4 Hour Professional Development Seminar HPRCT Workshop, Baltimore Maryland June 21, 2010
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Transcript of 4 Hour Professional Development Seminar HPRCT Workshop, Baltimore Maryland June 21, 2010
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4 Hour Professional Development SeminarHPRCT Workshop, Baltimore Maryland
June 21, 2010
Richard S. Hartley, Ph.D., P.E.
Janice N. Tolk, Ph.D., P.E.
This presentation was produced under contract number DE-AC04-00AL66620 with
High Reliability Operations
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What is a High Reliability Organization?
An organization that repeatedly accomplishes its mission while avoiding catastrophic events, despite significant hazards, dynamic tasks, time constraints, and complex technologies
A key attribute of being an HRO is to learn from the organization’s mistakes
A.K.A. a learning organization
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Examples of High Reliability Organizations or Not?
Nuclear NavyCommercial nuclear powerAircraft carrier operationsHospital patient careMilitary nuclear deterrentForest serviceAviationNuclear weapons assembly and disassembly
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Business Case for High Reliability
Is it right for you?
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1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Cas
es p
er 2
00,0
00 w
orkh
ours
YEAR
DOE TRC and DART Case Rates
All DOE TRC Rate All DOE DART Case Rate
Data as of 7/7/2009
Contractor ISM
deployed
DOE injury rates have come down significantly since Integrated Safety Management (ISM) was adopted
Does a Systems Approach Make Sense?Department of Energy Safety Improvement from 1993-2008
5
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Does a Systems Approach Make Sense?U.S. Nuclear Industry Performance 1985-2008
Rx Trips/ Scrams
Cost (¢/kwh)
SignificantEvents/Unit
Capacity Factor (% up)
Nuclear Energy Institute (NEI) Data6
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The Alternate to the HRO
The Normal Accident Organization
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Feeling Comfortable with a Good Safety Stats?
As Columbia and Davis-Besse have demonstrated, great safety stats don’t equal real, tangible organizational safety.
The tendency for normal people when confronted with a continuous series of positive “stats” is to become comfortable with good news and not be sensitive to the possibility of failure.
“Normal people” routinely experience failure by believing their own press (or statistics).
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NASA & ColumbiaJan 16, 2003
CAIB: “The unexpected became the expected, which became the accepted.”
When NASA lost 7 astronauts, the organization's TRC rate was 600% better than the DOE complex.
And yet, on launch day
3,233 Criticality 1/1R* hazards had been waived.
* Criticality 1/1R component failures result in loss of the orbiter and crew.
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Davis-Besse2002
Had some performance “hard spots” in the 80's
Had become a world-class performer in the next 15 years
Preceding initiating events of mid 90's
Frequently benchmarked by other organizations
While a serious corrosion event was taking place Complete core melt near miss in 2002
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SYSTEM ACCIDENT TIMELINE
1979 - Three Mile Island1984 – Bhopal India1986 – NASA Challenger1986 – Chernobyl1989 – Exxon Valdez
1996 – Millstone2001 – World Trade Center2005 – BP Texas City2007 – Air Force B-522008 – Stock Market Crash
What is Next? Who is Next?
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How do Organizations Get Themselves into System
Accident Space?Attempts to Understand & Prevent System Accidents
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Attempts to Understand & Prevent System Accidents(High Reliability vs. Normal Accident Theory)
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The Cure for Organization Blindness
"Most ailing organizations have developed a functional blindness to their own defects. They are not suffering because they cannot resolve their problems, but because they cannot see their problems.“
John Gardner
Weak Signals
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What is the Focus of an HRO?
Individual Accidents OR Systems Accidents?
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Individual Accident
An accident occurs wherein the worker is not protected from the plant and is injured (e.g. radiation exposure, trips, slips, falls, industrial accident, etc.)
Plant(hazard)
Human Errors(receptor)
Focus:Protect the worker from the plant
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Systems Accident
An accident wherein the system fails allowing a threat (human errors) to release hazard and as a result many people are adversely affected
Workers, Enterprise, Surrounding Community, Country
Human Errors(threat)
Plant(hazard)
Focus:Protect the plant from the worker The emphasis on the system accident in no way degrades the
importance of individual safety , it is a pre-requisite of an HRO
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System Accident vs. System Event
System accident - an occurrence that is unplanned and unforeseen that results in serious consequences and causes total system disruption (i.e. death, dose, dollars, delays etc.).
System event - any unplanned, unforeseen occurrence that results in the failure of the system that does not result in catastrophic consequences -- indicates a breakdown in the system vital to the well-being of many people and the survivability of the organization!
System accident - an occurrence that is unplanned and unforeseen that results in serious consequences and causes total system disruption (i.e. death, dose, dollars, delays etc.).
System event - any unplanned, unforeseen occurrence that results in the failure of the system that does not result in catastrophic consequences -- indicates a breakdown in the system vital to the well-being of many people and the survivability of the organization!
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Why Is Being an HRO So Important?
20
Some types of system failures are so punishing that they must be avoided at almost any cost.
These classes of events are seen as so harmful that they disable the organization, radically limiting its capacity to pursue its goal, and could lead to its own destruction.
Laporte and Consolini, 1991
Some types of system failures are so punishing that they must be avoided at almost any cost.
These classes of events are seen as so harmful that they disable the organization, radically limiting its capacity to pursue its goal, and could lead to its own destruction.
Laporte and Consolini, 1991
Some types of system failures are so punishing that they must be avoided at almost any cost.
These classes of events are seen as so harmful that they disable the organization, radically limiting its capacity to pursue its goal, and could lead to its own destruction.
