Safe As Podcast

E103: Does HOP Actually Work? Real Data From a 5-Year Study (Quickisode)

Does a Human & Organizational Performance (HOP) initiative improve learning and the quality of actions? And what happens when the initiative stops?This quickisode unpacks Christopher Mastrangelo’s 2026 Master’s thesis examining a multi-year HOP implementation at a large biopharmaceutical company. His project tracked operational data from 2020 through July 2025 across key metrics: a. deviation initiation ratesb. root cause classification practicesc. CAPA types, andd. cultural persistence after formal support was removed. The HOP initiative seemingly resulted in:a. A drop in quality deviationsb. A shift away from findings of 'human error' towards organisational improvementsc. Fixing systems rather than retraining peopleAnd what happens when the HOP initiative and key stakeholders are dissolved? After the dedicated HOP team was dissolved in mid-2024, formal training scores dropped, and 'human factors' classifications (e.g. focusing on people rather than the system) crept back in. But, frontline work execution and proactive learning mindsets persisted. Resources & Links:Website & Articles: https://safetyinsights.orgSupport the channel: https://buymeacoffee.com/benhutchinson

E102: Writing Better Safety Procedures Part 2: Rules vs Reality, WAI/WAD, Safety-II & Workarounds

In a 5-year petrochemical study examining over 1,400 work steps, 1/3 were performed differently from what was written in the procedure, but every task was completed successfully.Is this non-compliance or a display of worker aptitude and resilient skill? In Part 2 of our series on procedures, we look beyond the "100% compliance" rhetoric and unpack the gap between work-as-imagined (WAI) and work-as-done (WAD). We explore why workers adapt rules, how to categorise workarounds, and how to redesign safety procedures as resources for action rather than as tools for worker control. We cover: a. why procedures assume work is linear, predictable and controllable - and why real-world conditions constantly force adaptation b. The RES framework which explores three drivers of procedural adaptation: Routine, Efficiency, and Safety c. The difference between viewing procedures as top-down mandates (Model 1) vs localised, situated tools (Model 2) d. The limits of compliance checks, and how 'pencil whipping' procedures fails to assure adequate rule following, and why procedure quality and safety climate may matter more e. How airline pilots handle complex emergencies by drawing on fragments from checklists and SOPs rather than following linear scripts f. The challenges of over-specification vs under-specification, and why cramming in more details forces workers into a 'damned if you do, damned if you don't' trap g. Using Scenario-Based Training (SBT) & Gary Klein’s ShadowBox approaches, and HPOG’s Walk-Through Talk-Through to build expertise & redesign work systems Resources & Links:Website & Articles: https://safetyinsights.orgSupport the channel: https://buymeacoffee.com/benhutchinson

E101: From Blame to Restorative Justice: A Just Culture Tool (HOP / Safety-II / New View)

Do traditional approaches unintentionally blame front-line workers instead of fixing broken organisational systems?This Quickisode unpacks how an international energy company redesigned its Just Culture (JC) framework to shift focus from individual culpability to systemic weaknesses.This company found that traditional approaches relied on judgement terminology, like violation or negligence, and frequently misapplied as disciplinary tools.Their redesigned JC tried to address these limitations, including:a. decoupling the analysis from disciplineb. separating the evaluation of system conditions from HR disciplinary actionsc. neutral language by removing terms like violationd. evaluating supervisory influence and management decisions alongside worker actionsBased on this case study, they found that 90% of non-conformances stemmed from underlying system weaknesses, like from unclear procedures, resource constraints, or task complexity.The revised tool led to 55% of corrective actions being tied to system improvements, whereas disciplinary action occurred in only 5% of cases.Resources & Links:Website & Articles: https://safetyinsights.orgSupport the channel: https://buymeacoffee.com/benhutchinson

E100: Dr Linda Bellamy Part 2: Fatal vs Minor hazards, SIFs & Barrier Failures

Part 2 discussion with Dr Linda Bellamy on SIFs, fatal accidents, and barrier failures. Resources & Links:Website & Articles: https://safetyinsights.orgSupport the channel: https://buymeacoffee.com/benhutchinson

E99: 25 Questions for Better Incident Investigations | Safety-II / HOP

Do your investigations often conclude when you've identified 'human error', or a pesky person not following rules?Do you want to improve the quality and depth of your learning opportunities?One way is via local rationality: understanding why decisions & actions made sense to people at the time. It's a core feature in human factors / safety-II / and Human and Organizational Performance (HOP).This episode unpacks Louise Roe's Local Rationality Question Tool in her article presented at the Chartered Institute of Ergonomics & Human Factors (CIEHF) 2025 conference.The tool covers things like: - workload, time pressure & environmental cues; goals, assumptions & information available- training, policies & useable job aids- team dynamics & information flow- Expectations & imagined outcomes/'what ifs'Ref: Roe, L. (2025). Local rationality question tool: understanding why it made sense at the time. In Golightly, D., Balfe, N., & Charles, R. (Eds.), Contemporary Ergonomics and Human Factors 2025: Proceedings of the Chartered Institute of Ergonomics and Human Factors Annual Conference (pp. 360-362). CIEHF. Resources & Links:Website & Articles: https://safetyinsights.orgSupport the channel: https://buymeacoffee.com/benhutchinson

