When something goes wrong at work, what’s the first question most organisations ask?

Who did it?

This instinct to assign blame is deeply ingrained, but it’s also deeply flawed. Matt Schlapfer, Senior Consultant at Fisher Improvement Technologies, an Avetta partner, challenges this old view, introducing Human and Organisational Performance (HOP) as a framework for understanding error constructively.

His message: Errors are normal, blame fixes nothing, and systems — not individuals — drive behaviour.

HOP isn’t about excusing mistakes. It’s about recognising that human error is inevitable and designing systems that anticipate it, manage it, and learn from it. This shift moves organisations from reactive blame cycles to proactive resilience.

Normalise Error

Mistakes happen, even in the most well-trained teams. In fact, decades of research show that 90% of workplace incidents involve systemic factors, not just individual failings.

Matt explains why this matters: “People do what they do at the time for reasons that make sense to them at that time. If we don’t understand that, we’ll keep fixing symptoms instead of causes.”

Normalising error doesn’t mean lowering standards. It means acknowledging reality. Humans are fallible, and systems must be designed to absorb that fallibility. When organisations accept this, they stop chasing perfection and start building resilience.

The Five Principles of HOP

Matt highlights Todd Conklin’s Five Principles of Human and Organisational Performance; simple, powerful ideas that reshape how we think about mistakes:

1. Error is Normal: Mistakes will happen. Systems must be designed to anticipate and manage them.
2. Blame Fixes Nothing: You can blame or you can learn—but you can’t do both. Blame shuts down insight and improvement.
3. Systems Influence Behaviour: Context drives decisions. A bad system will beat a good person every time.
4. Response Matters: Leader reactions shape culture. There’s a world of difference between a knee-jerk reaction and a thoughtful response.
5. Learning is Essential: Lessons aren’t learned until behaviours and systems change sustainably.

“Consistency of outcome requires consistency of method. These principles give us that method.” – Matt Schlapfer, Senior Consultant, Fisher Improvement Technologies

Shifting the Mindset: From Blame to Systems Thinking

Traditional incident cycles typically look like this:

1. Identify the incident
2. Find the error
3. React
4. Blame
5. Coach or discipline the worker
6. Change the procedure

Sound familiar? The predictable outcome: flat injury rates, repeat events, and low trust.

Matt illustrates this with a common scenario: “We have an incident. We ask who did it. We coach the supervisor, tweak the procedure, and send out a lessons learned. Six months later, the same thing happens again.”

HOP flips this script. Instead of asking “who failed?”, we ask:

• What systemic drivers influenced behaviour?
• Were rules workable, intelligible, and reinforced?
• Did performance traps like time pressure or vague guidance play a role?

Reducing Risk Through Tools and Processes

Here’s where HOP gets practical. Understanding performance modes (skill-based, rule-based, and knowledge-based) helps predict error rates and tailor interventions:

• Skill-based tasks: These are habitual actions performed frequently and with little conscious thought, like driving the same route to work. Error rate: 1 in 1,000.
• Rule-based tasks: Actions guided by known rules or procedures, such as following a checklist. Error rate: 1 in 100; still relatively low, but higher than skill-based because memory and interpretation come into play.
• Knowledge-based tasks: Situations where workers face uncertainty or gaps in understanding—often first-time tasks or complex problem-solving. Error rate: as high as 1 in 2, meaning a 50% chance of error.

Why does this matter? Because most serious incidents occur when workers operate in knowledge-based mode without adequate support. They’re guessing, under pressure, and exposed to error traps like time constraints or vague instructions.

Using the right tool the right way can reduce error rates by a factor of 10, from 1 in 2, to 1 in 10,000.

Matt shares a simple but powerful example: “Pilots use ‘Verbalise, Point & Touch’ on take-off and landing. It’s a proven error-reduction tool. Apply the same principle to critical steps in your workplace – say it, point to it, touch it – and you’ll lock that action into memory.”

Other tools include:

• TEDS questioning (Tell, Explain, Describe, Show) for fact-finding without blame
• Deviation Adaptability Analysis to distinguish between errors and violations and uncover systemic drivers
• Pre-task briefs and workflow checks to identify error traps before work begins

Shared Language and Understanding

Definitions matter. Without a common understanding of terms like error, violation, and accident, conversations become opinion-based and investigations stall.

Matt explains: “If leaders don’t know the definition of error, it’s hard for the workforce to believe you want to prevent them.”

HOP provides science-based definitions and a shared language that enables meaningful dialogue across leaders, managers, and frontline staff. This consistency is critical for building trust and driving organisational learning.

Why Blame Fixes Nothing

Blame feels instinctive. When something goes wrong, our first reaction is often: Who messed up? Matt calls this the “11th error trap” – a human nature characteristic that can be managed.

“Treat blame like any other error trap. If leaders push pause before reacting, they can respond consciously instead of reflexively.”

This shift matters because blame shuts down learning. Workers become defensive, investigations stop at the individual, and systemic issues remain hidden. Managing blame means asking better questions, focusing on context, and creating psychological safety for reporting.

What’s in it for Workers and Leaders?

For workers, HOP means fewer surprises and safer outcomes. By recognising performance modes and applying the right tools, they avoid working in the face of uncertainty.

“If a worker knows they’re in knowledge-based mode, they’ll stop and seek help instead of guessing. That’s how you move error rates from 1 in 2 to 1 in 10,000,” Matt says.

For leaders, HOP provides a framework to design tasks, observe work, and respond appropriately. It shifts leadership from compliance policing to proactive engagement.

Matt continues: “Leader response really matters. There’s a difference between a reaction and a response, and that difference can change everything.”

Building a Learning-Oriented Culture

Learning isn’t just sharing a “lessons learned” memo. True learning happens when systems and behaviours change sustainably.

Matt emphasises that “lessons aren’t learned until individual and organisational behaviours and systems change. That’s the measure of success.”

Organisations that adopt HOP principles see tangible results:

• Lower incident rates
• Higher worker engagement
• Stronger trust and accountability
• Improved operational performance

Key Takeaways

Human error is inevitable, but how we respond isn’t. Organisations that cling to blame stay stuck in a cycle of reaction and repeat incidents. Those that adopt HOP principles move towards resilience, learning, and safer outcomes.

Here are some key takeaways and practical steps to move towards HOP principles in your organisation:

• Error is normal. Design systems that anticipate it.
• Blame fixes nothing. Focus on drivers, not individuals.
• Systems influence behaviour. Strengthen processes and context.
• Response matters. Leaders must move from reaction to conscious response.
• Learning is essential. Change systems and behaviours, not just procedures.

Ready to shift from blame to learning? Start by asking better questions, using better tools, and building a culture where safety is lived, not legislated.

For further reading on how to make your organisation safer, download Avetta’s Making Every Job Safe, Every Day Research Report.

This study of 518 Australian professionals working in high-risk industries exposes the growing gap between feeling safe and being safe – and what organisations must do to close it.  

Avetta is a SaaS software company providing supply chain risk management solutions. Avetta’s contractor management platform is trusted by over 130,000 suppliers in over 120 countries. Contact us to learn about how our we can help you build confidence beyond compliance.