3 Lessons from High Reliability Organizations
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Transcript of 3 Lessons from High Reliability Organizations
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3 Lessons from High Reliability Organiza7ons
Presenta*on to the Canadian Na*onal Energy Board at the 2015 Pipeline Safety Forum
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The world has changed!
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“Individual produc7vity”
Volume
Cost
Pre-‐Industrial Age
Driven by variable costs
“Economies of Scale”
Volume
Industrial Age
Driven by fixed costs
“Complexity”
Complexity
Post-‐Industrial Age
Driven by complexity costs
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Complexity is stretching the capabilities of most organizations
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TECHNOLOGY PRODUCTS & SERVICES
PROCESSES
ORGANIZATIONS
REGULATIONS
MARKETS
X
X X
X
X COMMUNICATIONS
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Complexity grows exponentially
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#Items #links
1 0
2 1
3 3
4 6
5 10
…
10 45
$
Complexity
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Characteristics of complex systems
1. Non-linear reactions
2. Emerging properties
3. Feedback loops
4. Unknown interactions
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Many companies are passing a complexity threshold
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Level of complexity you can support
VALUE (diminishing returns)
COST & RISK (exponen*al growth)
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Complexity
Few companies are s.ll here
Many companies are here
An increasing number of companies are here
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Increased complexity
Poor execution
Loss of process control
Poor performance
Added processes Vicious
Complexity Cycle
The typical response to complexity is to add even more complexity
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Catastrophic incidents are becoming more frequent and more severe
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1979 – Three-‐Mile Island core meltdown 1988 – Piper Alpha explosion 2005 – Texas City Refinery explosion 2010 – San Bruno Pipeline explosion 2010 – BP Deepwater Horizon oil spill 2011 – Fukushima Daiichi disaster 2013 – West Fer7lizer plant explosion
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Traditional risk management doesn’t address these “normal accidents” well
Too complex to anticipate
Too fast to address
Too infrequent to understand
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The Pessimist’s View
“Regardless of the effec*veness of management and opera*ons, accidents in systems that are
characterized by *ght coupling and interac*ve complexity will be
normal or inevitable as they oTen cannot be foreseen or prevented.”
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Yet a few High Reliability Organizations seem to defy the Pessimistic View!
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Birth of the Nuclear Navy
50+ year history
150 mobile nuclear reactors
6,000+ years of reactor plant opera*on
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The Nuclear Navy has never had a reactor accident over its
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Three Lessons from the Nuclear Navy
#1 Safety is not a GOAL!
#2 Simplify your management system
#3 Culture kills!
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Lesson #1
Achieving zero incidents should not
be a GOAL!
It should be an EXPECTATION!
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This has important implications for what we reward
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Lesson #2: Keep your management system as simple as possible, but no simpler
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The Nuclear Navy simplifies with one management system for all outcomes
People Process
Equipment Change
Key Controls
Safety
People Process
Equipment Change
Key Controls
Environ-‐ mental
People Process
Equipment Change
Key Controls
Quality
People Process
Equipment Change
Key Controls
Reliability
People Process
Equipment Change
Key Controls
Cost
Common Management System Approach
Nuclear Navy Management System
People Process
Equipment Change
Increased performance Accelerated learning
Reduced cost and overhead
Safety Quality
Environmental
Reliability
Compliance
Cost
Key Controls
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Don’t manage the outcomes... …manage the sources of risk!
Examples
Procedures
Training/ cer*fica*on
Performance mgmt
Engineering disciplines
Maintenance planning/ scheduling
MOC process
Culture
Risk ID
Examples
No expecta*ons
Lack of knowledge
Wrong incen*ves
Equipment not capable
Process not capable
Inadequate MOC
Leadership Employee
Accountability Risk ID
Risk Control Knowledge Sharing Change
Management Con7nuous Improvement
Safety
Environment
Compliance
Quality
Produc7vity
Yield
Cost
Outcomes Sources of Risk
Causes of Failure
Key Controls
Mgmt. System Elements
People
Processes
Equipment
Change
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The Nuclear Navy’s proactive management system allows it to learn faster
Reactive risk management
Proactive risk management
Proac7ve
Reac7ve
Proac7ve
Reac7ve
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Lesson #3: Culture is the key!
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Opera*onal Discipline is essen*al to the Navy’s superb safety and opera*onal record
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Human performance is the Nuclear Navy’s last layer of defense
Rob
ust E
quip
men
t
Rig
orou
s P
roce
dure
s
Ope
ratio
nal D
isci
plin
e
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The culture required was a vast departure from traditional military culture
Tradi7onal Military Culture
Follow orders
Do what you are told
Don’t ask ques*ons
Never ques*on your superiors
Rickover’s Cultural Pillars
Have a higher level of understanding
Follow procedures
Ques*on procedures when things don’t seem right
Back each other up
Do it all with integrity
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The Nuclear Navy’s OD DNA
Level of Knowledge
Formality
Ques7oning Actude
Forceful Watch Team Backup
Integrity
LEVE
L OF KN
OWLEDG
E
FORM
ALITY
QUESTIONING ATTITUDE
FORC
EFUL BA
CKUP
INTEGRITY
CONTINUITY OF POWER REACTOR SAFETY
Safety and reliability depend on specific operator behaviors
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The “Pillars of the Program”
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The Pillars are self-reinforcing
Ques:oning A=tude enhances Level of Knowledge
Integrity Level of Knowledge
Ques7oning Actude
Formality
Forceful Watch Team
Backup
Level of Knowledge allows ID of out-‐of-‐
the-‐ordinary condi:ons
Ques:oning A=tude supports process improvement, not work arounds
Ques:oning A=tude helps you spot what others may have missed
Level of Knowledge allows you to back up others
Integrity means you can be relied upon to support
your team
Backup drives
procedural compliance Formality ensures
backup is professional & produc:ve
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Changing culture requires more than posters and training
Beliefs
Consequences Behaviours
Leaders can’t force people to believe something…….
……or to behave in a certain way.
But they can change what is rewarded!
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Three Lessons from the Nuclear Navy
#1 Safety is not a GOAL!
#2 Simplify your management system
#3 Culture kills!
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Thank You
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Chris Seifert Partner, Opera:onal Excellence Prac:ce [email protected] (972) 800-‐3618 www.wilsonperumal.com
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