What Is Human and Organizational Performance (HOP)?

Human and Organizational Performance—usually shortened to HOP—starts with a different question about workplace safety.

When something goes wrong, instead of beginning with:

“Who made the mistake?”

HOP encourages us to ask:

“How did the conditions surrounding the work influence what happened?”

That does not mean individual choices no longer matter. It means human behavior does not occur in isolation.

People perform work inside systems containing:

• equipment,
• procedures,
• training,
• supervision,
• schedules,
• production demands,
• staffing,
• information,
• workplace conditions,
• organizational expectations, and
• controls.

Those conditions influence what people see, understand, decide and do. HOP helps organizations examine those interactions.

What Does HOP Mean?

It draws heavily from:

• human factors,
• systems thinking,
• organizational learning,
• resilience,
• human performance improvement, and
• safety science.

One important predecessor is the U.S. Department of Energy's Human Performance Improvement framework. DOE's Human Performance Improvement Handbook describes human performance as a system involving organizational factors, job-site conditions, individual behavior and results. That systems perspective is central to modern HOP thinking.

The basic idea is straightforward:

If you want to understand performance, you need to understand the system in which performance occurs.

HOP Is Not Simply Another Safety Program

Organizations sometimes hear about HOP and immediately ask:

“How do we implement the HOP program?”

That question can create problems.

HOP is better understood as a way of thinking that can influence:

• investigations,
• pre-job planning,
• leadership,
• operational learning,
• procedure design,
• control management,
• Learning Teams,
• safety conversations, and
• everyday decision-making.

It does not have to replace your existing safety management system. In fact, many HOP concepts can strengthen systems that already exist. DOE makes a similar distinction in its Human Performance Improvement Handbook, describing HPI as concepts and principles associated with a performance model rather than a stand-alone program.

The goal is not to create another binder. The goal is to improve how the organization understands work.

The Five Principles Commonly Associated With HOP

Many modern HOP practitioners use five principles popularized by Dr. Todd Conklin:

1. Error is normal.
2. Blame fixes nothing.
3. Context drives behavior.
4. Learning is vital.
5. How leaders respond matters.

The wording can vary slightly among practitioners and organizations. These should not be mistaken for a regulatory standard or universal certification requirement. They are a practical framework for thinking about human and organizational performance. Let's look at each one.

Principle 1: Error Is Normal

People make mistakes. Experienced people make mistakes. Well-trained people make mistakes. Supervisors make mistakes. Managers make mistakes. Engineers make mistakes. Safety professionals make mistakes. DOE's human-performance principles begin from the same basic recognition: people are fallible.

That does not mean:

“Mistakes don't matter.”

It means an organization should not build critical systems on the assumption that people will perform perfectly every time. If one ordinary human error can produce a catastrophic outcome, that should raise questions about the design of the system and its controls.

Ask:

• Can the error be prevented?
• Can it be detected?
• Can it be corrected?
• Can the consequences be reduced?
• Are there independent controls?
• Does the system provide opportunities for recovery?

The objective is not to accept poor performance. It is to design work with human fallibility in mind.

Error Is Normal Does Not Mean Error Is Random

This distinction matters. Errors often occur under identifiable conditions.

For example:

• confusing interfaces,
• poor visibility,
• interruptions,
• fatigue,
• time pressure,
• similar controls,
• unclear procedures,
• conflicting priorities,
• excessive workload, or
• missing information.

DOE's human-performance framework describes error-likely situations as conditions that can often be predicted and managed.

So HOP does not say:

“People make mistakes, so there is nothing we can do.”

It says:

“People make mistakes, so let's understand where error is likely and build better capacity around the work.”

Principle 2: Blame Fixes Nothing

This principle is frequently misunderstood.

It does not mean:

Nobody is ever accountable.

Accountability still exists. Intentional misconduct, reckless behavior and deliberate violations may require an appropriate organizational response.

The HOP question is different:

Does blaming the person explain the event?

Suppose an investigation concludes:

“The employee failed to follow the procedure.”

That may describe something that happened.

But it leaves important questions unanswered:

• Was the procedure usable?
• Did it match the actual task?
• Was the employee trained?
• Was the necessary equipment available?
• Was the procedure routinely followed?
• Did supervisors know how the work was actually being performed?
• Were there conflicting expectations?
• Had the deviation happened successfully before?
• What controls should have prevented serious consequences?

Labeling the worker may end the investigation before the organization understands the system. Blame identifies a target. Learning requires explanation.

Accountability and Learning Can Coexist

A learning-oriented organization does not have to ignore accountability.

Instead, it distinguishes among things such as:

• human error,
• system-induced behavior,
• routine adaptation,
• misunderstanding,
• at-risk choices,
• intentional violations, and
• deliberate harmful acts.

Context matters. Intent matters. History matters. Organizational contribution matters. The purpose is not to eliminate accountability. It is to make accountability more informed.

