When an incident occurs, the focus is often on finding fault. At Fisher Improvement Technologies, we champion a different approach rooted in Human and Organizational Performance (HOP), which shifts the goal from blame to genuine learning. Explore how you can conduct a more effective and insightful cause analysis.
A Practical Guide to HOP-Based Cause Analysis
Embrace That Error is Normal
A foundational principle of HOP is that people make mistakes, and complex systems make errors predictable. A HOP-based analysis doesn't seek a single "root cause" tied to a person's failure. Instead, it accepts human fallibility and examines the workplace conditions and systems that contributed to the decision-making process at the time.
Understand the Context of Events
To truly learn from an incident, we must investigate the context surrounding the actions taken. This involves speaking with those involved to understand what made their decisions seem reasonable at the moment. Look at factors like production pressures, available resources, conflicting procedures, and the overall work environment to build a complete picture.
Identify System Vulnerabilities
Rather than focusing on individual behaviors, a HOP approach identifies deeper vulnerabilities within your organizational systems. Are your defenses robust? Are there hidden weaknesses in training, communication, or procedures that create error-likely situations? Analyzing these systemic issues helps you move beyond fixing the person and toward improving the entire operational framework.
Prioritize Learning and Improvement
The primary goal of this type of cause analysis is organizational learning. The insights gained should lead to meaningful improvements that increase system resilience. This creates a culture where employees feel safe to report issues without fear of retribution, fostering collaboration between leadership and frontline teams to build more robust and reliable processes.
Our approach to cause analysis helps organizations stop chasing blame and start building stronger, more resilient systems. To learn more about implementing these principles, explore the solutions offered by Fisher Improvement Technologies.