Jake Mazulewicz, Ph.D.

Owner & Principal, JMA Companies

(540) 466-1357

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Handouts, Slides & Video

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7 ways that HPI Programs fail & 21 ways to avoid them

A one-page summary of the seven (7) ways that HPI Programs often fail, and 21 ways to help yours succeed.

Three Strategies for HPI

2017 NERC Human Performance Improvement Conference

28-30 March 2017 -- Atlanta, Georgia

Some HPI experts tell us to reduce human errors. Others warn us to stop focusing on the “humans.” Still others, argue that “errors” don’t exist at all. If you’re confused, you’re not alone. In this presentation, we cut through the confusion of the three modern, competing views of HPI, and reveal the fundamental links that connect them. Plenty of practical, real-world examples included as always.

Postcursor Video

Discover what's wrong with the classic concept of "Error Precursors" and get a practical solution you can apply immediately. Highlights include:

  • What's wrong with Precursors -- 00:21

  • How to fix it -- 02:07

  • An example of how an electric utility switching team could apply the solution -- 03:26

Resources From Video:

Department of Energy (DOE) Human Performance Improvement (HPI) Handbook 

"Decision-Making: One Brain: Two Systems"

22nd Annual Human Performance, Root Cause & Trending Conference

13-17 June, 2016 -- Colorado Springs, Colorado

When should you follow procedures? When should you trust your own professional judgment? In this presentation, participants learned 12 evidence-based, practical answers from Daniel Kahneman's Thinking Fast & Slow and Gary Klein's Sources of Power.

"How the US Military Learns From Experience -- The After Action Review (AAR)"

2014 NERC Human Performance Improvement Conference

17-19 March 2014 -- Atlanta, Georgia

Some people say they have "20 years of experience" when in reality they have only 1 year of experience repeated 19 times. What's the difference? The structured process that experts use to help them learn from every experience. Click below to get a handout to get the four key questions plus practical tips you can apply immediately. And in our live workshops, you'll get 14 additional tips plus hands-on practice leading an actual AAR. You'll walk out with the skills you need to start leading AARs with your teams. 

"The $100,000 Human Error: How to Make Bitcoin Transactions Safer & More Reliable"

Satoshi Roundtable -- An Invitation-Only Bitcoin Conference

26-28 February 2016 -- Port St. Lucie, Florida

One Bitcoin user put a decimal in the wrong place and lost $100,000. A recent research study found that at least 25% of all Bitcoin users have lost money due to Human Error. In this presentation, I revealed several recent errors in the Bitcoin world, then gave one principle and three resources to help make Bitcoin transactions safer & more reliable for everyone. 

"How to Teach HPI to End Users -- Build Interactive Teaching Cases"

2012 NERC Human Performance Improvement Conference

27-29 March 2012 -- Atlanta, Georgia

When I took responsibility as the HPI Lead for a 3,500 person business unit, I quickly learned that field crews didn't "get" conventional HPI curriculum... or want it.

 

After months of struggle, I discovered a solution. I used techniques pioneered by Ivy League business schools to build a series of popular, successful Interactive Teaching Cases.

 

Here's how you can build your own.

"HPI 101 -- A New Introduction to Human Performance Improvement"

A Half-Day Pre-Conference Workshop for the NERC HPI Conference

28-31 March 2016 -- Atlanta, Georgia

Vince Lombardi said, “Excellence is achieved by mastery of the fundamentals.”  In this interactive workshop, participants got field-tested innovations on classic concepts like the START questions, Situational Awareness, Error Traps, and Defenses, plus intros to organizational strategies like Just Culture & Crew Resource Management, plus a list of practical resources, and a few surprises. It was the most popular pre-conference workshop at the NERC Human Performance Conference.