Principle 3: Context Drives Behavior

People make decisions based on the situation they experience. Imagine an employee bypasses a step in a procedure.

From an office several days later, the explanation may seem obvious:

“They should have followed the procedure.”

But now examine the context.

Perhaps:

• the procedure did not match the equipment,
• the required tool was unavailable,
• the normal process took substantially longer,
• experienced employees routinely used the alternate method,
• supervisors had observed it before,
• production depended on the adaptation,
• the employee had used the method successfully dozens of times, or
• another hazard made the written method difficult.

None of those facts automatically makes the employee's decision correct. But they help explain it. And explanation creates better opportunities for improvement than simply labeling the behavior.

Behavior Makes Sense in Context

One of the most useful HOP habits is attempting to understand why an action made sense to the person at the time. The worker did not know the outcome. You do. That difference creates hindsight bias. After an incident, warning signs can appear obvious because we already know which details mattered.

Before the incident, the worker was surrounded by many signals, demands and uncertainties.

Ask:

• What did the person know?
• What could they see?
• What did they expect?
• What were they trying to accomplish?
• What competing demands existed?
• What had happened successfully before?
• What options appeared available?

Understanding the answer does not require agreeing with the decision. It requires reconstructing the situation fairly.

Principle 4: Learning Is Vital

Organizations cannot improve what they refuse to understand. Traditional safety systems sometimes concentrate heavily on adverse events. Someone gets hurt. Equipment is damaged. A near miss occurs. Then the organization investigates. HOP broadens the opportunity for learning. Ask about normal work too.

How does the task actually get completed every day?

Where is it difficult?

Where do employees have to adapt?

Which controls work well?

Which controls create problems?

What makes a successful day successful?

That information may reveal risk before an incident occurs.

Learn From Success, Not Only Failure

Most work succeeds. That is easy to overlook. Suppose a difficult task is performed 500 times and one event occurs. The event deserves investigation. But the other 499 performances contain information too.

Ask:

What normally keeps this task from going wrong?

Perhaps employees:

• communicate informally,
• reposition equipment,
• double-check one another,
• slow down at a particular point,
• wait for a better condition,
• use experience to detect weak signals, or
• compensate for a poorly designed process.

Those adaptations may represent useful capacity. They may also reveal vulnerabilities. You cannot understand either without learning from the people performing the work.

Principle 5: How Leaders Respond Matters

An employee makes a mistake.

What happens next?

Does the supervisor:

• immediately blame the employee,
• threaten discipline,
• demand retraining, or
• tell everyone to be more careful?

Or does the supervisor first ask:

“Help me understand what happened.”

The response matters because workers observe it.

If reporting a mistake reliably leads to humiliation or punishment, people learn something:

Do not bring management bad news.

If raising a concern leads to curiosity and appropriate action, they learn something different:

Speaking up can improve the work.

Leader response influences what information travels through the organization. And an organization cannot learn from information it never receives.

HOP Does Not Mean “No Rules”

Another misconception is that HOP means procedures no longer matter. They do. Standards matter. Critical controls matter. Training matters. Accountability matters. HOP simply asks whether those things actually support the work as intended. A procedure sitting in a binder is not automatically an effective control.

Ask:

• Can employees use it?
• Does it match the task?
• Is it available where needed?
• Is it understandable?
• Does it conflict with other expectations?
• Does following it produce workable results?
• What happens when conditions change?

The goal is not less rigor. The goal is more effective rigor.

Work-as-Imagined and Work-as-Done

A useful concept in HOP is the difference between work-as-imagined and work-as-done.

Work-as-imagined is how the organization expects the task to happen.

It appears in:

• procedures,
• training materials,
• policies,
• job plans,
• risk assessments, and
• management expectations.

Work-as-done is how the task actually happens in the field. The two may differ. That difference does not automatically mean workers are doing something wrong.

The written process may not account for:

• changing conditions,
• equipment differences,
• customer demands,
• physical limitations,
• interruptions,
• staffing,
• weather,
• simultaneous work, or
• practical constraints.

Understanding that gap can reveal improvement opportunities.

Go See the Work

One of the simplest applications of HOP is also one of the most powerful:

Go where the work happens.

Talk with the people doing it.

Ask:

• What is difficult about this job?
• What surprises you?
• Where do you have to improvise?
• What makes the work go well?
• Which controls help?
• Which controls get in the way?
• What worries you?
• What would you change?

Then listen. Do not turn every conversation into an inspection. If workers believe every answer will become a violation, they will quickly learn to stop showing you how work really happens.

People Are a Source of Capacity

Traditional safety thinking can sometimes treat people primarily as a source of error. HOP recognizes something else. People also make systems work.

They:

• notice changing conditions,
• detect weak signals,
• solve unexpected problems,
• compensate for imperfect equipment,
• communicate,
• adapt,
• recover from mistakes, and
• prevent small problems from becoming serious events.

Human variability creates challenges. It also creates resilience. A strong system should account for both.