Laporte and Consolini, 1991
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Comparing & Contrasting High Reliability Theory with
Normal Accident TheoryHROs vs. NAT Organizations
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High Risk or High Consequence?
R = C x P
If we are truly working with high-risk operations, ethically and morally we should not be in business!
Risk = Consequence x Probability
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High Reliability Organization (HRO) vs. Normal Accident Theory (NAT)
Belief of HROAccidents can be avoided by
organizational design and management i.e. Risk = C x P is manageable
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Dr. Karlene Roberts
Dr. Charles Perrow
Belief of NATAccidents are inevitable in
complex and tightly coupled operationsi.e. Risk = C x P is too high
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High Reliability Organization (HRO) vs. Normal Accident Theory (NAT)
Belief of HROAccidents can be avoided by
organizational design and management i.e. Risk = C x P is manageable
Belief of NATAccidents are inevitable in
complex and tightly coupled operationsi.e. Risk = C x P is too high
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Control of Risk DOE reduces “C” by:
· minimizing the hazard and/or · mitigating the consequence
DOE reduces “P” - human performance improvement· human performance error precursors· barriers
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Complex vs. Linear InteractionsLinear interactions
Expected & familiar production or maintenance sequencesVisible, even if unplannedSimple -- readily comprehensible
Complex interactionsOne component can react with others outside normal production sequence
Nonlinear
Unfamiliar sequences, or unplanned and unexpected sequences not visible nor immediately comprehensible
25
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Complex vs. Linear Interactions
Linear interactions
Expected & familiar production or maintenance sequencesVisible, even if unplannedSimple -- readily comprehensible
Complex interactionsOne component can react with others outside normal production sequenceNonlinearUnfamiliar sequences, or unplanned and unexpected sequences not visible nor immediately comprehensible
26
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Complex vs. Linear Interactions
27
Complex Interactions
1
23
Linear Interactions
1 2 3
4
For linear interactions 4 events lead to 4 interactions.
1
23
4
56
1
23
4
56
7
8 9
Complex Interactions
1
23
4
56
7
8 9
10
11
12
For complex interactions, 4 events lead to 12 possible interactions.
Greatly amplifies difficulty in determining and responding to the problem.
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Complex Interactions Alone Insufficient
Complex interactions not necessarily high-risk systems with catastrophic potential, examples:
UniversitiesR&DFederal Government
Also takes another key ingredientTight coupling
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Loose vs. Tight CouplingLoosely coupled systems:
Delays possible; processes can remain in standby modeSpur-of-the-moment redundancies and substitutions can be found Fortuitous recovery aids possibleFailures can be patched more easily, temporary rig can be set up
Tightly coupled systems:Time-dependent processes: they can’t wait or standbyReactions in chemical plants – instantaneous, can’t be delayed or extendedSequences invariantOnly one way to reach production goalLittle slack; quantities must be precise, resources can’t be substitutedBuffers and redundancies must be designed in, thought of in advance
29
Ever done this?
Supe
r Glue
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Example of Loose vs. Tight Coupling
30
Loose Coupling Tight Coupling
All rights reserved © B&W Pantex 200831Normal Accidents –Living with High-Risk Technologies, Perrow
Loos
e <
- -- -
- -- -
--- -
- Cou
p li n
g --
- -- -
---
Tigh
t
Mor
e tim
e to
act
<--
--- -
Coup
li ng
----
L ess
tim
e t o
act
1 2
3 4
(Incr
ease
s es
cala
tion
to
full-
blow
n ev
ent)
(Can
put
in st
andb
y m
ode)
Interaction/Coupling Chart(Adapted from Fig 9.1 Perrow)
Visible Interactions < --------------------Interactions --------------------- > Hidden Interactions
1 2
3 4
(Decreases the probability of dangerous incident)
(Increases the probability of dangerous incident)
Linear < ----------------------Interactions ------------------------- > Complex
Loos
e <
- -- -
- -- -
--- -
- Cou
p li n
g --
- -- -
---
Tigh
t
Visible Interactions < --------------------Interactions --------------------- > Hidden Interactions
Mor
e tim
e to
act
<--
--- -
Coup
li ng
----
L ess
tim
e t o
act
1 2
3 4
Nuclear Power
Nuclear Weapon
Accidents
AircraftDNA
ChemPlant
Space
PowerGrids
Marinetransport
Airways
Dams
Railtransport
Assembly lineproduction
TradeSchools
Most Mfg. Plants
JuniorCollege
Single goal agenciesMotor vehicle, post office
Mining
Military
Universities
R&D Firms
Multi goal agenciesDOE, OMB
MilitaryEarly warning
(Incr
ease
s es
cala
tion
to
full-
blow
n ev
ent)
(Decreases the probability of dangerous incident)
(Increases the probability of dangerous incident)
(Can
put
in st
andb
y m
ode)
Less likely to have system accident
Linear < ----------------------Interactions ------------------------- > ComplexMore likely to have system accident
Loos
e <
- -- -
- -- -
--- -
- Cou
p li n
g --
- -- -
---
Tigh
t
Visible Interactions < --------------------Interactions --------------------- > Hidden Interactions
Mor
e tim
e to
act
<--
--- -
Coup
li ng
----
L ess
tim
e t o
act
1 2
3 4
Nuclear Power
Nuclear Weapon
Accidents
AircraftDNA
ChemPlant
Space
PowerGrids
Marinetransport
Airways
Dams
Railtransport
Assembly lineproduction
TradeSchools
Most Mfg. Plants
JuniorCollege
Single goal agenciesMotor vehicle, post office
Mining
Military
Universities
R&D Firms
Multi goal agenciesDOE, OMB
MilitaryEarly warning
More likely to have system accident
(Incr
ease
s es
cala
tion
to
full-
blow
n ev
ent)
(Decreases the probability of dangerous incident)
(Increases the probability of dangerous incident)
(Can
put
in st
andb
y m
ode)
Less likely to have system accident
Linear < ----------------------Interactions ------------------------- > ComplexHROs must neutralize
bad effects here
Normal Accidents –Living with High-Risk Technologies, Perrow
YourOrganization?
