2025 Community of Human and Organizational Learning 31st Annual Conference

This session proposes a new approach to strengthening mission success and preventing failures by addressing human error at a cultural level. Traditional efforts have been focused on optimizing either safety or production, often at the cost of the other. The Framework of Risk Awareness for Mission Excellence (FRAME): High Consequence Events Prevention (HCEP) utilizes a taxonomy of behaviors to establish a Risk Aware Culture and ultimately support the ideal balance of safety and production. This session will illuminate the benefits of defining and implementing a Risk Aware Culture and provide practical guidance on how to do so.
FRAME began with the comprehensive investigation of numerous high consequence events across recent decades, during which the meltdown of the Fukushima nuclear powerplant highlighted a key concept. Tokyo Electric Power Company was staffed with skilled, technically competent people, yet the company did not effectively exercise that competence in the years before the disaster, resulting in major environmental damage and distrust toward a key energy source for Japan. The Chairman of the investigation identified “ingrained conventions of Japanese culture” to be the fundamental cause of the incident, specifically calling out several human element weaknesses central to their cultural failings. Similar manifestations of organizational cultures lacking risk awareness can be found repeatedly across scores of accidents analyzed from many domains (public and private).
Today, most analyses of accidents focus on learning from technical failures but fail to consider the role of the human element in the decision-making process. There are many examples illustrating the pitfalls of ignoring the human element, including the loss of the Space Shuttles Challenger and Columbia. A surface level understanding of these incidents would call out an O-ring failure and a foam strike on lift off, respectively. However, to really understand the root of these failures we need to understand why decisions were made. Why did Challenger launch after engineers warned of the O-ring risk in cold weather? Why were the foam strikes seen on every prior shuttle Columbia launch not fully investigated? FRAME focuses on getting to the final “why,” to the underlying Human Element Weaknesses that influence decision making. Once identified, Risk Aware Behaviors can assist with corrective actions that address the human root causes.
Developing the deliberate design for an organizational cultural can be daunting. FRAME provides both the structure to understand why decisions that led to failures were made and the tools to promote a Risk Aware Culture. Throughout the session, we plan to discuss key lessons learned during the design, development, implementation, and measurement of FRAME in a real-world setting. Furthermore, this session will arm attendees with a deeper understanding of the role of human error in decision making, citing real-world examples. Finally, attendees can expect to get exposure the specific behaviors that, if consistently and correctly demonstrated across an organization, can act to mitigate risk.

A recent paper by David Woods claims to resolve the command-adapt paradox by using “guided adaptability” to cope with complexity.  Many safety practitioners learned that safety was accomplished through a “telling” style: telling workers the rules, telling workers to comply, and instructing workers what to do.  David Woods notes “increasing pressure for compliance with plans, standards, and procedures inevitably increases brittleness and degrades the ability of the system and organization to adapt to challenges ahead.”  So, what is a safety professional to do?
New View Safety and Resilience Engineering philosophies believe that learning is the key to keeping people safe…and learning is best accomplished with Safety Teams who coach, support, and serve. Teams aligned with New View Safety believe that workers are experts in how to do the work and understand that work is always variable (Work As Imagined seldom equals Work As Done). Resilience Engineers expand from a STATIC view of risk: identify all hazards and risks PRIOR to starting work –and you’ll be ok - to acknowledging that work is variable, and risk is DYNAMIC thus people need to adapt to get work done successfully.
In this workshop, we will explore developing Safety Teams who can work successfully with New View Safety and Resilience Engineering philosophies. We will explore how Safety Teams can enable guided adaptability when people and systems are challenged within the dynamic environments that ALWAYS exist.

Has your company’s cause analysis program been ineffective when it comes to reducing the frequency and severity of incidents?  If so, your program may be missing its single most important ingredient, which is integration with Human & Organizational Performance (HOP) principles.  In the absence of a thorough understanding of HOP principles and solid cause analysis processes that prompt their consideration, analysts and leaders will often lock on to human acts and equipment issues that triggered an incident rather than identifying the fundamental reasons why they occurred.  The resulting shallow analysis typically spawns weak corrective actions that leave the door open for incident recurrence.

Join Rick Foote, co-author of IEEE Standard 1707-2015 (IEEE Recommended Practice for the Investigation of Events at Nuclear Facilities), as he discusses proven approaches for integrating HOP principles with cause analysis protocols, thereby improving overall program efficiency and effectiveness.

