04/19/2023

HRO Perspectives on Interdependence in and across Organizations

Peter M. MadsenMarriott School of Management,

Brigham Young University

Center for Catastrophic Risk Management, University of California, Berkeley

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Organizational Disaster

• Disaster: 1: “A sudden calamitous event

bringing great damage, loss, or destruction;”

2: “A sudden or great misfortune or failure.”

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Fukushima I Nuclear Power Plant

Deepwater Horizon Explosion & Oil Spill

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Upper Big Branch Mine Explosion, 2010

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Imperial Sugar Explosion, 2008

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Spinach Recall, 2006

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Systems View of Organizations

• Organizations as socio-technical systems– People, groups & units– Technological components, information

networks

• Complexity in organizations– Combinatorial complexity: large numbers of

potential interactions, tight coupling– Dynamic complexity: delayed effects,

feedback loops, feedforward loops

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

System Accidents

• Distinct from simple component failures– Including human error

• Driven by unplanned and unexpected interactions between system components– Non-independence– Combinatorial and dynamic complexity

• Extremely difficult to predict and prepare for– “Normal accidents”

• Examples– Three Mile Island– Petrobras P36

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Fukushima I Nuclear Power Plant

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

System Accidents

• Distinct from simple component failures– Including human error

• Driven by unplanned and unexpected interactions between system components– Non-independence– Combinatorial and dynamic complexity

• Extremely difficult to predict and prepare for– “Normal accidents”

• Examples– Three Mile Island– Petrobras P36

Combinatorial Complexity & System Accidents

Number of System Components Number of Possible Pairwise Interactions

2 1

3 3

5 10

10 45

100 5000

1000 500,000

10,000 50,000,000

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

System Accidents

• Distinct from simple component failures– Including human error

• Driven by unplanned and unexpected interactions between system components– Non-independence– Combinatorial and dynamic complexity

• Extremely difficult to predict and prepare for– “Normal accidents”

• Examples– Three Mile Island– Petrobras P36

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

TMI 2

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Petrobras P36

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Petrobras P36

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Prevention of System Accidents

• HRO strategies for managing system accidents– Learning from non-events– Resiliency

• HRO requirements– Vigilance– Shared Cognition– Constrained Improvisation– Safety Culture

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Inter-Organizational System Accidents

• Inter-organizational systems• Interdependencies cross organizational boundaries

– Contractors– Suppliers/Vendors– Unions– Regulators– Customers– Competitors

• Inter-organizational system accident examples– Avianca flight 52– Mumbai High North– Deepwater Horizon

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Avianca flight 52

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Mumbai High North

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Mumbai High North

Deepwater Horizon Explosion & Oil Spill

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Inter-Organizational System Accident Prevention

• HRO strategies are the same– Learning from non-events– Resiliency

• HRO requirements are the same– Vigilance– Shared Cognition– Constrained Improvisation– Safety Culture

• But challenges are much greater

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Challenges to HRO in Inter-Organizational Systems

• Vigilance– Warning signs in multiple organizations– Need for rapid, rich information sharing

• Shared Cognition– Need for shared mental models across

organizations

• Constrained Improvisation– Coordination of activities across groups with

no history of joint action

• Examples:

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

9/11 Attacks

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Challenges to HRO in Inter-Organizational Systems

• Vigilance– Warning signs in multiple organizations– Need for rapid, rich information sharing

• Shared Cognition– Need for shared mental models across

organizations

• Constrained Improvisation– Coordination of activities across groups with

no history of joint action

• Examples:

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Oakland Hills Fire of 1991

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

HRO Implementation in Inter-Organizational Systems

• Cultural compatibility– Cultural consideration in partner selection– Long-term relationships– Development of trust

• Rich information sharing– Accident and near-miss reporting– Contracts with economic incentives for “safety” are

counterproductive

• Joint training and planning– Build relationships– Develop shared cognition– Establish parameters for constrained improvisation

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

U.S. Air Force and Aerospace Corporation

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Grand Teton Dam Failure

04/19/2023Center for Catastrophic Risk Management, University of California, Berkeley

Conclusion

• System errors occur in inter-organizational systems

• Inter-organizational HRO implementation is challenging

• HRO may be introduced through:– Development of compatible safety

cultures– Norms of rich information sharing– Joint training

04/19/2023

HRO Perspectives on Interdependence in and across Organizations

Peter M. MadsenMarriott School of Management,

Brigham Young University

Center for Catastrophic Risk Management, University of California, Berkeley