YourOrganization?
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Effect of Complex vs. Linear Interactions
According to Perrow:
Interactiveness increases the magnitude of accident because of unrecognized connections between systems
Tight coupling increases the probability of initiating the accident
32
Together they are the makings of a normal accident
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Interactive Complexity & Coupling Lets Discuss
Provide examples
In your own organization
In other organizations
In other places throughout the world
33
Where is today’s world going with regards complexity and coupling?
Is this good or bad?
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HROAccidents can be avoided by
organizational design and management
NATAccidents are inevitable in
tightly coupled and complex operations.
Better technologies
1
2Better organizational processes
Perrow states that there are two primary ways that organizations try to counter
interactive complexity (NAT)
High Reliability or Accident Waiting to Happen?
Dr. Charles Perrow
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HROAccidents can be avoided by
organizational design and management
HROs use the rational-closed system construct to accomplish their goal by:
1. Maintaining safety as a leadership objective
2. Using redundant systems
3. Focusing on three operational and management factors · decentralization, · culture, and · continuity
4. Being a learning organization
The Limits of Safety, Scott Sagan
High Reliability or Accident Waiting to Happen?
Dr. Scott Sagan
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HROAccidents can be avoided by
organizational design and management
HROs use the rational-closed system construct to accomplish their goal by:
1. Maintaining safety as a leadership objective
2. Using redundant systems
3. Focusing on three operational and management factors · decentralization, · culture, and · continuity
4. Being a learning organization
The Limits of Safety, Scott Sagan
High Reliability or Accident Waiting to Happen?
Multiple & Independent
Barriers
Workers have to call the shots.
Leaders want workers to call the shots as they would.
Want workers to call the shots based on experience – keep the
plant open.
Learn from small mistakes – information-
rich events!
Without leadership, safety is but a facade.
HROs use the rational-closed system construct to accomplish their goal by:
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NATAccidents are inevitable in
tightly coupled and complex operations.
The Limits of Safety, Scott Sagan
NATs believe the natural-open organizational system prevails because:
1. Conflicting leadership objective prevail
2. There are perils in redundant systems
3. There is no effective management of· decentralization, · culture, or· continuity
4. Organizational learning is restricted
High Reliability or Accident Waiting to Happen?
NATs believe the natural-open organizational system prevails because:
Signs of Natural ActorsNo clear consistent goals
Mgt at different levels have conflicting goals
Unclear technology – organizations don’t understand their own processes
Signs of Open OrganizationsDecision-makers come and goSome pay attention, others don’tKey meetings dominated by biased,
uninformed, uninterested personnel
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NATAccidents are inevitable in
tightly coupled and complex operations.
The Limits of Safety, Scott Sagan
NATs believe the natural-open organizational system prevails because:
1. Conflicting leadership objective prevail
2. There are perils in redundant systems
3. There is no effective management of· decentralization, · culture, or· continuity
4. Organizational learning is restricted
Pressure to maintain production only slightly modified by increased
interests in safety.
Redundant barriers, not independent.
Redundancy makes system opaque.Redundancy falsely makes system
appear more safe.
Not enough time to improvise – tightly coupled.
Leaders don’t know enough about their operations to evaluate whether workers are responding correctly or
not.
Causes of accidents and near-misses unclear –hard to learn.
Incentives to fabricate positive records abound.
High Reliability or Accident Waiting to Happen?
NATs believe the natural-open organizational system prevails because:
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HROAccidents can be avoided by
organizational design and management
NATAccidents are inevitable in
tightly coupled and complex operations.
HROs use the rational-closed system construct to accomplish their goal by:
1. Maintaining safety as a leadership objective
2. Using redundant systems
3. Focusing on three operational and management factors · decentralization, · culture, and · continuity
4. Being a learning organization
The Limits of Safety, Scott Sagan
NATs believe the natural-open organizational system prevails because:
1. Conflicting leadership objective prevail
2. There are perils in redundant systems
3. There is no effective management of· decentralization, · culture, or· continuity
4. Organizational learning is restricted
High Reliability or Accident Waiting to Happen?Attributes of HROs and NATs
BadGood
HROs use the rational-closed system construct to accomplish their goal by:
NATs believe the natural-open organizational system prevails because:
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HROAccidents can be avoided by
organizational design and management
NATAccidents are inevitable in
tightly coupled and complex operations.
HROs use the rational-closed system construct to accomplish their goal by:
1. Maintaining safety as a leadership objective
2. Using redundant systems
3. Focusing on three operational and management factors · decentralization, · culture, and · continuity
4. Being a learning organization
The Limits of Safety, Scott Sagan
NATs believe the natural-open organizational system prevails because:
1. Conflicting leadership objective prevail
2. There are perils in redundant systems
3. There is no effective management of· decentralization, · culture, or· continuity
4. Organizational learning is restricted
High Reliability or Accident Waiting to Happen?Attributes of HROs and NATs
BadGood
HROs use the rational-closed system construct to accomplish their goal by:
NATs believe the natural-open organizational system prevails because:These are attributes of
HROs and NATs.
The literature is silent on how they are achieved or avoided.
