Using the Human Performance Index (HPI) to Reduce Shipping Industry Incidents

A holistic and proactive approach to incident reduction

Since the early 1990s, there has been a shift in what we know about the human element and how we can manage it in industry. Due to incidents like Three Mile Island in 1979 and Chernobyl in 1986, researchers have redirected their efforts towards a better understanding of why people do what they do, and why it makes sense to them at that moment.

Dr. James Reason wrote a book entitled “Human Error” that shifted what we know and can manage related to human fallibility and followed that book up a few years later with “Managing the Risks of Organizational Accidents”. These two books were important first steps in a paradigm shift related to understanding the workforce’s and leader’s roles in incidents. Dr. Sidney Dekker followed up Dr. Reason’s work with “The Field Guide to Understanding Human Error” which started us down the road of the practical understanding and application of the science of errors.

While comparing the shipping industry with the likes of nuclear and aviation, there appears to be a low understanding of how and why significant incidents occur. As the UK Marine Accident Investigation
Branch (MAIB) states…, “one factor still dominates the majority of maritime accidents; human error.”

From Torrey Canyon oil spill incident in 1967 to the grounding of Costa Concordia cruise ship in 2012 and the most recent collision incident of the vessel Sanchi in 2018, most of the investigations, assessments, and analyses stop at the human or their behaviour and do not take into account what is currently known in other industries about what drives incidents.

This paper, developed by author Rob Fisher in conjunction with Rachit Jain and Ian Collins, brings the knowledge and lessons learned from other high-risk industries into a usable set of ideas and indicators to form the “Human Performance Index” (HPI).

Rob Fisher, the subject matter expert (SME) in human performance and organisational psychology, has been on the front lines of reducing, eliminating, and mitigating human errors that result in incidents for over 30 years. He was responsible for developing the practical application of the strategies for managing the human element in the Nuclear & Utility Industry, Oil & Gas, Petrochemical & Manufacturing, and Healthcare. He is bringing the expertise associated with over 200 successful organisational deployments of human error reduction globally into the shipping industry.

Rachit Jain, an entrepreneur and tanker shipping professional with over 25 years of experience including working for oil majors such as BP and ExxonMobil. His passion for ship operation and quality assurance gave great exposure to studying and evaluating management systems of over 350 shipping companies and investigating over 100 shipping incidents.

Lan Collins, a long-time practitioner, author, entrepreneur, and owner of has deployed and integrated human performance, human factors, and the human element science bases concepts in high-risk industries all over the globe.

Using the Human Performance Index (HPI) to Reduce Shipping Industry Incidents

Lord Kelvin reportedly said… “I often say that when you can measure what you are
speaking about, and express it in numbers, you know something about it; but when
you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory
kind; it may be the beginning of knowledge, but you have scarcely, in your thoughts,
advanced to the stage of science, whatever the matter may be.1

HPI is a tool for organisations to understand the attributes important to sustainable incident reduction  and the metrics that help them discover how well they are working towards that goal.

While HPI is a simple formula, it takes some deeper understandings of what makes up the individual variables to get the human element results needed to improve overall performance.

Sustainably reducing incidents requires a holistic approach to minimise human error, maximise  defences, and mitigate potential consequences. The HPI equation is:


Each of the additives has well-known and very specific actions that need to be understood, done and measured to get the best outcomes.

Reducing Errors

Effective error reduction has five primary components:

1. Science-Based Understanding

Understanding the science-basis and definitions for error,
deviation, violation, latent error, and active error.

You will not effectively prevent that which you cannot define.

