Human performance improvement – A beneficial way to investigate your laser incidents

The traditional approach to investigating near misses or incidents frequently results in fault finding and the creation of a blame culture. Often these by-products of an investigation mask underlying systemic issues and in reality, they do not prevent future incidents. New theories on incident investigation embraced by the Federal Aviation Administration (FAA), Department of Energy (DOE) and National Aeronautic and Space Administration (NASA) turn the traditional investigation upside down. The practice of Human Performance Improvement (HPI) recognizes human fallibility, while helping to identify how organizational systems influence human behavior. HPI empowers leaders to help their organizations positively influence human behavior. This paper examines a near miss event that occurred at a DOE national laboratory from an HPI perspective.