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Don’t Dismiss the Normal AccidentNAT theorists take their case to the extreme but don’t dismiss their warnings
“Normal” implies it is likely to happen with “normal” organizationsIt is “normal” to be human
We all relax if things go rightWe all know we cut corners when we get busy We all do what we have done beforeWe do what we see others do The lack of negative response reinforces our belief that perhaps the rules were too strenuous so we start cutting more corners more often
Those dealing with high consequence operations never have the luxury of being “normal”
41
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Fundamentals of Systems Approach
Reality EngineeringUnderstanding Socio-Technical Systems to
Improve Bottom-Line
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Central Theme of an HRO
Focus on what is important
Measure what is important
43
The most important thing,
is to keep the most important thing,
the most important thing.
Steven Covey, 8th Habit
Not a New Initiative
Logical, Defensible Way to Think
Based on Logic & Science
Logic & Science are Time and New Initiative Invariant
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HROs Think and Act Differently
Take a physics-based system approach
Measure gaps relative to physics-based system
Explicitly account for peoplePeople are not the problem, they are the solutionPeople are not robots, pounding won’t improve performancePeople provide safety, quality, security, science etc.
Sustain behavior – account for cultureImprove long-term safety, security, quality
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Spectrum of Safety
Spectrum of Safety
Squishy People Part of Safety• Average IQ of the organization• It is a systems approach • Gaussian curve
As People Do
Hard Core Safety Physics• Physics invariant• Prevent flow of unwanted energy• Delta function
As Engineers Write
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Spectrum of Safety
Spectrum of Safety
Old Mind-SetCompliance-based safety High Reliability Organization
Explicitly consider human error Take into account org. culture Maximize delivery of procedures Improve system safety
Hard Core Safety Physics• Physics invariant• Prevent flow of unwanted energy• Delta function
Squishy People Part of Safety• Average IQ of the organization• It is a systems approach • Gaussian curve
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Construct of an HRO
A Systems Approach to Safety
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Remember if it is the System Accident
Human Errors(threat)
Plant(hazard)
If a systems approach is required to ensure we don’t have to rely on every individual having a perfect day every day to avoid the catastrophic accident,
then we had better take the best approach to implementing that system!
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Construct of the HROSystems Approach to Avoid Catastrophic Accidents
Deming’s Theory
of Profound
Knowledge (TPK)
provides a
foundation for
the systems
approachW. Edwards Deming
We used Deming’s
Theory of Profound
Knowledge to
develop a process
to attain those HRO
attributes identified
by the High
Reliability Theorists
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• Organizations have cultures that influence the system and desired outcome
• Theory, prediction, and feedback as the basis of learning
• Statistical process control is the foundation of process optimization
• Organizations are systems that interact within their internal and external environments
Knowledge of Systems
Knowledge of
Variation
Knowledge of
Psychology
Knowledge of
Knowledge
Construct of the HROSystems Approach to Avoid Catastrophic Accidents
Deming’s Theory of Profound Knowledge (TPK) used to provide foundation for the systems approach
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• Knowledge of Systems
• Knowledge of Variation
• Knowledge of Psychology
• Knowledge of Knowledge
HRO Practice #1
Manage the System, Not
the Parts
HRO Practice #2
Reduce Variability in HRO System
HRO Practice #3
Foster a Strong
Culture of Reliability
HRO Practice #4
Learn & Adapt as an Organization
Fundamental HRO Practices HRO Practices Cross-Walked to Deming TPK
Knowledge of Systems
Knowledge of
Variation
Knowledge of
Knowledge
Knowledge of
Psychology
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• Knowledge of Systems
• Knowledge of Variation
• Knowledge of Psychology
• Knowledge of Knowledge
HRO Practice #1
Manage the System, Not
the Parts
HRO Practice #2
Reduce Variability in HRO System
HRO Practice #3
Foster a Strong
Culture of Reliability
HRO Practice #4
Learn & Adapt as an Organization
Fundamental HRO PracticesActions Associated with Each HRO Practice
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• Ensure system provides safety
• Manage system, evaluate variability
• Foster culture of reliability
• Model organizational learning
•Deploy system•Evaluate operations – meas. variability•Adjust processes
• Provide capability to make conservative decisions
• Make judgments based on reality
• Openly question & verify system
• Generate decision-making info• Tiered
approach• Refine HRO
system
HRO Practice #1Manage the System, Not
the Parts
HRO Practice #2
Reduce Variability in HRO System
HRO Practice #3
Foster a Strong
Culture of Reliability
HRO Practice #4
Learn & Adapt as an Organization
Fundamental HRO PracticesActions Associated with Each HRO Practice
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• Ensure system provides safety
• Manage system, evaluate variability
• Foster culture of reliability
• Model organizational learning
• Deploy system• Evaluate
operations – meas. variability
• Adjust processes
• Provide capability to make conservative decisions
• Make judgments based on reality
• Openly question & verify system
• Generate decision-making info• Tiered
approach• Refine HRO
system
HRO Practice #1Manage the System, Not
the Parts
HRO Practice #2
Reduce Variability in HRO System
HRO Practice #3
Foster a Strong
Culture of Reliability
HRO Practice #4
Learn & Adapt as an Organization
Fundamental HRO PracticesActions Associated with Each HRO Practice
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• Ensure system provides safety
• Manage system, evaluate variability
• Foster culture of reliability
• Model organizational learning
• Deploy system• Evaluate
operations – meas. variability
• Adjust processes
• Provide capability to make conservative decisions
• Make judgments based on reality
• Openly question & verify system
• Generate decision-making info• Tiered