"Brain-Based Training: Four Strategies that Technical Educators Should Apply Today"

WECC Train-the-Trainer Conference

19-22 July 2016 -- Folsom, California

"Jake is not your ordinary keynote speaker. Like most, he is entertaining. But what sets Jake apart is a hands-on, experiential method of delivering a powerful and memorable message... Last year’s keynote, How To Freeze Time included an exercise so profound that I now build it into all of my training. This year’s keynote, Brain Based Learning, with three key tips, had the same profound impact."

~ Deveny Bywaters, Training Mgr., Western Electricity Coordinating Council (WECC)

In the Press

For articles in Efficient Plant Magazine, POWER Magazine, Plant Services Magazine and others, please visit our Press page.

Recommended Reading

Managing the Risks of Organizational Accidents

James Reason

Often considered the start of serious academic study of human error. Every legitimate HPI expert that I've spoken with has read it, often multiple times. See especially his arguments for managing organizational defenses (as opposed to merely individual ones).

 

 

The Field Guide to Understanding Human Error

Sidney Dekker

The best guide for Root Cause Analyses for human errors that I've ever read. Not a step-by-step procedure, but a set of timeless principles that any reasonably skilled event analyst can apply to their own process. See especially Dekker's sections on "counterfactuals" and why "human error" is never a root cause.

 

 

Flawless Execution

James Murphy 

Written by pilots for civilians, this book explains some of the most powerful core error-prevention tools used by the US Military, especially pilots. The core idea is the "plan-brief-execute-debrief" cycle.

 

Set Phasers on Stun: True Tales of Design, Technology & Human Error

Steven Casey

No concepts, theories, or cheese-based models. Just jaw-dropping stories. Some are classics, like those about Chernobyl, Bhopal, and the 2003 Northeast Blackout. Others will be fresh and unknown to most readers, and involve elements like: WWII Frogmen, Swedish rockets, hospital IV pumps, and peppermint-flavored bar drinks.

 

 

The Checklist Manifesto: How to Get Things Right

Atul Gawande

The tool itself is deceptively simple. But the organizational battles to get checklists accepted into common everyday practice (outside of aviation) are anything but simple. An excellent read on one of the most versatile HPI tools in existence.

 

 

Managing the Unexpected: Assuring High Performance in an Age of Complexity

Karl E. Weick & Kathleen M. Sutcliffe ​

The flight decks of aircraft carriers. The control rooms of nuclear power plants. Air traffic control centers. How do these "High-Reliability Organizations" deliver near perfect results year in and year out? Weick and Sutcliffe elegantly explain the five (5) traits supported by 30 years of research.

 

High Reliability Organizing (HRO)

A great set of resources based on 30+ years of research into organizations and teams that consistently deliver safe, reliable results in high-risk industries like air traffic control, aircraft carrier operation, & wildlands firefighting.

 

 

Whack-a-Mole: The Price We Pay for Expecting Perfection

David Marx

Wise leaders know they cannot "punish their way to excellence." Yet far too many corporate cultures seem driven to "fix blame" not "fix problems." Marx gives a great introduction to the solution - the concept of the "Just Culture." 

 

Black Box Thinking:
Why Most People Never Learn from their Mistakes, but Some Do

Matthew Syed

A great introduction to the applied psychology of human error. No jargon. No unnecessary academic terminology. Just powerful stories of real world errors and evidence-based ideas for how to manage them better.

Online Resources

A Just Culture Health Care Journey (20 minute video)

Outcome Engineering

Interviews of leaders in a North Carolina hospital before, during and after they evolved to Just Culture. Many leaders show this video to boses, and skeptics to open productive conversations on the Just Culture.

Examples of Clever Medical Device Designs

US Department of Energy (DOE) Human Performance Improvement Handbooks

Classic, thorough, and free to use since they're in the Public Domain, courtesy your Department of Energy. They are a bit dated (2009) so use them as an encyclopedia, not a How-To Guide.  

Volume 1 of 2 -- Concepts & Principles 
Volume 2 of 2 -- Tools for Individuals, Work Teams & Management

After Action Reviews (AARs)

A great set of resources on After Action Reviews. See especially, "The US Army's After Action Reviews: Seizing the Chance to Learn."