Have you attended training only to have the content slip away after completing the program?  The combination of spaced repetition with existing human performance solutions can significantly contribute to optimized performance by fostering retention of new skills and knowledge.  Spaced repetition increases the impact of your organization’s traditional, just-in-time (JIT), on-the-job training (OJT), and performance support solutions.  The presenter will describe a methodology and approach that increases memory recall while simultaneously supporting a more effective transfer of new knowledge and skills from the training program to the job site.  It is based on proven research about memory: Knowledge and skills that are not quickly applied after training erode.  Spaced repetition of previously learned info/skills in small chunks (approximately 5 minutes) repeated over time greatly improves retention while simultaneously significantly reducing the knowledge and skill erosion associated with learning new information without immediate reinforcement.  The presenter will describe a proven process that combines technology-based spaced repetition with modern adult learning and human performance to provide timely and relevant training based on key job-task performance needs, experience, and other factors.  It enhances, not replaces, extant training and performance solutions to help individuals retain what they learn from their formal, informal, JIT, and OJT programs more effectively, with greater efficiency, and at minimal cost.  This approach is particularly useful to support high performance for job-tasks that are infrequently performed yet critically important, including those best practices associated with high reliability.  Spaced repetition is delivered directly to the performer as part of their normal daily routine.  Spaced repetition is not a refresher course or a short form of an existing course. Instead, key performances and their associated knowledge and skills are reinforced via a simple direct targeted multi-week campaign.  The result: Improved long-term knowledge and skill retention with a subsequent boost to performance, especially for challenging tasks (i.e., infrequent yet complex systems repair, language training to reduce erosion/provide easy practice, safety and security tasks that are a function of a non-primary duty, new system training, and competency development).  An added benefit of this approach is to reinforce critical behaviors required to establish and maintain a high reliability organization, reinforce organizational culture, and other associated behaviors.  The presenter will cite and leverage the science behind memory and training retention and the core best practices and technology associated with this approach.

“No one ever rises to the occasion, but rather, they sink to their highest level of preparation”.
Significant increases in losses attributed to the lack of operator response, as well as an influx of inexperienced operators at the control boards of industrial manufacturing complexes, is the driving the need for improvements in operator training procedures. Scenario-based training should be implemented as a reoccurring part of the ongoing training of all operators within industrial operations. Scenario-based training includes a detailed analysis and assessment of an operator’s response to specific abnormal situations, and what corrective actions need to be made under these adverse conditions. The goal being to minimize the response time for operators to assess a specific situation and utilize conditioned responses to limit and prevent catastrophic loss from occurring; thus, protecting the safety of plant personnel and the integrity of processed machinery.
Industrial complexes across the planet are faced with a consistent problem of experienced operators retiring and taking decades of real-world experience with them. Many of these retirees have had long careers and witnessed the modernization of automatic control systems dedicated to the safety of the equipment and plant personnel. They began their careers operating the plants with analog components, manual valves, visual gauges, and radios. Furthermore, less experienced operators coming into the workforce have never witnessed a large-scale, low probability, high severity event such as explosions caused by leaking fuel systems, or a fire involving pressurized hydraulic fluids or lubrication oil cascading down multiple tiers and pooling under critical equipment. Modern automatic control systems have made routine operations easier for the operator, although the infrequent and difficult scenarios of abnormal conditions are still required to be controlled by their swift actions.
Operator error is an ever-increasing loss driver in industrial facilities. Statistics from a large property insurer reported over 1000 documented incidents in the last 10 years that were caused or worsened by an operator error. Effective operators are responsible for the identification of opportunities to improve process flow, the detection of concerns to normal operations, the knowledge and capability to correct any abnormal situation, and the ability and authority to shut down operations and or bring the process to a safe state under emergency response conditions. However, statistics show that operators in modern industrial facilities are not being effectively trained to minimize damages during an abnormal situation, prolonging corrective actions, and sometimes exacerbating the size and scope of the loss. The only solution is a Scenario Based Training Program, customized to the specific equipment of the plant, and tailored to the operators and plant personnel.

Because there are no perfect systems, learning is as essential to mission success as production and delivery activities. A systems approach to learning recognizes the complexity of systems and considers them together with their interfaces and interactions as a whole. The performance of the system is more than the performance of the individual components—none of the individual parts can do what the whole can do. How do you know what to change when the whole is not working?

Most successes and events occur because many managers do not truly understand their organization. Frontline workers create value, often in spite of clunky organizations and subsystems. With that in mind, this poster session will illustrate a “collective mental model” of H&OP that is useful in both 1) building and aligning a system structure for success at the sharp end, and 2) refining that system’s reliability, safety, and resilience in response to opportunities and failures. This means that monitoring and analyses of human performance, especially in the workplace, must adopt a holistic perspective, looking for context and leverage—understanding interactions with other parts of the system and other goal-oriented systems before realigning the system.