HOP and Incident Investigation

HOP can substantially change the questions asked during an investigation.

Instead of stopping at:

“The operator made an error.”

ask:

“What conditions made this error more likely?”

Instead of:

“The employee violated the procedure.”

ask:

“How was the work normally performed, and why?”

Instead of:

“Who failed?”

ask:

“Which controls were expected to prevent or mitigate this outcome, and how did they perform?”

This produces a more complete account of the event. Human error can be part of the story. It should not automatically be the end of the story.

HOP and Learning Teams

Learning Teams are one method organizations can use to apply HOP principles.

A Learning Team brings people together to understand:

• how work normally happens,
• what makes the work difficult,
• where variation exists,
• what adaptations people make,
• which controls are effective, and
• where improvement opportunities exist.

Learning Teams can follow an incident. They can also be proactive. You do not need to wait for someone to get hurt before learning about difficult work. Importantly, a Learning Team is not synonymous with HOP. HOP is the broader philosophy. A Learning Team is one practical learning method.

HOP Is Not the Same as an Investigation Method

HOP can inform an investigation without replacing disciplined investigation.

You still need to:

• preserve evidence,
• establish facts,
• develop timelines,
• interview people,
• evaluate controls,
• test competing explanations, and
• support conclusions with evidence.

HOP influences how you interpret human behavior and organizational context. It does not eliminate the need for evidence.

HOP Does Not Mean Every Event Is “The System's Fault”

That statement would be just as simplistic as blaming every event on a worker. People make choices. Sometimes those choices matter substantially.

But organizations also:

• design the work,
• select equipment,
• establish staffing,
• write procedures,
• set schedules,
• define priorities,
• create incentives,
• provide training, and
• establish controls.

A useful investigation examines the interaction. The objective is not to move blame from the worker to management. The objective is to understand how the outcome was produced.

What Does HOP Look Like in Practice?

Consider a delivery employee who fails to complete a required equipment inspection.

A traditional response might be:

Finding: Employee failed to complete inspection.

Corrective action: Retrain employee.

A HOP-informed response asks more.

• How is the inspection actually performed?
• How long does it take?
• When does it occur?
• Is the form easy to use?
• Is the equipment accessible?
• What happens when defects are found?
• Do employees receive conflicting expectations about departure time?
• How often are inspections missed?
• Do supervisors know?
• Is the inspection detecting meaningful problems?
• What makes completion easier or harder?

Perhaps retraining is necessary. Perhaps it is not. The organization should know before choosing the corrective action.

HOP Changes the Quality of Questions

Compare these questions.

Traditional question

Who caused the event?

HOP-informed question

What conditions contributed to the event?

Traditional question

Why didn't they follow the rule?

HOP-informed question

How is the work normally performed, and what influenced the difference?

Traditional question

Who needs retraining?

HOP-informed question

What needs to change so the work is more reliable?

The second set does not excuse people. It simply generates more information.

HOP and Safety Management Systems

HOP does not need to compete with a Safety Management System. It can improve how organizations perform activities already inside the system.

For example:

Risk assessment:
Include knowledge from the people performing the work.

Incident investigation:
Examine context, controls and organizational influences.

Corrective action:
Improve conditions rather than defaulting to reminders and retraining.

Management review:
Look for weak signals and operational learning.

Worker participation:
Learn how work is actually performed.

Continuous improvement:
Use field learning to improve systems and controls.

HOP can therefore operate inside existing management structures rather than beside them as another independent initiative.

HOP Is Not About Achieving Zero Human Error

Human perfection is not a realistic control strategy.

The more useful objective is to build systems that:

• prevent predictable errors where possible,
• make important errors easier to detect,
• allow recovery,
• provide effective controls, and
• limit consequences when errors occur.

That is a much stronger strategy than:

“Tell everyone not to make mistakes.”

How Can an Organization Start Using HOP?

You do not need a giant launch campaign. Start with the quality of your questions.

When something goes wrong, ask:

1. What happened?
2. What made sense to the people involved at the time?
3. What conditions influenced their actions?
4. How is this work normally performed?
5. What controls were supposed to prevent or reduce the consequence?
6. How did those controls perform?
7. What usually makes this work successful?
8. What can we change to make success more likely?
9. What can leaders learn from this?
10. How will we know the improvement worked?

Those questions begin shifting the organization from judgment toward learning.

HOP Is Ultimately About Better Understanding

HOP does not ask organizations to lower standards. It asks them to understand performance more realistically. People make mistakes. Systems influence behavior. Work varies. Employees adapt. Controls succeed and fail. Leaders influence what information reaches them. Organizations can learn from both failure and success. Once those ideas become part of how an organization thinks, safety conversations change.

Investigations change. Leadership conversations change.

And perhaps most importantly:

The organization becomes more interested in understanding why work makes sense to the people doing it before deciding how the work should change.

That is the foundation of Human and Organizational Performance.

Supporting resources

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