A Powerful Approach to System Failure and Human Reliability Analysis

When It Comes to Systems Thinking, Don’t Leave the Human Reliability Analysis Out

Failures have a way of forcing us into systems thinking. Unfortunately, when organizations dig into root cause analysis, they often default to the physical components—pumps, valves, servers, sensors—while giving only cursory attention to the human side of the system. That imbalance leads to incomplete conclusions and, worse, repeated failures. If we are serious about systems thinking, then human reliability analysis (HRA) must be part of the conversation from the start.

This article offers a practical, streamlined way to incorporate human factors into reliability and risk assessments. The goal is not to turn every engineer into a human‑factors specialist. The goal is to ensure that the human element is treated with the same rigor as the mechanical and digital elements with which it interacts every day.

A Real‑World Reminder

A recent water system emergency left a small town without normal water service for several days. After the crisis, the system owner commissioned a formal reliability and risk assessment to understand what went wrong and how to prevent a repeat event.

It’s not the first time I have been called in to assess a failed water system. A standard approach I use is a proven seven‑step reliability process aligned with the international risk standard, ISO 31000. The assessment includes equipment reliability, human factors, and system interfaces. Traditional tools and techniques, such as failure modes and effects analysis (FMEA), reliability block diagrams, fault tree analysis, and facilitated workshops, are used to evaluate the physical system.

Our team also takes the critical step of formally examining human performance. As a default, two human‑factors methods are applied:

• HFACS (Human Factors Analysis and Classification System) to evaluate management practices, training, communication, and organizational influences.

• HEART (Human Error Assessment and Reduction Technique) to estimate the probability of human‑driven failure modes and to quantify the impact of error‑producing conditions.

The combination of techniques provided a more complete picture of how people, processes, and equipment interacted to create the crisis. More importantly, the assessment provided how the system could be prioritized for improvement.

Why Human Reliability Analysis (HRA) Matters

People make errors. Those errors are predictable, measurable, and manageable when approached systematically. Ignoring the human element produces misleading risk estimates and unreliable mitigation strategies.

HRA methods fall into two broad categories:

• Qualitative methods use structured facilitation to identify contributors to human error and uncover root causes.

• Quantitative methods use databases of human tasks and their associated error rates to estimate failure likelihood and prioritize mitigation.

Qualitative approaches are usually sufficient for understanding contributors to human error. Quantitative approaches are valuable for comparing risks, justifying investments, and measuring improvement over time.

Two Practical Methods: HFACS and HEART

HFACS

HFACS breaks human error into four levels:

1. Unsafe acts

2. Preconditions for unsafe acts

3. Unsafe supervision

4. Organizational influences

Its strength is found in its ability to push teams beyond operator error into the management and cultural conditions that enable failure. In most organizations, this is where the true root causes reside.

HEART

HEART provides a structured framework for estimating the probability of human error for specific tasks. It classifies tasks, identifies error‑producing conditions, and calculates the overall probability of failure. HEART’s advantage is that it produces a number, useful for prioritization and for demonstrating the value of mitigation strategies. Its limitation is that it requires significant subjective judgment, which must be calibrated through experience and team discussion.

Its major advantage is that it produces a number.

Using More Than One Technique

A simplified approach—using HFACS to understand contributors and HEART to quantify risk—gives organizations a practical, defensible way to bring human reliability into the systems‑thinking conversation. The result is a more complete understanding of risk and a clearer path to meaningful improvement.

Don’t Leave HRA Out of Your Systems Thinking

The most effective reliability and risk assessments integrate equipment, human factors, and system interfaces. Leaving out the human element creates blind spots that eventually show up as failures, outages, regulatory scrutiny, or reputational damage.

Human error is not an afterthought. It is part of the system. Treat it that way.

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Need help getting started? JD Solomon Inc. specializes in asset management systems, reliability, and root cause analysis.

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JD Solomon is the founder of JD Solomon, Inc., the creator of the FINESSE Fishbone Diagram®, and the co-creator of the SOAP criticality method^©. He is the author of Communicating Reliability, Risk & Resiliency to Decision Makers: How to Get Your Boss’s Boss to Understand and Facilitating with FINESSE: A Guide to Successful Business Solutions.