This poster session will attempt to educate the learner by introducing the fundamental principles of the following aspects of SYSTEMS LEARNING:

•    Systems, Complex Systems, Systems Learning, Systems Thinking, Mental Models, and Leverage
•    The concept of emergence in human performance systems
•    How systems thinking explains the difference between work-as-done and work-as-planned
•    Why understanding success and failure in complex systems requires more than linear cause-and-effect thinking
•    How mental models influence the management of successful human performance in the workplace, and the analysis of and response to events and adverse trends
•    The three phases of SYSTEMS LEARNING

This presentation is to share the journey of a Transmission & Distribution business unit in implementing the Five  HOP Principles as defined by Todd Conklin.  The purpose is to share information on mistakes made, to challenge learning from those mistakes, and to evaluate what was successful. This starts with Edgar Schein’s definition of culture and walks through strategy, communications, and measurement tools used to demonstrate how the organization is applying HOP as a business philosophy through the safety department. The presentation ends with some lessons learned for practitioners to consider in their journey of applying these principles within their organization.  
Under strategy, the discussion will cover the four things needed for a turnaround based on Edgar Schein’s work. These are a turnaround manager or team, clear direction, change model, and power to implement the model. This section will describe how this business unit applied these concepts.
Under communications, the presenter will discuss the six methods used to share the safety message to influence the leadership and the various levels within the organization on using the HOP Principles and using the New View of Safety.
Under Tools to measure, the discussion will show the changes in how the organization finds solutions to problems and the “Safety II” way to perceive, think about, and respond to those problems. Included in this section are lessons learned by the presenter to help others avoid similar mistakes and evaluate what would be successful in their organizations.

The learning team approach considers both the human and technical aspects of work.  By including the frontline workers it creates a sense of ownership and collaboration.  This approach empowers employees to share their knowledge, insights and experiences.  The frontline encounters problems everyday that go unnoticed by management and other departments.  By bring them together we learn their perspective and experiences to identify issues, risks, bottlenecks and inefficiencies that are in their work everyday.  We will explore insights gained from doing thousands of learning teams over the past 8 years from all aspects of work.

In this session, we’ll explore what created the capacity for the system to respond the way it did during the Las Vegas Shooting. 

• How did the plans for the unexpected change in real-time? 
• How did “native resilience” emerge? 
• After the event, what was different? 
• How might we translate this learning into our organizations?

Operational excellence is commonly defined as continuous improvement in all aspects of the business and business processes. Safety performance is one of those aspects of business performance that can lead to operational excellence. It is well documented that organizations that have and continuously improve safety performance also perform well in quality, cost and customer satisfaction. In all cases, we must see the opportunities for improvement if we are going to address them.

This presentation will focus on how managing and reducing risk is critical to continuously improving safety performance and operational excellence. In order to manage and reduce risk, we must see the hazards and other precursors that can result in injuries, quality issues, equipment failures, and other losses to the business. We will also illustrate how increasing the “inputs” to our business processes such as risk assessment results in a more complete understanding of our current reality and frames meaningful action planning to improve safety and business performance.

Participants will:
- Learn how the quality and quantity of inputs to safety and other business processes impacts the quality of our risk analysis and action planning.
- Learn how a simple Five Step process for Hazard Identification and Mitigation can improve safety performance.
- Learn how some simple tools can improve what we actually see in the workplace and how that translates to more meaningful actions.

Participants will leave with tools that can be implemented immediately to improve safety and other business processes that will contribute to achieving operational excellence.

Rick Foote, co-author of IEEE Standard 1707-2015 (IEEE Recommended Practice for the Investigation of Events at Nuclear Facilities), will lead a session intended to help attendees identify stronger, leaner, and more cost-effective corrective action plans in response to significant incidents.  

While many investigation approaches include detailed processes and structured tools for identifying the causes of incidents, few provide more than minimal guidance when it comes to developing the associated corrective action plan. As a result, organizations often struggle when it comes to implementing sustainable corrective actions that reduce the risk of incident recurrence to acceptable levels.

Attendees will learn a structured approach for resolving incidents with ‘surgical strikes’, thereby avoiding costly ‘shotgun’ corrective action plans that seek to address everything (while often resolving nothing). Attendees will also learn how to distinguish between corrective actions that are truly capable of long-term risk reduction and those that provide no lasting benefit.