approach• Refine HRO
system
HRO Practice #1Manage the System, Not
the Parts
HRO Practice #2
Reduce Variability in HRO System
HRO Practice #3
Foster a Strong
Culture of Reliability
HRO Practice #4
Learn & Adapt as an Organization
Fundamental HRO PracticesActions Associated with Each HRO Practice
All rights reserved © B&W Pantex 200856
• Ensure system provides safety
• Manage system, evaluate variability
• Foster culture of reliability
• Model organizational learning
• Deploy system• Evaluate
operations – meas. variability
• Adjust processes
• Provide capability to make conservative decisions
• Make judgments based on reality
• Openly question & verify system
• Generate decision-making info
•Tiered approach• Refine HRO system
HRO Practice #1Manage the System, Not
the Parts
HRO Practice #2
Reduce Variability in HRO System
HRO Practice #3
Foster a Strong
Culture of Reliability
HRO Practice #4
Learn & Adapt as an Organization
Fundamental HRO PracticesActions Associated with Each HRO Practice
All rights reserved © B&W Pantex 200857
• Ensure system provides safety
• Manage system, evaluate variability
• Foster culture of reliability
• Model organizational learning
• Deploy system• Evaluate
operations – meas. variability
• Adjust processes
• Provide capability to make conservative decisions
• Make judgments based on reality
• Openly question & verify system
• Generate decision-making info
•Tiered approach• Refine HRO system
HRO Practice #1Manage the System, Not
the Parts
HRO Practice #2
Reduce Variability in HRO System
HRO Practice #3
Foster a Strong
Culture of Reliability
HRO Practice #4
Learn & Adapt as an Organization
Fundamental HRO PracticesActions Associated with Each HRO Practice
All rights reserved © B&W Pantex 200858
• Ensure system provides safety
• Manage system, evaluate variability
• Foster culture of reliability
• Model organizational learning
• Knowledge of Variation
• Generate decision-making info• Tiered
approach• Refine HRO
system
HRO Practice #1Manage the System, Not
the Parts
HRO Practice #2
Reduce Variability in HRO System
HRO Practice #3
Foster a Strong
Culture of Reliability
HRO Practice #4
Learn & Adapt as an Organization
Fundamental HRO PracticesHRO Practice #2
All rights reserved © B&W Pantex 200859
• Ensure system provides safety
• Manage system, evaluate variability
• Foster culture of reliability
• Model organizational learning
• Deploy system• Evaluate
operations – meas. variability
• Adjust processes
• Generate decision-making info• Tiered
approach• Refine HRO
system
HRO Practice #1Manage the System, Not
the Parts
HRO Practice #2
Reduce Variability in HRO System
HRO Practice #3
Foster a Strong
Culture of Reliability
HRO Practice #4
Learn & Adapt as an Organization
Fundamental HRO Practices HRO Practice #2
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Breaking the Chain Between Threat and Hazard
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STEP5
FOSTER A CULTURE OF RELIABILITY
System Acciden
t To Avoid
HumanPerformance
Error Precursors
Threat From
Individual Errors
Hazard to
Protect & to
Minimize
Break-the-Chain Framework
HumanPerformance
Error Precursors
Hazard to
Protect & to
Minimize
STEP 6 –LEARN FROM SMALL ERRORS TO PREVENT BIG ONES
STEP4
MANAGE DEFENSES
STEP 3
RECOGNIZE THREAT POSED BY HUMAN ERROR – ERROR
PRECURSORS
STEP 1
FOCUS ON THE
CONSEQUENCES
STEP 2
RECOGNIZE & MINIMIZE HAZARD
“Break the Chain” at Any Point & Stop the System Accident“Break
TheChain”
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Organizational Culture
Evaluating the HRO
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• Provide capability to make conservative decisions
• Make judgments based on reality
• Openly question & verify system
• Generate decision-making info• Tiered
approach• Refine HRO
system
HRO Practice #1Manage the System, Not
the Parts
HRO Practice #2
Reduce Variability in HRO System
HRO Practice #3
Foster a Strong
Culture of Reliability
HRO Practice #4
Learn & Adapt as an Organization
Fundamental HRO Practices HRO Practice #3
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Why is Culture Important to an HRO?
Spectrum of Safety
High Reliability Organization Explicitly consider human error Take into account org. culture Maximize delivery of procedures Improve system safety
Hard Core Safety Physics• Physics invariant• Prevent flow of unwanted energy• Delta function
Squishy People Part of Safety• Average IQ of the plant• It is a systems approach • Gaussian curve
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Organization’s Culture Provides
1. Sustainabilityor
2. Inhibitors
What does Culture to for You?
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An organization’s values and behaviors, modeled by its leaders and internalized by its members, which serve to make safe performance of work the overriding priority to protect the public, workers, and the environment.
EFCOG Safety Culture Task Group, 2008
Definition of Safety Culture
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An organization’s values and behaviors, modeled by its leaders and internalized by its members, which serve to make safe performance of work the overriding priority to protect the public, workers, and the environment.
EFCOG Safety Culture Task Group, 2008
Definition of Safety Culture
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An organization’s values and behaviors, modeled by its leaders and internalized by its members, which serve to make safe performance of work the overriding priority to protect the public, workers, and the environment.
EFCOG Safety Culture Task Group, 2008
Definition of Safety Culture
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An organization’s values and behaviors, modeled by its leaders and internalized by its members, which serve to make safe performance of work the overriding priority to protect the public, workers, and the environment.
EFCOG Safety Culture Task Group, 2008
Definition of Safety Culture
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Basics of Culture
Most of the content of this section is adapted from Schein, Organizational Culture and Leadership, 2004
Dr. Edgar Schein
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Culture begins when leadership imposes its values and assumptions on a group
If the group is successful because they use the leader’s values and assumptions
likely these assumptions will be taken for granted and as a result
you then have a culture defined for later generations
Leadership’s Challenge with Culture(new organization, e.g. new start-up company)
What if the external environment changes?
