HOP safety in practice: work as imagined vs. work as done

• HOP safety (Human and Organizational Performance) recognizes that human error is normal and focuses on understanding the systems and conditions that influence how people work.
• Work as imagined vs. work as done describes the gap between how policies and procedures say work should happen and how frontline workers actually perform under real-world conditions.
• Safety-II looks beyond incidents and failures to understand why work usually goes right, recognizing workers’ everyday adaptations as an important part of safety learning.
• The gap between policy and practice can create safety drift when workarounds and deviations gradually become normalized while official procedures remain unchanged.
• Organizations can close this gap by designing safe systems of work with frontline workers, encouraging near-miss and workaround reporting, and regularly aligning procedures with how work is actually done.

Introduction

There is ‘how a job is supposed to happen.’ And then there is ‘how it actually happens.’ On paper, the procedure is clear. The right equipment is available. Staffing levels are adequate. Every step happens in the correct order, and nobody is under unexpected pressure.

Then comes Tuesday afternoon.

A colleague calls in sick. A machine starts behaving unpredictably. The correct tool is being used elsewhere. Production is behind schedule, and an experienced worker knows a workaround that will get everything moving again.

This difference between work as imagined vs. work as done sits at the heart of Human and Organizational Performance (HOP) safety.

Table of contents

Click on a specific section below to navigate to that area:

1. 1. What is HOP safety (Human and Organizational Performance)?
2. 2. Work as imagined vs. work as done: the gap at the heart of HOP
3. 3. Safety-II: learning from why work usually goes right
4. 4. When the gap between policy and practice becomes safety drift
5. 5. Closing the gap: safe systems of work that reflect reality
6. FAQs

What is HOP safety (Human and Organizational Performance)?

HOP safety, or Human and Organizational Performance, is an approach to safety that recognizes human error as normal and looks at the systems and conditions surrounding people’s actions. Rather than simply asking who made a mistake, HOP asks why that action made sense in the context of the work.

This represents an important shift in thinking. Traditional safety management can sometimes assume that if organizations create the correct procedure, train workers to follow it, and enforce compliance, safe work should follow.

When something goes wrong, the obvious question then becomes: who didn’t follow the procedure?

HOP asks a different question: what was happening around that person that influenced what they did?

That might include workload, equipment design, staffing, conflicting priorities, time pressure, training, supervision, or the availability of resources.

The U.S. National Safety Council describes HOP as part of a broader change in safety thinking driven partly by the continued occurrence of fatalities and life-altering injuries despite decades of conventional safety improvement. Its work on serious incident prevention also highlights how organizational and human performance can provoke errors or weaken the defenses designed to prevent serious harm.

The five HOP principles

Dr. Todd Conklin popularized five principles of Human Performance that provide a useful foundation for HOP:

1. 1. People make mistakes – error is a normal part of human performance, so systems need to anticipate it.
   
2. 2. Blame fixes nothing – identifying someone to blame does not necessarily explain why an event occurred or prevent recurrence.
   
3. 3. Context drives behavior – decisions make more sense when we understand the circumstances in which people made them.
   
4. 4. Learning is vital – organizations need to learn from everyday work as well as incidents.
   
5. 5. Response matters – how leaders respond when something goes wrong influences whether workers share information or hide it.

These principles are widely attributed to Conklin’s ‘The 5 Principles of Human Performance’ and are reflected in contemporary HOP guidance.

Why HOP safety reframes error as a starting point, not a cause

Imagine an incident investigation concludes that an employee “failed to follow procedure.”

Technically, that may be true, but it isn’t much of an explanation.

Why did they deviate? Was the procedure practical? Was the equipment available? Did following every step create another problem? Had colleagues been using the same workaround successfully for months?

Stopping at “human error” closes down these questions. HOP treats the error as the beginning of the investigation rather than the end of it. This does not mean ignoring accountability. It means looking beyond the last person who touched the system so you can understand the conditions that shaped their actions.

Work as imagined vs. work as done: the gap at the heart of HOP

Work as imagined is how managers, procedures, and policies expect a job to happen. Work as done is how people actually perform that job under real-world conditions. Understanding the difference is essential because this gap is where safety risks can develop.

Erik Hollnagel and Robyn Clay-Williams describe Work-as-Imagined (WAI) as how we think work should be performed to achieve an intended outcome. Work-as-Done (WAD), in contrast, represents the direct experience of the people actually carrying out that work.

Crucially, they argue that we should not automatically treat one as “right” and the other as “wrong.”

The objective isn’t simply to force work as done to comply with work as imagined. It is to acknowledge the difference, understand why it exists, and find ways to address it.

What is work as done, and why does it never match the procedure?

Procedures are written in advance. Work happens in the present. That distinction matters.

A procedure cannot always anticipate the combination of circumstances a worker will encounter: a new contractor, an unexpected fault, bad weather, missing equipment, a delayed delivery, or competing production priorities.

Workers adapt, and adaptation is not inherently unsafe. In fact, those adjustments are often exactly what allow organizations to function successfully despite changing conditions. The problem occurs when management knows only the procedure and not the adaptations.

