2019 HPRCT Conference

This session discusses what we, as practitioners, can learn from the result of analyses of serious incidents or accidents at facilities that have implemented, or are implementing, Human Performance Improvement (HPI) or High Reliability Organization (HRO) principles. Our mission as practitioners in the field of human performance, root cause, and trending is almost always conducted in a high stakes environment, with multiple opinions, and strong emotions. Whether we come into our mission with a root cause, human performance, or reliability perspective our common goal is helping our organizations achieve safety and reliability by preventing events and organizational learning. As such, we should always be striving to learn about the successes and failures when we implement these principles into organizations. This session presents learnings from cause analyses of significant events including major equipment failures, injuries, and fatalities. In many of these events, the organization had implemented, or were implementing human performance or HRO principles. While the events are tragic, analysis of these events can give us insights into how to more effectively implement HPI or HRO principles into our organizations to avoid future events. This session is not intended to point fingers or place blame for lapses in implementation of these principles; it is intended as a crucial conversation so that we all can learn important lessons that will improve our efforts.