Schein, Organizational Culture and Leadership, 2004
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Environment changesGroup runs into adaptive difficultiesSome assumptions are no longer validLeadership needs to step up once again
Leadership’s Challenge with Culture(existing organization, e.g. organization needing change)
Leadership needs to step outside culture the leader created and start evolutionary change to adapt to new environment.
Ability to perceive limitations of one’s own culture and to evolve culture adaptively is the essence and ultimate challenge of leadership!
Schein, Organizational Culture and Leadership, 2004
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Culture refers to:Customs and rituals
Practices organization develops around their handling of
people
Espoused values and credo of an organization
Culture (good, bad, functionally effective) depends:not only on the culture alone (internal integration), but
on the relationship of the culture to environment in which it
exists (external adaptation and survival)
Culture -- An Empirically Based Abstraction
Schein, Organizational Culture and Leadership, 2004
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Culture points us to phenomena below surfacePowerful in their impact but
Invisible and, to a considerable degree, unconscious
Just as our personality and character guide and
constrain our behavior, so does culture guide and constrain behavior of members of
a group through the shared norms that are held in that group
Schein, Organizational Culture and Leadership, 2004
Culture -- An Empirically Based Abstraction
Culture is to a group what personality is to an individual
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The organization’s culture is its comfort zone while adapting to survive its external environment
Personal examples of difficulties getting out of comfort zones:
DietsExercise
Other examples?
Adapted from Schein, Organizational Culture and Leadership, 2004
Culture -- An Empirically Based Abstraction
Changes in culture require us to: resurrect, reexamine, and possibly change some of the more stable portions of our cognitive structure
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Schein, Organizational Culture and Leadership, 2004
Basic assumptions: non-confrontable; non-debatable; hard to changeChanges intrinsically difficult -- release large quantities of anxietyRather than tolerate anxiety, we tend to distort, deny, or falsify what is going on Must decipher underlying assumptions if hope to interpret and act on artifacts
Underlying Assumptions
What “ought to be” versus what “is”Leader poses a solution to a problem not yet a shared basis Group takes joint action and observes outcomeIf outcome successful perceived value is transformed to shared values or beliefs Espoused value = what “ought to be” vice what “is”
Espoused Beliefs and
Values
Easy to Observe – Difficult to DecipherIncludes what one sees, hears, feels when one encounters a new groupIncludes visible products, architecture, language, technology, clothingClimate – organizational processes, charters, org charts, etc.
Artifacts and Behaviors
Below the surface
Schein Levels of Culture
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Perspectives from Schein’s Levels of Culture
What You Really Feel You Should
DoUnderlying Assumptions
What You Say You’re Going
To DoEspoused Values and Beliefs
What You Do Artifacts and Behaviors
Schein, Organizational Culture and Leadership, 2004
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Balance and alignment between underlying assumptions and
espoused values indicates leaders walking-the-talk
Balance and alignment between espoused values and artifacts or behaviors indicates employees
buying-into safety culture
The next level of safety improvement will be the most challenging
Its what I do, not what I say.
Adapted from Schein, Organizational Culture and Leadership, 2004
Underlying Assumptions
Espoused Beliefs and
Values
Artifacts and Behaviors
Healthy Organizational Culture
Becoming an HRO
Desire to be an HRO
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Schein, Organizational Culture and Leadership, 2004
Underlying Assumptions
Espoused Beliefs and
Values
Artifacts and Behaviors
Below the surface
Assessing Health of an Organization’s Culture
Determine by interviewing leadership
Determine by observing work
Misalignment hints at deeper underlying assumptions keeping the organization from attaining its desired balance between production and safety
Underlying assumptions must be understood to properly interpret artifacts and to create change
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Underlying Assumptions
Espoused Beliefs and
Values
Artifacts and Behaviors
Becoming an HRO
Desire to be an HRO
Healthy Organizational CultureThis cultural alignment is influenced by the way the organization:
Adapts and survives to its
external environment
Integrates internally to adapt as an organization
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Steps in External Adaptation and Survival
81
Remember culture concepts:
Leader imposes values and assumptions (what he/she thinks will work)
Organization struggles to use the leader’s values to adapt to its external environment
If the organization is successful, leaders values are accepted as their values and the culture has changed
Schein, Organizational Culture and Leadership, 2004
Correction
Measurement
Means
Goals
Mission & Strategy
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Steps in External Adaptation and Survival
82
Leader establishes a shared understanding of core mission, primary task, and manifest and latent functions
Leader develops consensus on goals, as derived from the core mission
Leader develops consensus on means used to attain goals, such as organization structure, division of labor, reward system, and authority system
Leader develops consensus on criteria used to measure how well group fulfils its goals
Leader develops consensus on the appropriate remedial or repair strategies to be used if goals are not being met
Schein, Organizational Culture and Leadership, 2004
Correction
Measurement
Means
Goals
Mission & Strategy
Leader may provide strategies tie the mission to the goals
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Steps in External Adaptation and Survival
83
Leader establishes a shared understanding of core mission, primary task, and manifest and latent functions
Leader develops consensus on goals, as derived from the core mission
Leader develops consensus on means used to attain goals, such as organization structure, division of labor, reward system, and authority system
Leader develops consensus on criteria used to measure how well group fulfils its goals
Leader develops consensus on the appropriate remedial or repair strategies to be used if goals are not being met
Schein, Organizational Culture and Leadership, 2004
Correction
Measurement
Means
Goals
Mission & Strategy
Leader may provide strategies tie the mission to the goals
This is just management 101 but perhaps now you have a better understanding of the “why” behind the “what” of your organization’s behavior.