Why Most Board Chairs and Facilitators Fail: The Rules of Order They Never Learn

In every setting, rules of order are the quiet force that turns a collection of individuals into a functioning decision‑making body.

Most group failures don’t come from bad intentions or weak expertise. They come from leaders who don’t understand the rules of the environment they’re operating in. Whether you’re facilitating a team session or chairing a board meeting under Robert’s Rules of Order, the principle is the same: process discipline is not optional. It’s the backbone of clarity, fairness, and legitimacy.

From the Real World

“So, you mean we have to take two votes on the final plan, and they must be one month apart?” asked one of the 25 members of the river basin council.

“That’s correct,” I stated as the lead facilitator of the multi-year effort.

“That seems like a complete waste of time,” came the reply.

“Well, first, those are the rules we agreed to over two years ago when we started the effort. They are in the by-laws, and we all agreed to that,” I stated. “But second, the reason is that we want to understand if anyone has issues before the final vote. The thirty days give us time to work out any differences that members may have.”

The member went on to say he didn’t like it, but he had agreed to it. And it would take more time to change the rules than just going by them. After all, the rules are the rules.

Why Rules Matter in Every Setting

Rules are not about bureaucracy. They are about the three P’s - predictability, protection, and progress. A skilled facilitator uses ground rules to keep a team focused and productive. A board chair uses Robert’s Rules to ensure fairness, order, and legitimacy. Both roles rely on structure to prevent the meeting from becoming a contest of personalities or power.

When leaders know the rules—whether self‑created or formally adopted—they create an environment where people can contribute without worrying about being cut off, ignored, or steamrolled. The rules serve as the neutral referee, keeping the work moving.

Five Parallels Between Team Facilitation and Robert’s Rules

These are five principles that every facilitator and board chair should be familiar with, regardless of whether your rules of order are established or must be developed by the body. Robert’s Rules of Order (12th ed.) references are aligned to each of the five parallels. These are the sections most directly tied to the underlying principle.

1. Rules Create Predictability

Teams thrive when they know how decisions will be made. Boards thrive when members know the sequence of motions, debate, and voting. Predictability reduces anxiety and keeps the group focused on substance.

Relevant RRO Sections

For example, these sections define the predictable flow of meetings and the rationale for structured procedure.

• §3–§4 (pp. 3–18) — The “Deliberative Assembly” and its standard order of business

  
  

• §41 (pp. 360–373) — Standard order of business and agenda

  
  

• §4:1–4:6 — Why predictable procedure matters

2. Rules Protect Participation

Facilitators use structured techniques to balance voices. Robert’s Rules guarantees equal rights to speak, make motions, and challenge errors. In both settings, rules protect people, not procedures.

Relevant RRO Sections

These are the core protections that guarantee every member has equal rights to speak, move, and challenge errors.

• §3:1–3:6 (pp. 3–9) — Fundamental rights of members

  
  

• §43 (pp. 387–399) — Rules of debate and equal opportunity to speak

  
  

• §61 (pp. 650–653) — Protecting minority rights

3. Rules Define Boundaries

A facilitator sets limits on time, scope, and behavior. A chair enforces limits on debate, germaneness, and authority. Boundaries prevent drift and keep the group within its mission.

Relevant RRO Sections

These sections define what is “in bounds,” what is not, and how the chair enforces those limits.

• §39 (pp. 343–350) — Limits of debate

  
  

• §12 (pp. 134–140) — Germaneness of amendments

  
  

• §56 (pp. 589–591) — Scope of authority and limits of boards and committees

4. Rules Enable Forward Motion

Facilitators use tools like prioritization and consensus checks. Chairs rely on the motion hierarchy to avoid circular debate. Forward motion is engineered, not accidental.

Relevant RRO Sections

These are the mechanisms that prevent circular discussion and keep the body moving toward a decision.

• §6–§10 (pp. 59–125) — The motion hierarchy and precedence

  
  

• §16 (pp. 184–199) — Previous Question (closing debate)

  
  

• §17 (pp. 200–210) — Limit or Extend Limits of Debate

5. Rules Provide Neutrality

A facilitator stays neutral by relying on process. A chair stays neutral by applying Robert’s Rules consistently. When the leader is neutral, the group trusts the outcome—even when they disagree with it.