  • Leaders who start to use good, science-based definitions for these terms immediately start changing their language and behaviours and start to drive very rapid change in the organisation.
  • Poor or no definitions of these terms leads to the rapid decay of the understanding of the human element in organisations.
  • By understanding the concepts of human fallibility and why people do what they do at the time they do it, it leads to better prevention of errors and incidents and sets up for improved performance in the other attributes of HPI

Using the Human Performance Index (HPI) to Reduce Shipping Industry Incidents

2. Preventing Errors

  • Once the organisation understands what errors are and what drives people to make them, they can then work on the prevention of errors, especially those that could prove to be catastrophic.
  • This requires a systemic approach to understanding the drivers of error2 and incidents as represented by the “Task-Based System©” (Figure 2).
  • The task-based system is an interdependent system where people being aware of and managing their personality tendencies interact with other people, programs, processes, work environments, orgainsations and equipment.
  • All of the systemic drivers on the outside of the system are dynamic and impact each other, they all impact the individual, and the individual will tend to react to changes in the system in very predictable ways and along specific personality lines.3
  • Individuals with different personality tendencies will see and manage the risk coming from systemic drivers differently.
  • The individual in the middle of the system is also impacted by both physical hazards (which are typically evaluated on a Job Hazard Analysis or a Risk Analysis), and performance hazards (which are rarely identified and a major subject of this paper).
  • Since all errors cannot be prevented, organisations need to be aware of, understand and manage the elements associated with reducing the probability that an error happens.
  • To do this, you must first understand what drives errors, and what tools can be used to reduce their probability.
  • The General Error Modeling System (GEMS) helps understand human vulnerability in the
    form of an error rate associated with specific performance modes.
  • The error rate for habitual tasks (Skill-Based ~1:1,000), the error rate for process tasks (Rule-Based ~1:100) and the error rate for tasks where there are gaps in knowledge (Knowledge-Based ~1:10 to ~1:2) all need to be understood to use the right tool the
    right way to reduce the probability of an error being made.

4. Performance Modes, Traps and Triggers

3. Reducing the Probability of Errors


Using the Human Performance Index (HPI) to Reduce Shipping Industry Incidents

  • Without knowing and understanding when, where, and how the error reduction tools are effective, then the vulnerabilities cannot be controlled.
  • Traps are task-related predicaments that increase the probability that someone will make an error. In the early 1990s, Performance Improvement International assessed almost 5,000 significant incident reports. Rather than focus on the common causes
    of the incidents, they looked deeper into things that contributed to the human condition that was present
    when the errors associated with the incidents occurred.
  • The data they discovered became known as the “Top 10 Error Traps” (Figure 3) and has been used all over the world to help organisations and
    individuals be more predictive about when a trap may be present and dealing with that trap before the error occurs.
  • It may not be practicable to eliminate all the error traps or conditions, however, an organisation can effectively manage to reduce the probability of such errors.
  • Triggers are clues or signals that tell you that a trap exists and that you are vulnerable to error. Knowing the triggers gives you a precursor to the trap driving an error.
  • Organisations need to effectively educate leaders, managers,supervisors, and the workforce in how to recognise the trigger that indicates a trap exists, and the tools to deal effectively with the trap.

5. Personality Tendencies

  • Humans have known about and acknowledged the differences in our personalities for over 3,000 years. Over the past 15 years, Equilibria, Ltd. ( has collected and analysed over 600,000 data points on: o how we see and manage risk,
    o how we get hurt,
    o what makes it difficult to follow procedures,
    o how the error traps impact us,
    o how we deal with the traps, and
    o how we like to communicate – all related to risk
  • The Personality Diversity Indicator (PDI) helps individuals determine their ”E-Colors” which helps them understand themselves better, and how each of the elements listed above can be better managed.
  • The E-Colors methodology has been independently validated to accurately represent the tendencies associate with the four primary E-Colors (Red, Green, Blue, Yellow) and the discriminatory characteristics that delineate the combinations of the E-Colors in most individuals.4
  • Being aware of and managing our personality tendencies is an important attribute of reducing errors.