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Steps in External Adaptation and Survival
84
Leader establishes a shared understanding of core mission, primary task, and manifest and latent functions
Leader develops consensus on goals, as derived from the core mission
Leader develops consensus on means used to attain goals, such as organization structure, division of labor, reward system, and authority system
Leader develops consensus on criteria used to measure how well group fulfils its goals
Leader develops consensus on the appropriate remedial or repair strategies to be used if goals are not being met
Schein, Organizational Culture and Leadership, 2004
Correction
Measurement
Means
Goals
Mission & Strategy
Leader may provide strategies tie the mission to the goals
Now lets see how the organization aligns itself and integrates its internal functions to be successful adapting to their external environment.
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Group members create common language to communicate
Group defines itself with respect to who is in, and who is out and by what criteria membership determined
Group determines its pecking order, how members get, retain, and lose power
Group works out its rules for peer relationships, for relationships between sexes, in the context of managing the organizations tasks how the organization deals with subcultures
Group defines what is heroic and sinful -- rewards and punishment
Group that faces unexplainable events develops meaning so that members can respond to them
Schein, Organizational Culture and Leadership, 2004
Explaining the Unexplainable
Allocating Rewards &
Punishments
Developing Norms of Intimacy
Distributing Power & Status
Defining Group Boundaries
Creating Common Language
Steps in Internal Integration
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We have seen what it takes to get the various levels of culture aligned to attain a healthy culture.
Now lets see what is required to sustain this alignment and balance.
Sustainable Culture
Correction
Measurement
Means
Goals
Mission & Strategy
Explaining the Unexplainable
Allocating Rewards &
Punishments
Developing Norms of Intimacy
Distributing Power & Status
Defining Group Boundaries
Creating Common Language
External adaptation survival
Internal integration
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Contractor
Local Customer
Head Office
87
The most relevant model to describe the formation of culture is what the organization does to:
Survive its adaptation to its external environment
Adapted from Schein, Organizational Culture and Leadership, 2004
Sustainable Culture(subcultures align)
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Contractor
Local Customer
Head Office
88
The most relevant model to describe the formation of culture is what the organization does to:
Survive its adaptation to its external environment
Integrate its internal processes to ensure the capacity to continue to survive and adapt
Adapted from Schein, Organizational Culture and Leadership, 2004
Safety is a non-event.
Production schedules are exciting events.
The next level of safety improvement –
sustainment - will be the most challenging
Its what we do, not what we say.
Sustainable Culture(subcultures align)
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Without financial survival and growth, no service to shareholdersEconomic environment perpetually competitiveBecause of size of organization it becomes depersonalized and must be run by rules, routines, and rituals
Schein, Organizational Culture and Leadership, 2004
Nature can and should be masteredOperations should be based on science and technologyPeople are problem – design out of system
No matter how good the engineering is, we have to deal with unpredictable contingenciesSuccess of organization depends on usWe have to learn and operate as a team
Executive Culture
Engineering Culture
Operator Culture
Organizational Challenges of Subcultures
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Internal to Plant
External to Plant
SupportFunctions
ContractorManagement Site Office
Day Shift
Night Shift
Security Manufacturing Maintenance Fire Dept
Unions
Adapted from Schein, Organizational Culture and Leadership, 2004
Organizational Challenges of Subcultures
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Acci
dent
Rat
es fo
r Ind
ivid
ual A
ccid
ents
or
Susc
eptib
ility
for S
yste
ms
Acci
dent
s
Murphy Margin
Stage #2Stage #2 - Management perceives safety performance as important even in the absence of regulatory pressure.
Stage #3Stage #3 - Organization has adopted idea of continuous improvement and applied the concept to safety performance.
Stage #1Stage #1 - Organization sees safety as an external requirement and not as an aspect of conduct that will help the organization to succeed
Health and Safety Executive (HSE) Human Factors Briefing Note No. 7 “Safety Culture.” Safety Culture Maturity Model. ISBN 0717619192
Stages of Culture Maturity
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Organizational Learning
Work-as-Imagined vs. Work-as-Done
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• Knowledge of Knowledge
HRO Practice #1
Manage the System, Not
the Parts
HRO Practice #2
Reduce Variability in HRO System
HRO Practice #3
Foster a Strong
Culture of Reliability
HRO Practice #4
Learn & Adapt as an Organization
Fundamental HRO PracticesHRO Practice #4
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• Generate decision-making info
•Tiered approach• Refine HRO system
HRO Practice #1Manage the System, Not
the Parts
HRO Practice #2
Reduce Variability in HRO System
HRO Practice #3
Foster a Strong
Culture of Reliability
HRO Practice #4
Learn & Adapt as an Organization
Fundamental HRO Practices HRO Practice #4
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Central Theme of an HRO
Focus on what is important
Measure what is important
96
The most important thing,
is to keep the most important thing,
the most important thing.
Steven Covey, 8th Habit
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Artwork courtesy of Marshall Clemens of Idiagram. All rights reserved. [email protected]
Work-as-Imagined
vs.