Relevant RRO Sections

These sections establish the chair’s duty to apply rules fairly and without bias.

•  §47:7–§47:12 (pp. 451–456) — The impartial role of the chair

  
  

• §48 (pp. 457–466) — How the chair manages debate and maintains neutrality

  
  

• §61 (pp. 650–653) — Protecting rights through impartial procedure

When You Don’t Know the Rules

Not knowing the rules changes the power dynamics of the entire group. 

1. Meetings drift. Without structure, discussions wander, priorities blur, and decisions get postponed.

2. Strong personalities dominate. In the absence of rules, the loudest or most forceful voice wins. That’s not leadership; that’s luck.

3. Legitimacy erodes. When a chair misapplies Robert’s Rules, members lose confidence in the process. When a facilitator ignores ground rules, teams disengage.

4. Conflicts escalate. Rules provide a neutral way to resolve disagreements. Without them, disagreements become personal.

5. Decisions become vulnerable. Poor process creates openings for challenges, appeals, and second‑guessing—sometimes long after the meeting ends.

The irony is that people often blame the group, the personalities, or the culture when the real problem is that the leader didn’t know the rules well enough to guide the group through the work.

Some Additional Insights on Rules of Order

Most people seize on the rights of the minority and individual members to speak, make motions, appeal rulings, etc. That’s true and that’s the visible part of the rules of order in meetings. However, majority rule is the default mechanism.

Rules of order frameworks assume that, after a fair process, the majority decides. Debate, amendments, and procedural safeguards prepare the group for a legitimate majority decision. Once that happens, rules of order are in place to ensure that the body moves forward.

Some members and most observers don’t see how:

1. Agenda control shapes outcomes.

2. Committee recommendations frame decisions.

3. Majority thresholds ultimately govern passage.

Most rules of order, including Robert’s Rules, are a balance of efficiency and fairness, but tilted toward getting to a decision. The protections exist to legitimize the outcome, not to prevent it. Groups or individuals that overemphasize “everyone gets heard” without recognizing the built-in preference for majority action and committee structure often end up frustrated.

The Real Job of the Leader

Whether you’re facilitating a strategic planning session or chairing a formal board meeting, your job is not to be the smartest person in the room. Your job is to create the conditions where the group can do its best thinking and make defensible decisions.

Creating the conditions requires knowing the rules—your rules, the group’s rules, or Robert’s Rules—well enough to apply them confidently and consistently. When you do, the group moves with clarity and intent. When you don’t, the group stalls, struggles, or fractures.

Rules of Order Matter

In every setting, rules of order are the quiet force that turns a collection of individuals into a functioning decision‑making body. Know them. Use them. Rely on them. When the leader knows the rules, the group can focus on making good decisions that stand up to scrutiny.

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JD Solomon champions practical communication skills that help technical professionals convey complex ideas clearly and confidently. Need help getting started? Visit his company’s website, www.jdsolomonsolutions.com.

Trusted Advisors Create Trust By Asking Better Questions

The approach of trusted advisors to asking questions is fundamentally different from that of short-term persuaders or manipulators.

Asking questions as a trusted advisor is a nuanced and deliberate process that unfolds over time. Trusted advisors guide decision makers on some of their biggest life and career decisions. Asking questions as a trusted advisor contrasts with persuasion or manipulation, where narratives and emotions carry the day (like buying a car or shirt). The long-game approach to communicating as a trusted advisor requires empathy, patience, consistency, and an in-depth understanding of context. Remember, asking better questions as a trusted advisor is a long game.

"A trusted advisor gets one shot at credibility."

1. Building a Foundation of Trust

When asking questions as a trusted advisor, the primary focus is on building and maintaining a long-term relationship based on trust and mutual respect. Unlike one-off questions aimed at persuading or influencing a decision in the short term, trusted advisors ask questions demonstrating a deep understanding of needs, values, and long-term objectives.

This approach involves two key aspects.