Using the Human Performance Index (HPI) to Reduce Shipping Industry Incidents

Maximising Defences

Traditionally the layers of protection between any driver or root cause of incidents and the human action that initiates the incident are described using the “hierarchy of controls” (Figure 4) and apply mostly to physical hazards.5

  • The most advanced understanding and application of the human element must include more than managing
    the defences related to the physical hazard.
  • In order to have sustainable improvements in the human element concepts you also have to integrate the knowledge of the personality tendency attributes related to errors and the performance hazard attributes
    related to errors.
  • Dr. James Reason and Dr. Patrick Hudson proposed the “Swiss-Cheese Model” in the early 1990s as a way to explain the barriers or defences needed to protect from the causes of an incident.
  • The current practical application of this model includes sections for the prevention of incidents as well as sections for the correction of incidents and near misses. At each layer of “swisscheese”, you have people trying to establish that layer of protection who are subject to and need to manage the potential limiters of their personality tendencies (Figure 5).
  • To effectively maximise and manage defences, people at each level of the creation and use of the hierarchy of controls need to be aware of and manage their personality tendencies.
  • At the individual and administrative layers of protection, there needs to be effective tools that are utilised to minimise the probability of errors and to prevent errors from propagating into an incident.
  • The individual must first recognise their vulnerability, and then apply the right error-reudction tool the right way at the right time.
  • Doing this effectively results in an average factor of 10 reductions in error rate for each tool used.

Using the Human Performance Index (HPI) to Reduce Shipping Industry Incidents

  • Understanding where the risk may be coming from by using the task-based system (Figure 1), either as an individual or an organisation,minimises the probability that an error will be made, or that if an error is made it will result in a bad outcome.
  • The values of the smaller part of an organisation have more impact on the performance of a team or individual than the values of the larger organisation.
  • Leaders at all levels of the organisation must know and understand the techniques and differences between observations (watching and discussing how work is done) and engagements (discussing the whys of work, processes, and values).
  • Most organisations have KPI targets related to the number of observations, which are then trend analysed and actioned for weak areas. These are typically called “Method-based Observations”,
    where judgments are made against whether the task was done right or wrong, safe or unsafe.
  • On the other hand, “Values-Based Engagements” are discussions with people at all levels of the workforce that describe and reinforce the values, mission, vision, and goals of the organisation in a way that identifies mismatches BEFORE they drive errors and incidents.

Method-based observations are more about the “what and how” of work. Whereas, Valuesbased engagements are about the “why”.

  • Fisher Improvement Technologies (FIT), through hundreds of deployments of human performance strategies, has determined that in order to discover values mismatches that can lead to incidents, organisations should focus more on doing values-based engagements instead of just method-based observations.
  • All companies document their expectations through own’s Safety Management System. One of the identified Top-10 Error Traps (Figure 3) is “vague or poor written guidance”.There are 25 known sub-traps in this one error trap that people who write the guidance inadvertently put in their documents which actually DRIVES errors to occur instead of preventing them.6
  • In most organsations, the people assigned to develop written guidance have never been trained on:
    o what these written guidance traps look like,
    o how they drive field errors, or
    o how to avoid putting the error traps in the written guidance.

If the writers aren't aware of and managing these traps, they will not be seen until after an incident, and then only if the analysis is very good at determining written guidance systemic drivers.

  • Corrective actions from previous near misses and near hits comprise the last element of maximising defences as the actions if correctly and timely, serve to create a layer of protection for future incidents. Corrective actions should be developed using SMART criteria:
    o Specific – The level of detail should be such that the individual who is assigned to carry out the action or meet the expectation can understand both the reasons for the action or expectation and each step, task, action, or behaviour required to effectively implement the action or expectation. There are physical
    actions included, not just an end state.
    o Measurable – The desired outcome or behaviour should be clearly described such that it can be seen physically (during an observation), or the physical outcome is obvious.

o Achievable – The stated actions can and should be done by the organization or individual assigned.
o Realistic – The proposed action needs to address the problem being corrected or prevented or address the action item.
o Timely– Actions need to have a specific time for completion that corrects the issue before the next challenge.

  • Without effective causal analysis, it is difficult to create sustainable and effective long-term corrective actions.
  • Organsations should measure the quality of incident and near-miss analyses to ensure that they have the capability and capacity to perform timely and effective root cause investigations.
  • Corrective action effectiveness probability should also be assessed before actions are put in place as potential defences (Figure 6). By focusing on actions that are known to be more effective, the defences are maximised.
  • Corrective action effectiveness is a measurable attribute of overall performance improvement.

