4 Hour Professional Development Seminar HPRCT Workshop, Baltimore Maryland June 21, 2010

All rights reserved © B&W Pantex 2008

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


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


Examples of High Reliability Organizations or Not?

Nuclear NavyCommercial nuclear powerAircraft carrier operationsHospital patient careMilitary nuclear deterrentForest serviceAviationNuclear weapons assembly and disassembly


Business Case for High Reliability

Is it right for you?


0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

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


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


The Alternate to the HRO

The Normal Accident Organization


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).


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.


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


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?


How do Organizations Get Themselves into System

Accident Space?Attempts to Understand & Prevent System Accidents


Attempts to Understand & Prevent System Accidents(High Reliability vs. Normal Accident Theory)

http://www.google.com/imgres?imgurl=http://news.stanford.edu/news/2008/april30/gifs/aaas_sagan.jpg&imgrefurl=http://news.stanford.edu/news/2008/april30/aaas-043008.html&h=400&w=300&sz=27&tbnid=T8130l-O61iNyM:&tbnh=124&tbnw=93&prev=/images?q=Picture+of+Scott+D.+Sagan&usg=__Ev_-t-WEVg7bq4IgHQS6oLUOIJ4=&ei=SPCHSrS6JpivtgffsNznDA&sa=X&oi=image_result&resnum=3&ct=image


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


What is the Focus of an HRO?

Individual Accidents OR Systems Accidents?


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


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


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!


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








Comparing & Contrasting High Reliability Theory with

Normal Accident TheoryHROs vs. NAT Organizations


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


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

23

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


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

24

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


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

http://upload.wikimedia.org/wikipedia/commons/d/d6/A-line1913.jpg


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


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.


Complex Interactions Alone Insufficient

Complex interactions not necessarily high-risk systems with catastrophic potential, examples:

UniversitiesR&DFederal Government

Also takes another key ingredientTight coupling

http://en.wikipedia.org/wiki/File:Capitol_Building_Full_View.jpg


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


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


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)



(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


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)



(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?


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


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?


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




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


Dr. Scott Sagan













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.






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



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










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?Attributes of HROs and NATs

BadGood



















High Reliability or Accident Waiting to Happen?Attributes of HROs and NATs

BadGood


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.


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


Fundamentals of Systems Approach

Reality EngineeringUnderstanding Socio-Technical Systems to

Improve Bottom-Line


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


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


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


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


Squishy People Part of Safety• Average IQ of the organization• It is a systems approach • Gaussian curve

http://upload.wikimedia.org/wikipedia/commons/4/48/Dirac_distribution_PDF.svg


Construct of an HRO

A Systems Approach to Safety


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!


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


• 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


• 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


• Knowledge of Systems


• Knowledge of Psychology


HRO Practice #1


the Parts

HRO Practice #2


HRO Practice #3

Foster a Strong


HRO Practice #4


Fundamental HRO PracticesActions Associated with Each HRO Practice


• 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


HRO Practice #3

Foster a Strong


HRO Practice #4








• Deploy system• Evaluate

operations – meas. variability

• Adjust processes






system


the Parts

HRO Practice #2


HRO Practice #3

Foster a Strong


HRO Practice #4
















system


the Parts

HRO Practice #2


HRO Practice #3

Foster a Strong


HRO Practice #4














• Generate decision-making info

•Tiered approach• Refine HRO system


the Parts

HRO Practice #2


HRO Practice #3

Foster a Strong


HRO Practice #4

















the Parts

HRO Practice #2


HRO Practice #3

Foster a Strong


HRO Practice #4











system


the Parts

HRO Practice #2


HRO Practice #3

Foster a Strong


HRO Practice #4


Fundamental HRO PracticesHRO Practice #2











system


the Parts

HRO Practice #2


HRO Practice #3

Foster a Strong


HRO Practice #4


Fundamental HRO Practices HRO Practice #2


Breaking the Chain Between Threat and Hazard


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”


Organizational Culture

Evaluating the HRO







system


the Parts

HRO Practice #2


HRO Practice #3

Foster a Strong


HRO Practice #4




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


Squishy People Part of Safety• Average IQ of the plant• It is a systems approach • Gaussian curve

http://upload.wikimedia.org/wikipedia/commons/4/48/Dirac_distribution_PDF.svg


Organization’s Culture Provides

1. Sustainabilityor

2. Inhibitors

What does Culture to for You?