E98: Writing better procedures part 1: Action verbs, human factors & more

Why are so many procedures technically accurate, but barely workable in practice?In Part 1 of this two part series on procedural systems, we unpack the technical side of writing better, more useable procedures: exploring how to reduce safety clutter, choosing the right type of rule, and structure instructions so they support work.We unpack:• Types of rules: performance goal vs. process vs. action rules & how they limit or enable discretion• Formatting: Action-verb steps, concrete language & single-action steps• Critical steps: Highlighting actions where mistakes cause immediate or unrecoverable harm• Warnings & alerts: What guidelines and research suggests about effective warning placementAnd more.In Part 2, we go beyond technical writing and structure to unpack procedures from a Resilience Engineering and Safety-II perspective – procedures as resources for action.Resources & Links:Website & Articles: https://safetyinsights.orgSupport the channel: https://buymeacoffee.com/benhutchinson

E97: Investigating when 'Nothing' Failed: a Safety-II/HOP debrief tool (Quickisode)

This quickisode races through a Safety-II / HOP inspired debrief tool which can help unearth 'hidden' insights about work that doesn't rely on incidents for learning.Resources & Links:Website & Articles: https://safetyinsights.orgSupport the channel: https://buymeacoffee.com/benhutchinson

E96: Dr Linda Bellamy Part 1: Fatal vs Minor hazards, SIFs & Barrier Failures

Is there a relationship between fatal and minor hazard exposures? Recent SIF research & movements suggest 'NO' - what kills people aren't the same as what hurts them. But is that scientifically accurate? Part 1 discussion with Dr Linda Bellamy, who undertook perhaps the largest study of this kind exploring the connection - and, there ** is ** a connection. We discuss barrier/control systems & how they fail and succeed, weak signals, indicators and more. Resources & Links:Website & Articles: https://safetyinsights.orgSupport the channel: https://buymeacoffee.com/benhutchinson

E95: Critical Controls & Barriers - Part 4: What do barrier models leave out? A Safety-II critique

A bowtie or critical control register may be useful tools, but they aren't the work.In Part 4 of this series, I unpack what control / barrier models can leave out: e.g. changing conditions, competing goals, control dependencies, unintended consequences and the adaptations people make to keep work functioning.I also explore how controls can change the systems they are introduced into, why more barriers don't always mean greater risk control, and why successful work may conceal degraded controls and poor design.We should specify, support and verify barriers but also ask: "What do the people using the control know that the bowtie doesn’t show?"Part 1: https://youtu.be/qQfORHGC4BsPart 2: https://youtu.be/7sPqw5NAyiEPart 3: https://youtu.be/Ly1mEn_KCLQResources & Links:Website & Articles: https://safetyinsights.orgSupport the channel: https://buymeacoffee.com/benhutchinson

E94: Dr Marcin Nazaruk Part 2: HOP, New View, Learning from Daily Work

Today I interview Dr Marcin Nazaruk, who shares his practical experience and research on learning from normal work / daily work, HOP / New View / Safety-II, to improve learning and risk management.The discussion also explores themes around risk controls, work constraints, risk assessments, and error traps.Support the channel: https://buymeacoffee.com/benhutchinson

E93: Critical Controls & Barriers & Safeguard | Part 3: Human Factors & Human Performance

How do we set realistic and effective human performance expectations in our barrier approaches?In part 1 we looked at definitions of controls and barriers, whereas in part 2 we explored a deeper dive into their applications and escalation factors.This episode unpacks a few key sources to explore critical human factors and human performance considerations for barrier / control systems.Website & Articles: https://safetyinsights.orgSubscribe to the series for Part 4.Support the channel: https://buymeacoffee.com/benhutchinson

E92: Dr Marcin Nazaruk Part 1: HOP, New View, Learning from Daily Work

Today I interview Dr Marcin Nazaruk, who shares his practical experience and research on learning from normal work / daily work, HOP / New View / Safety-II, to improve learning and risk management.The discussion also explores themes around risk controls, work constraints, risk assessments, and error traps.Support the channel: https://buymeacoffee.com/benhutchinson

E91: Critical Controls & Barriers & Safeguards | Part 2: From paper to practice (e.g. bow-ties & more)

How do we translate a paper barrier system into one that's functional and verified as effective?Whereas part 1 looked at key definitions of control, barrier, safeguard, support, and verification activity - this episode dives deeper into the use of such frameworks.In particular, we unpack escalation / degradation / erosion factors, and the necessary support mechanisms to ensure controls work as intended, when intended.Key sources analysed in this episode:International Council on Mining and Metals (ICMM) – Critical Control Management FrameworkThe Chartered Institute of Ergonomics & Human Factors (CIEHF) – Human Factors in Barrier ManagementConstruction Safety Research Alliance (CSRA) & Professor Matthew HallowellPetroleum Safety Authority (PSA) NorwayResources & Links:Website & Articles: https://safetyinsights.orgSubscribe to the series for Parts 3, and 4.Support the channel: https://buymeacoffee.com/benhutchinson