Mitigating Consequences

Hazard and risk recognition must include an acknowledgement of human fallibility and minimise the impact of WHEN the error happens, not just IF an error may happen.

  • The systems an organisation establishes must evaluate and prepare for potential errors in order to minimise the impact of those errors. One example is the establishment of a “drop-zone” around lifting heavy loads.
  • The establishment of a safe work zone or exclusion area is an acknowledgment that at some point a load will get dropped, and the organisation needs to be prepared and have taken mitigating strategies as a part of task preparation.
  • In the safety industry, reduction and elimination of fatalities and serious injuries are partially about the prevention side and even more about the mitigation side of keeping the error from propagating into a serious incident.

Using the Human Performance Index (HPI) to Reduce Shipping Industry Incidents

“Leader response to failure matters…”7

  • Mitigating consequences requires mitigating the physical outcomes, and the organisational response. How an organisation responds to failure impacts how well the organisation manages the human element.
  • Using the Essential Leadership Cycle© (Figure 7) to guide leaders in understanding is vital to creating
    integrated and sustainable outcomes. The Essential Leadership Cycle (ELC) starts with three “driving elements” or things that make the rest of the cycle work and ends with five “resultant
    conditions” or things that are the
    outcomes, good or bad, of the driving elements.
  • Self & Team Awareness –Leaders and the workforce must be aware of and manage their personality tendencies
    related to seeing and managing risk. Leaders and the organisation must acknowledge what they know, and what they may NOT know related to managing risk related to the sciencebases of the human element.
  • Shared Vision & Values – The mission, vision, values, and goals of the organization should be shared in such a way that individuals with different personality tendencies can see whether
    they are aligned or whether there is a mismatch. When there is a mismatch in the values, mission, vision, or goals, there is also a mismatch in performance expectations.
  • Clear Roles and Processes – If an organisation has valid and verified shared vision and values, then you can create clearer roles, responsibilities, accountabilities, and authorities (R2A2)
    for the workforce. By tying these to the values, mission, vision, and goals, the organisation can ensure more sustainable outcomes.
  • Trust – There is a large personality tendency element to trust. It needs to be developed, not demanded. For some individuals, if you ask them to trust you instead of taking the time to
    develop trust, they think you are trying to hide something, and trust is depleted instead of gained.
  • Diversity and Inclusion – If you ask for diverse and inclusive thought, but have not taken the time to develop trust, then the input you get will only be to the limit that people trust that
    you will do the right thing.
  • Commitment – This element is personal to each individual. Organisations that demand commitment will only get it to the limit that the people respect and trust the organisation to do the right thing.

Using the Human Performance Index (HPI) to Reduce Shipping Industry Incidents

  • Accountability – You may notice how far around the cycle accountability resides. This is because if it is developed, then it will be powerful, but if it is demanded, it will be misused at all levels of the organisation.
  • Learning & Continuous Improvement – Learning from things that don’t happen (or almost happened) is vital to understanding how to prevent failures. Organisations that truly learn lessons ensure that they understand the human element science-based components to good-catches, near-misses, near-hits, and incidents before they apply corrective actions. Corrective action effectiveness is predicted and measured to ensure that the probability of re-occurrence is minimized.


Revisiting the HPI Equation

Now that we have discussed the critical attributes of understanding the human element and the human performance index, let’s take another look at the equation with all of the components (Figure 8). Each of the elements observable and measures can be established to ensure that sustainable results will be assured.

  • There are three things to watch for as you deploy human element concepts that will tell you if you are on the right path:

(1) The number and quality of pre-task briefings will be increasing.
(2) The number and quality of manager engagements on human element concepts will be increasing.
(3) The number and quality of near-miss reports will be increasing.

  •  If these three indicators are getting better, you are on the right path. If one or more is not getting better, the organisation will probably struggle with the deployment and integration of the human element concepts FIT, Equilibria, AERO, and SafeLanes have established tested and effective protocols for deploying the knowledge and skills needed in an organisation to successfully and sustainably integrate the human element concepts.

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