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














Basics of Culture

Most of the content of this section is adapted from Schein, Organizational Culture and Leadership, 2004

Dr. Edgar Schein


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


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!



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



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



Culture is to a group what personality is to an individual


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


Changes in culture require us to: resurrect, reexamine, and possibly change some of the more stable portions of our cognitive structure



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


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



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.




Values


Healthy Organizational Culture

Becoming an HRO

Desire to be an HRO





Values


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




Values


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


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


Correction

Measurement

Means

Goals

Mission & Strategy



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


Correction

Measurement

Means

Goals

Mission & Strategy

Leader may provide strategies tie the mission to the goals



83







Correction

Measurement

Means

Goals

Mission & Strategy


This is just management 101 but perhaps now you have a better understanding of the “why” behind the “what” of your organization’s behavior.



84







Correction

Measurement

Means

Goals

Mission & Strategy


Now lets see how the organization aligns itself and integrates its internal functions to be successful adapting to their external environment.


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


Explaining the Unexplainable

Allocating Rewards &

Punishments

Developing Norms of Intimacy

Distributing Power & Status

Defining Group Boundaries

Creating Common Language

Steps in Internal Integration


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


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


Sustainable Culture(subcultures align)


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


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)


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


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


Internal to Plant

External to Plant

SupportFunctions

ContractorManagement Site Office

Day Shift

Night Shift

Security Manufacturing Maintenance Fire Dept

Unions


Organizational Challenges of Subcultures


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


Organizational Learning

Work-as-Imagined vs. Work-as-Done



HRO Practice #1


the Parts

HRO Practice #2


HRO Practice #3

Foster a Strong


HRO Practice #4


Fundamental HRO PracticesHRO Practice #4





the Parts

HRO Practice #2


HRO Practice #3

Foster a Strong


HRO Practice #4




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


Artwork courtesy of Marshall Clemens of Idiagram. All rights reserved. [email protected]

Work-as-Imagined

vs.

Work-as-Done

97


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”






Values


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(∆)


Artwork courtesy of Marshall Clemens of Idiagram. All rights reserved. [email protected]

Compliance-Based = “what”

Cultural-Based = “why”

Together = “organizational learning”

100


Five Tiers to Organizational Learning

Mechanics or “What” Did Not Work Right


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”







Interactions

Tier 0: Startup

Learn and Adapt as an Organization(Tier 0: Startup of New Processes)

HRO “Engine”







Interactions

Tier 0: Startup

Learn and Adapt as an Organization (Tier 1: Daily Supervisor-Worker Interactions)

HRO “Engine”







Interactions

Tier 0: Startup

Learn and Adapt as an Organization (Tier 2: Tracking and Trending)

HRO “Engine”







Interactions

Tier 0: Startup

Learn and Adapt as an Organization (Tier 3: Causal Factors Analysis)

HRO “Engine”







Interactions

Tier 0: Startup

Learn and Adapt as an Organization (Tier 4: Learn from Other’s Mistakes)

HRO “Engine”



Methods to Evaluate Organizational Culture

(A Measure of Effectiveness of the HRO Practices “Why” things are the way they are


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


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


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


Some organizations have no choice except to be a

High Reliability Organization!

Can your organization afford

any less?112


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.


Resources onHigh Reliability Organizations


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


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


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


QUESTIONS?

118


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

Documents

4 Hour Professional Development Seminar HPRCT Workshop, Baltimore Maryland June 21, 2010