E90: Dr Guido Carim Jr Part 2

Part 2 of our interview with Dr. Guido Carim Junior, Associate Professor of Aviation, pilot, researcher, and safety scientist. We pick up the conversation with digital checklists, examining the potential role of AI and how "smart" features risk narrowing human decision-making rather than supporting it.Guido shares critical thoughts on the line between genuine organizational resilience and workarounds that mask underlying brittleness. We discuss the "tragedy of adaptability" and potential blind spots within Safety-II and HOP when organizations over-rely on human adaptation instead of fixing flawed systems.We also cover how to surface informal practices for learning without turning them into rigid, bureaucratic rules, and why safety audits need to look past green-checking compliance documents to tune into weak signals and daily operational reality.Please Like, Subscribe and Share. Also check out my blog at https://SafetyInsights.OrgSupport the channel here: https://buymeacoffee.com/benhutchinson

E89: Critical Controls, Barriers & Safeguards | Part 1: Definitions & Inconsistencies

Is that a control, barrier, safeguard, support, or verification activity? Is it an object, a human act, a system or just a procedure? Does it actually address the hazardous energy, or does it sound good on paper?If we label every single checklist and administrative task a "critical control," do we risk diluting the operational focus required to prevent high-consequence events? If everything is critical, nothing is.Part 1 of this 4-part series unpacks how these terms are used (and misused) across the industry, evaluating the baseline definitions that dictate how we manage risk.Key sources analysed in this episode:International Council on Mining and Metals (ICMM) – Critical Control Management FrameworkThe Chartered Institute of Ergonomics & Human Factors (CIEHF) – Human Factors in Barrier ManagementConstruction Safety Research Alliance (CSRA) & Professor Matthew HallowellPetroleum Safety Authority (PSA) NorwayResources & Links:Website & Articles: https://safetyinsights.orgSubscribe to the series for Parts 2, 3, and 4.Support the channel: https://buymeacoffee.com/benhutchinson

E88: Dr Guido Carim Jr Part 1

Interview with Guido part 1

E87: Risk Management vs. Rule Compliance: The False Choice

When you're standing on the front line making an operational call, risk doesn't come with a green or red light. You have to make a binary decision: stop or go.We don't necessarily make it easy for our decision-makers to make good, defendable decisions.This video unpacks Andrew Hopkins’ 2011 Safety Science article, "Risk Management & Rule Compliance: Decision-making in hazardous industries". Hopkins argues that choosing between risk management and rule compliance is a false choice - they're complementary, not contradictory.Because risk sits on a continuum but decisions require a definitive line in the sand, high-hazard industries must translate broad risk management principles into clear operational rules for the sharp end.What is covered:a. Why risk management and rule compliance must co-exist and complement each other.b. Why frontline workers need clear "do it or don't" thresholds rather than numerical risk criteria.c. Goal, Process, and Action Rulesd. Why risk assessments can be more 'legitimation rituals'Support the channel: https://buymeacoffee.com/benhutchinson

E86: CEO speeches: Talking Our Way to Disaster #DeepWaterHorizon #BP

On April 15, 2010, BP CEO Tony Hayward reassured shareholders that the company was safer and more efficient than ever. Five days later, the Deepwater Horizon disaster happened. This video unpacks a study that evaluated CEO speeches and how rhetoric and slogans can be disconnected with actual behaviour and resourcing.It explores how relentless cost-cutting and corporate rhetoric set the stage for catastrophe.Support the channel: https://buymeacoffee.com/benhutchinson

E85:When Success Leads to Disaster: Practical Drift & the 1994 Black Hawk Friendly Fire Shootdown

In 1994, two US Air force F15 fighters shot down two friendly US Army Black Hawk helicopters.This event shouldn't have been possible: there were experts, radio communications, radar, AWACS and more.However, this isn't a tragedy due to human error or a lack of safeguards, it happened in spite of the safeguards.This episode unpacks a few findings from the seminal book from Scott Snook called 'Friendly Fire'. We’ll explore how "Practical Drift" - the slow, invisible uncoupling of local practice from centralised procedure, turned a routine mission into a catastrophe. This book is a masterclass in what can happen when our Work-as-Imagined has little to do with the reality of Work-as-Done on the frontline.Support the channel: https://buymeacoffee.com/benhutchinson

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E84: The pitfalls of safety reporting metrics and 'safewashing' our way to disaster

Can our safety reporting and indicators mask signals that organizations are drifting to major accident?This episode unpacks two reports from O'Neill and colleagues looking at the pitfalls of safety reporting measures, and also explores weaknesses in annual safety reports - particularly how reports may be 'safewashing'. More research at SafetyInsights.Org Intro/Output "Dark Synth Wave" by ElephantGreen (PixaBay.com) Make sure to subscribe to Safe As on Spotify/Apple, and if you find it useful then please help share the news, and leave a rating and review on your podcast app. I also have a Safe As LinkedIn group if you want to stay up to date on releases.

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