage.

Did the retributive safety culture of the U.S. Navy prevent the lessons learned from being disseminated?  Did ridding the U.S. Navy of the institutional knowledge of those involved in such collisions prevent organizational learning?

Which brings us back to HOP.  HOP concepts were developed within the past quarter century through work in the nuclear power industry and Los Alamos National Laboratory in New Mexico.   They are based, at least in part, on the ideas of W. Andrew Deming, a mid-20th century industrial thinker.  As Deming noted, “A bad system will beat a good person every time.”

Statistically, 80% of all incidents on merchant vessels are due to human error.  The varying types of human error are a topic for another time, but we have to consider whether we are preserving and heeding the lessons learned from these incidents, both large and small.

So, when the next bad thing happens, will we address the outcome through the principles of HOP or through a retributive safety culture?  Changing both the individual mindsets of investigators and vessel crew and the collective mindset of shipping companies might be a heavy lift, but the long-term benefits could be lucrative.

Additional Reading and Links

UK MCA – Improving Safety and Organisational Performance Through A Just Culture

Britannia Club – Just Culture

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