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Quiz: What is the level of Human Performance culture in your team?

Take this quick 10 question quiz to get a scored assessment of the current Human Performance culture in your team.

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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.


Interview in Plant Services

"A realistic (and more effective) approach to error management" 

By Thomas Wilk and Christine LaFave Grace

Jan 23, 2019

In this Big Picture Interview, Jake Mazulewicz, Ph.D., says focus on the root of the problem rather than on assigning blame.




Podcast - Red Wing’s Oil & Gas HSE


Episode OGHSE100

December 26, 2018

Patrick and Mark had a chance to talk with Jake J. Mazulewicz, Ph.D., Director of JMA, LLC, about how they teaches leaders in high-risk industries how to reduce, mitigate, and learn from errors.


Quoted in POWER Magazine


"New Thinking About Old Safety Issues"

By Thomas W. Overton, JD

June 1, 2016

In this article, Jake recommends, “Once you find a good exemplar, then learn as much as you reasonably can about when, how, and why they took responsibility for it. Seek the ‘ground truth.’ Take steps to make sure that people don’t just tell you what they think you want to hear. Be prepared to learn some insights that will challenge your assumptions and existing mental models...” (p.4).

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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.

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.

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"How to Learn From Experience

After Action Reviews (AARs)"

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. 

"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)

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.

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."