The Tuesday-afternoon reality: an example from the frontline

Consider a maintenance task in manufacturing:

Work as imagined: Two trained employees isolate a machine. The correct tools are immediately available. The permit is reviewed. Isolation is verified. The work begins.

Work as done: It’s Tuesday afternoon. One trained employee has been pulled onto another urgent job. The preferred isolation point is difficult to access because materials have been temporarily stored nearby. Production wants the machine running before the next shift.

The maintenance technician has completed this job dozens of times. They know another way.

And it works.

Nothing goes wrong.

That last point is important. The workaround has now been reinforced by success. If the same circumstances arise next week, why wouldn’t they do it again? This is one way the gap between policy and practice can develop into safety drift.

Safety-II: learning from why work usually goes right

Safety-II (and Safety-I) is a perspective on how to think about systems and safety. Safety-II focuses on understanding how work succeeds under changing conditions, rather than learning only from accidents and failures. It recognizes that the same human adaptability involved in unwanted events is also helping organizations complete work safely every day. This matters because most work goes right.

If you investigate only the rare occasions when something fails, you are ignoring a huge source of safety information: regular work.

Safety-I vs. Safety-II: from counting failures to understanding success

Safety researchers Hollnagel, Robert Wears, and Jeffrey Braithwaite’s influential ‘From Safety-I to Safety-II’ whitepaper describes the distinction clearly:

Safety-I defines safety as a state where as few things as possible go wrong. Safety-II focuses instead on ensuring as many things as possible go right.

The approaches do not need to be mutually exclusive. We still need to investigate incidents, identify hazards, and prevent failures. Safety-II simply asks us to expand the picture.

Why did the previous 200 maintenance jobs go well? What did experienced workers notice? What adjustments did they make? Which controls helped when conditions changed? That is safety information too.

People as the solution, not the problem

This is perhaps one of HOP’s biggest mindset changes.

Your workers are not simply a source of human error that needs to be controlled. They are also the people constantly detecting problems, adjusting plans, and keeping operations running safely.

If we want to understand work as done, we need their knowledge, and we need them engaged with safety.

When the gap between policy and practice becomes safety drift

The gap between policy and practice becomes safety drift when repeated adaptations and workarounds gradually become normalized, while the organization’s official procedures remain unchanged.

Eventually, the documented system presents one version of safety while everyday work operates according to another.

This rarely happens overnight – a worker discovers a shortcut because the prescribed method is difficult. It works. So they use it again.

A colleague learns the same approach. Months later, “that’s how we do it here.” Meanwhile, the procedure still describes something entirely different.

How small, seemingly sensible workarounds accumulate into invisible risk

This is what makes safety drift difficult to see.

Individual adaptations often appear completely reasonable in context. The equipment has always behaved like that. The workaround has never caused an accident. Everyone knows the procedure takes twice as long as the job actually allows.

Operational success provides reassurance that the adaptation is safe. Until it isn’t.

The question for safety leaders isn’t simply, “Are people following the procedure?”

A better question is: “What makes it difficult to follow this procedure during real work?”

Five signs your policy and practice have drifted apart

Your organization may have a growing gap between work as imagined and work as done if:

Closing the gap: safe systems of work that reflect reality

Safe systems of work need to reflect how work actually happens, not simply how organizations hope it happens. Closing the gap means involving frontline workers in procedure design, learning from everyday adaptations, and continuously testing documented systems against operational reality.

Caponecchia and Wyatt describe the provision of a safe system of work as a fundamental concept within occupational health and safety duties internationally. They also point out that there is surprisingly little consistency around what the term actually means.

A procedure sitting in a document management system is not enough. A genuinely safe system needs to work in the environment for which it was designed.

Design safe systems of work with the people who do the work

If you want to understand whether a procedure works, ask the people using it. Walk the task with them. Ask them:

Some useful KPIs that are a mix of leading and lagging indicators can include:

• What steps are difficult?
• Where does the procedure slow them down?
• What happens when staffing is lower than planned?
• Which tools are unavailable?
• Where do competing priorities appear?
• Most importantly: What do you actually do when that happens?

That final question will reveal more about operational risk than another perfectly completed checklist.

Your safety management system should help capture this reality and turn frontline learning into practical improvements.

Use frontline reporting to keep procedures matched to work as wone

Workers also need an easy way to tell you when reality changes. That includes incidents, but it should go much further.

Near misses, observations, recurring workarounds, and concerns about procedures can all provide early warning that work as imagined and work as done are drifting apart.

Making near-miss and incident reporting simple is important. So is what happens after somebody reports. If reporting a workaround immediately results in blame, workers learn not to tell you about workarounds.

If it results in a conversation about why the workaround exists and whether the system can be improved, you gain visibility into how work actually happens.

This understanding is one of the most valuable things HOP safety can give you. Your aim isn’t to create a workplace where nobody ever adapts; it’s to create one where management understands those adaptations before today’s sensible workaround becomes tomorrow’s invisible risk.

You can take your first step by assessing the level of safety drift in your organization. See where you stand by taking our 3-minute quiz!

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