We have used the Hybrid Learning Teams method on several occasions, and it is quite effective. How does the Hybrid Learning Teams Method (format) work? The Hybrid Learning Teams format is how the group session is actually facilitated.
This format establishes what I creatively call a TRICKY "Tree Risks That Can Kill You" Conversation. An adaptation of the existing "STKY" model made famous by Quanta Services, among others.
This TRICKY conversation (and format) is flexible so that a facilitator can begin the conversation anywhere along this list - with the exception of the solution.
The topics below help identify the following:
•    Hazards. Not all climbers identify all hazards on the job site.
•    Risks associated with each hazard.
•    Control measures in general. Climbers must select a proper tie-in or securement point using a non-rated anchor point.
•    Serious Incident and Fatality (SIF) level energies.
•    Critical controls needed to mitigate the SIF level energies.
•    Laws, regulations, rules, standards, and policies used for that activity.
•    Myths surrounding that activity.
•    Bad habits surrounding that activity and what would constitute a good habit.
•    Unintended consequences involved such as those encountered when applying the hierarchy of controls or when latent errors are predicted when finding a gap.
•    Note: The solution, or realization of the lack of a solution is the ultimate goal and is efficiently and effectively reached when using the format above.
Please consider that running through this format (and especially when intertwined into the solution) that I believe that there are five (5) key elements of Safety Management as it relates to developing a procedure for a certain activity. They are:
•    People issues. Knowledge, education, experience, skill, ability, training, understanding, and retention. And, self-discipline, professionalism, and attitude.
•    Equipment and Gear Issues. Remember that not everyone has the latest and greatest gear. The guiding principle here is compliance. If the gear meets the standard, that would technically be sufficient. Inspecting and maintaining equipment and gear are assumed to take place at this point in the discussion, but certainly are required.
•    Procedures: Should be clear, concise, free of conflicts, and free of error traps.
•    Surroundings: Consider the variability, uncertainty, complexity, and ambiguity that exists while climbing and working in the tree care industry in general.
•    Infrastructure: Ensuring that engineering controls are in place, effective, and never bypassed.
Who should be in the Learning Team?
•    Safety, Education and Training (SET) Team members.
•    Top Climbers.
•    Apprentice climbers - for gauging their understanding.
•    Facilitators who are subject matter experts but who also have TRICKY facilitation skills.
•    Legal teams / Risk teams.
•    Climbers are needed from different geographical regions with different species of trees and climbing scenarios.
When is the Learning Team Assembled?
•    After identification of exposure to fall hazards and risks.
•    For general prevention purposes and on a regular, ongoing basis. Controls degrade over time.
• When events / incidents increase (post incident).

Serious Injuries and Fatalities (SIF’s) predominantly occur in routine work activities that employees and management have become accustomed to. Work performed at height, around mobile/heavy equipment, or with hazardous energies are examples of SIF-Risk Activities commonly faced in construction.
Precursors are factors that contribute to a higher probability for SIF exposures/events. Precursors are often identifiable before a SIF occurs, however many of those contributors are underlying conditions that are “below the water” that must be uncovered.
In this session we will discuss the dangerous interaction of SIF-Risk Activities combining with an unmanageable number of precursors such as: fatigue, lack of oversight, inadequate training, and schedule pressure – leading to a breakdown of controls, and employees inevitably making costly errors that likely could have been prevented or planned for.
ACIG's SIF Precursors model and event/exposure analysis worksheet will be shared with all attendees. These tools will help provide a practical path forward for organizations ready to improve the language they use surrounding risk, error, and failure.

Many individuals attempt to overcome and perform yet they do not readily recognize that the internal state of their mind keeps them from optimal performance. Often we attempt to lead teams, and communities or be leaders in our industry yet we have difficulty understanding how to lead ourselves. This presentation focuses on the formation of the human identity and how this identity creates a framework for our thinking and the narrative that we as human beings learn to tell ourselves. When we understand, recognize, and comprehend the stories that we tell ourselves as leaders, we also can identify the emotions that are destructive to our performance. Identification of destructive emotions as it allows us to understand the thoughts that keep us from performing at an optimal level.
This presentation includes three steps to enhancing your leadership and performance. These three steps are often overlooked, underdeveloped, and underrated. However, these three steps are the critical elements that are required for successful leadership and high performance. Every participant will be able to glean valuable insights and gain practical application from this presentation to immediately create a pathway to 10X their performance.

Part 2

The learning team approach considers both the human and technical aspects of work.  By including the frontline workers it creates a sense of ownership and collaboration.  This approach empowers employees to share their knowledge, insights and experiences.  The frontline encounters problems everyday that go unnoticed by management and other departments.  By bring them together we learn their perspective and experiences to identify issues, risks, bottlenecks and inefficiencies that are in their work everyday.  We will explore insights gained from doing thousands of learning teams over the past 8 years from all aspects of work.

As humans, we are all prone to unconscious biases, whether we recognize them or not. Most of the time these natural psychological processes help us reduce our cognitive load when coping with the inherent complexity of our world. However, these sneaky mental shortcuts can also prevent us from developing an objective and accurate picture of the set of circumstances leading to an outcome. This presentation will introduce some common cognitive biases that could impact your decision making when evaluating an event and discuss some proven ways to mitigate their influence.