A. Demonstrating Empathy and Understanding

Trusted advisors start by asking questions that show they genuinely care about the decision maker. That’s why having empathy is one of the seven bones in the FINESSE fishbone diagram. Trusted advisors are committed to understanding their decision makers' unique challenges and goals and putting those needs above their own.

Example: A trusted advisor might ask, "Can you share more about the key challenges you've faced in your industry and how they've influenced your current strategy?" This type of question shows a deep interest in the client's journey and helps establish a foundation of trust.

B. Focusing on Long-Term Goals and Values

While short-term questions often focus on immediate decisions or quick wins, trusted advisors prioritize questions that align with the decision maker’s long-term goals and values. Trusted advisors ask questions that seek to understand the context and why that context is important to the decision makers.

Example: Instead of asking, "How can we boost sales this quarter?" a trusted advisor might ask, "What are your long-term growth objectives, and how can we align our current initiatives to support those goals?" This approach makes sure that the advice given is consistent with the decision maker’s long-term vision, further solidifying the advisor's role as a trusted partner.

2. Navigating Complexity and Uncertainty

Trusted advisors are often called upon to guide complex and uncertain decisions. That's why the underpinning context of Communicating with FINESSE is communicating in high levels of complexity and uncertainty. The trusted advisor’s questioning techniques differ significantly from those used in short-term persuasion or manipulation. They are focusing on a comprehensive understanding of the situation and potential risks.

A. Encouraging Deep Reflection

Trusted advisors ask questions that encourage deep reflection and critical thinking in situations of complexity and uncertainty. They help decision makers explore different perspectives and consider various scenarios, enabling them to make more informed decisions.

Example:  A trusted advisor might ask, "What are the potential risks and benefits of each option we are considering, and how might they impact our long-term objectives?" Such questions help decision makers look beyond the immediate issue and consider broader implications, fostering a more thoughtful decision-making process.

B. Exploring Alternatives and Contingencies

Trusted advisors ensure that clients are aware of all alternatives and contingencies. They ask questions that prompt clients to think about different courses of action and prepare for potential challenges.

Example: Exploring alternatives and contingencies might include questions like, "What alternative strategies could we pursue if our initial plan doesn't yield the expected results?" or "How can we build flexibility into our plan to adapt to unforeseen changes?" By exploring these alternatives, trusted advisors help decision makers navigate uncertainty with greater confidence and resilience.

3. Prioritizing Open Dialogue and Collaboration

The nature of the questions trusted advisors ask fosters open dialogue and collaboration, creating an environment where decision makers feel comfortable sharing their thoughts and concerns.

A. Creating a Safe Space for Open Discussion

Trusted advisors prioritize creating a safe and open environment. Decision makers must feel comfortable discussing their concerns and uncertainties.

In a safe space for open discussion, trusted advisors can ask questions that invite honest feedback and encourage expressing thoughts freely.

Example: A trusted advisor might ask, "What are your biggest concerns about this project, and how can we address them together?"

However, if your decision makers feel like they are getting only part of the story or being persuaded and manipulated, forget about it. You only get one shot at creating a safe space for discussion, just as you get only one shot at credibility.

B. Facilitating Joint Problem-Solving

Trusted advisors focus on facilitating joint problem-solving. They ask questions to encourage decision makers to participate actively in the decision-making process, leveraging their expertise and insights.

Example:  A trusted advisor might ask, "What are some possible solutions you've considered, and how can we build on those ideas to develop a robust strategy?" This collaborative approach empowers decision makers.

However, if you force-feed solutions without any open problem-solving from decision makers, then forget about it. You are finished as a trusted advisor.

Better Questions, Trusted Advisors, and the Long Game

The approach of trusted advisors to asking questions is fundamentally different from that of short-term persuaders or manipulators. Empathy and putting the needs of the decision maker above your own are key. You get one shot at credibility. And you get one shot at asking good questions when it comes to developing trust and relationships as a trusted advisor. Asking questions about big decisions with complexity and uncertainty is a long game.

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JD Solomon champions practical communication skills that help technical professionals convey complex ideas clearly and confidently. Need help getting started? Visit his company’s website, www.jdsolomonsolutions.com.