Work-as-Done
97
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Spectrum of Safety
Hard Core Safety Physics Squishy People Part of Safety
Work-as-imagined
Work-as-done ∆
Compliance-Based Performance Gaps (∆) Provide Indication of Human Variability
“What”
HRO “Engine”
Break-the-Chain Framework
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Schein, Organizational Culture and Leadership, 2004
Underlying Assumptions
Espoused Beliefs and
Values
Artifacts and Behaviors
Below the surface
Cultural-Based AssessmentsGap Provides Indication of Organizational Issues
“Why”
Determine by interviewing leadership
Determine by observing work
Misalignment hints at deeper underlying assumptions keeping the organization from attaining its desired balance between production and safety
Underlying assumptions must be understood to properly interpret artifacts and to create change
Work-as-done
Work-as-imagined
Gap(∆)
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Artwork courtesy of Marshall Clemens of Idiagram. All rights reserved. [email protected]
Compliance-Based = “what”
Cultural-Based = “why”
Together = “organizational learning”
100
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Five Tiers to Organizational Learning
Mechanics or “What” Did Not Work Right
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Tier 4: Learn From Others’ Mistakes
Tier 3: Causal Factors Analysis
Tier 2: Tracking & Trending
Tier 1: Daily Supervisor-Worker
Interactions
Tier 0: Startup
Learn and Adapt as an Organization (5 Tiers of Organizational Learning)
HRO “Engine”
Break-the-Chain Framework
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Tier 4: Learn From Others’ Mistakes
Tier 3: Causal Factors Analysis
Tier 2: Tracking & Trending
Tier 1: Daily Supervisor-Worker
Interactions
Tier 0: Startup
Learn and Adapt as an Organization(Tier 0: Startup of New Processes)
HRO “Engine”
Break-the-Chain Framework
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Tier 4: Learn From Others’ Mistakes
Tier 3: Causal Factors Analysis
Tier 2: Tracking & Trending
Tier 1: Daily Supervisor-Worker
Interactions
Tier 0: Startup
Learn and Adapt as an Organization (Tier 1: Daily Supervisor-Worker Interactions)
HRO “Engine”
Break-the-Chain Framework
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Tier 4: Learn From Others’ Mistakes
Tier 3: Causal Factors Analysis
Tier 2: Tracking & Trending
Tier 1: Daily Supervisor-Worker
Interactions
Tier 0: Startup
Learn and Adapt as an Organization (Tier 2: Tracking and Trending)
HRO “Engine”
Break-the-Chain Framework
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Tier 4: Learn From Others’ Mistakes
Tier 3: Causal Factors Analysis
Tier 2: Tracking & Trending
Tier 1: Daily Supervisor-Worker
Interactions
Tier 0: Startup
Learn and Adapt as an Organization (Tier 3: Causal Factors Analysis)
HRO “Engine”
Break-the-Chain Framework
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Tier 4: Learn From Others’ Mistakes
Tier 3: Causal Factors Analysis
Tier 2: Tracking & Trending
Tier 1: Daily Supervisor-Worker
Interactions
Tier 0: Startup
Learn and Adapt as an Organization (Tier 4: Learn from Other’s Mistakes)
HRO “Engine”
Break-the-Chain Framework
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Methods to Evaluate Organizational Culture
(A Measure of Effectiveness of the HRO Practices “Why” things are the way they are
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Before Beginning to Assess Culture of Reliability
Organizational culture can be studied in a variety of ways
The method one chooses should be determined by one’s purpose
Just assessing culture is as vague as assessing personality or character in an individual
Think of the assessment in terms of the problem you want to correct – start with the end in mind!
Use the tools to get the information required to fix problem, not necessarily to fix the culture
109
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Methods of Assessing Culture of Reliability Direct observations of work place behavior
Causal Factors Analyses or Root Cause Analyses
Surveys
Face-to-face interviews
Review of key safety culture related processes
Performance indicators
VPP assessments
Adapted from EFCOG Task Group on Safety Culture, 2008
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Chronic Unease
“If the price of peace is eternal vigilance, then the price of safety is chronic unease.”
James Reason
Managing the Risks of Organizational Accidents, James Reason
Dr. James Reason
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Some organizations have no choice except to be a
High Reliability Organization!
Can your organization afford
any less?112
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Should Your Business Be A High Reliability Organization?Simply put, if your organization cannot recover from the consequences of a system accident in your operations, then consider learning and applying the concepts and practical application of high reliability.
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Resources onHigh Reliability Organizations
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Contains: Background on High Reliability Bad Signs of Normal Accidents Logical Safety Framework How Organizational Accidents Occur
and How to Investigate Basis for Conducting CFAs
Investigations
Integrated organizational concepts of high reliability with proven science-based safety to produce a practical guide to become an HRO to protect
High Reliability Operations Guide
Authors: Hartley, Tolk, SwaimAvailable through GPOhttp://bookstore.gpo.gov/collections/hro.jsp
All rights reserved © B&W Pantex 2008
Contains: Investigative Tools Step-by-Step Process Examples and Templates Method to Interpret Results and
Provide Feedback to HRO Outline for Consistency Criteria for Quality
Folded high reliability concepts with systematic root cause investigation techniques to unveil underlying organizational contributors to prevent significant events
Causal Factors Analysis Handbook
116
CAUSAL FACTORS ANALYSISAn Approach for Organizational Learning
Learn from Information Rich Events
Authors: Hartley, Swaim, CorcoranAvailable through GPOhttp://bookstore.gpo.gov/collections/hro.jsp
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Recommended Reading MaterialThe Limits of Safety, Scott D. Sagan
Normal Accidents – Living with High-Risk Technologies, Charles Perrow
Managing the Unexpected, Karl E. Weick & Kathleen M. Sutcliffe
Managing the Risks of Organizational Accidents, James Reason
Organizational Culture and Leadership, 3rd ed., Edgar Schein
Field Guide to Human Error Investigations, Sidney Dekker
The 8th Habit, From Effectiveness to Greatness, Stephen Covey
Pantex High Reliability Operations Guide
Pantex Causal Factors Analysis Handbook
All rights reserved © B&W Pantex 2008
QUESTIONS?
118
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Richard S. Hartley, Ph.D., P.E.Principal [email protected]&W PantexP.O. Box 30020Amarillo, TX 79120-0020
Want to learn more?
Janice N. Tolk, Ph.D., P.E.Manager, Applied Technology & R&[email protected]&W PantexP.O. Box 30020Amarillo, TX 79120-0020