Updated September 2026: we’ve corrected the citation for Amy Edmondson’s hospital study (1996, not 1999) and described its findings more precisely. Introduction As a result of the ever-increasing scale and complexity of healthcare systems, hierarchies and layers of management have […]
Human and Organisational Performance (HOP)
Human and Organisational Performance (or sometimes Potential) is based on five principles, originally defined by Dr Todd Conklin, in his book, “The Five Principles of Human Performance“.
These five principles shape and influence the way organisations think, act, view success and respond to failure. These five principles are integrative and work together to change the way we think about work and how to improve it.
1. People make mistakes
2. Blame fixes nothing
3. Context drives behaviour
4. Learning is vital
5. Response matters
Updated September 2026: we’ve corrected our account of the L’Aquila earthquake, which slightly overstated Giampaolo Giuliani’s radon warning. A few issues ago, we covered various kinds of retrospective – the practice of looking back and learning from work, as well […]
John Boyd and The OODA Loop John Boyd’s OODA loops are more than just an esoteric strategic concept; they’ve earned a huge following online and around the world. In this article, I highlight key points about OODA loops along with a glimpse into […]
Crew Resource Management (CRM) and the Centrality of Psychological Safety CRM was developed in the 1970s and operationalised psychological safety in safety-critical, complex environments. Crew Resource Management (CRM) recognised, as a result of accidents such as Tenerife in 1977, that […]
The Theory of Constraints (ToC) A long time ago, I read a book that profoundly changed the way I think about work. That book was The Goal, written by Eli Goldratt in 1984, The story revolves around Alex Rogo, a […]
Learning From Work In the spirit of looking back and learning, I thought it’d be nice to dive into a few different practices of learning from the work we do. In this issue, we’re going to have a look at […]
The Challenger Disaster: AKA The Normalisation of Risk In previous articles we’ve differentiated error into three types: slips and lapses, mistakes, and violations. This time, we’re exploring a certain type of violation called the “normalisation of deviance”, a term coined […]
The Whitehall Studies and The Social Gradient of Health The relationship between formal or positional power (seniority & status) and psychological safety is strong. In general, we know that people holding more senior and higher status roles often feel safer […]
We cannot adequately respond to changes, incidents or threats if we’re operating at capacity. And it applies to people, machines, computers, traffic and more – whether you’re running a factory floor, a busy kitchen, a software development team, or a hospital ER, percentage utilisation is impacting how well your team can adapt to a changing environment.
15/5 Reports To manage teams in a way that fosters psychological safety requires clear communication and feedback channels. Team members should have well-defined platforms to share achievements, voice concerns, and seek assistance. Ideally, these feedback mechanisms will be consistent, high-cadence and […]
Deming’s 14 Points of Management I’m a Deming fan, and sad that I never got to meet him or attend any of his lectures. W. E. Deming is possibly most well known for his “PDCA” (Plan-Do-Check-Act) cycle, which is actually […]
Crew Resource Management In preparing for my conference talk this week, I was reading up further on the 1977 Tenerife disaster and the history of Crew Resource Management (CRM), and came across this excellent paper: The Evolution of Crew Resource Management Training […]
Reason’s theory holds that most accidents can be traced to one or more of four levels of failure:
Organisational influences,
Unsafe supervision,
Preconditions for unsafe acts, and
The unsafe acts themselves.
Normal Accidents Charles Perrow is regarded as a pivotal figure in the theory of why and how things fail. He served as a sociology professor at Yale and Stanford and was primarily focused on the influence of large organisations on […]
Statistical Process Control and Understanding Variation In a chat with a great client this week, we got talking about different approaches to measurement and metrics. I introduced the concept of Statistical Process Control (SPC), so that’s what this week’s newsletter […]
Local Rationality “People do reasonable things given their goals, knowledge, understanding of the situation and focus of attention at a particular moment.” We do things that make sense to us at the time. And a fundamental premise of psychological safety […]
A man goes out on the beach and sees that it is covered with starfish that have washed up in the tide. A little boy is walking along, picking them up and throwing them back into the water. “What are […]
Understanding and Implementing the Patient Safety Incident Response Framework (PSIRF) This week we’re having a look at the new NHS Patient Safety Incident Response Framework (PSIRF). Whilst this is clearly relevant to our UK healthcare readers, I believe that the […]
Article Summary – Causes of Disaster at Chernobyl: The Absence of Psychological Safety (See below for the complete article) In 1986, the nuclear power plant at Chernobyl in the Ukrainian SSR (the territory of modern Ukraine) suffered a catastrophic failure […]
Everest, and psychological safety in the mountains Thanks so much to a client of mine, the excellent Paul Verrico at Eversheds Sutherland, I was lucky enough to attend the 70th anniversary of the first Everest ascent, at the Royal Geographical Society […]
If we think about how we can apply sociotechnical theory in practice, we realise that organisational change or technological change will fail if we focus on one component (social or technical) in isolation and to the exclusion of others. We must consider how people are affected by technologies, and likewise, how technologies affect the way people behave.
High Performing Teams & Psychological Safety at Work: Psychological safety is the foundation for team performance, whether we’re oriented towards consistent quality, innovation, adaptation, safety or a combination of all outcomes. When people feel psychologically safe, they feel more able […]
What is “Safe to Fail”? Recently, I failed a motorbike test. This might sound like a mistake, but I fully expected to fail. In the UK, you must pass multiple tests before you’re allowed out on the roads on a […]
Psychological Safety Behaviours: The Big List (Updated Sept 2026) Psychological safety is a belief that the group is safe for interpersonal risk taking (Edmondson, 1999). There are many ways we can help to foster these environments, but it’s important to […]
Checklists I read Atul Gawande’s “Better” some time around 2008 and absolutely loved it, so when he published “The Checklist Manifesto” in 2009, I grabbed a copy immediately. The Checklist Manifesto describes the power of checklists in reducing human error and increasing effectiveness across various industries, […]
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