High Reliability Organization A Practical Approach This presentation was produced under contract...
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High Reliability Organization A Practical Approach This presentation was produced under contract number DE-AC04-00AL66620 with chard S. Hartley, Ph.D., P.E
Transcript of High Reliability Organization A Practical Approach This presentation was produced under contract...
High Reliability OrganizationA Practical Approach
This presentation was produced under contract number DE-AC04-00AL66620 with
Richard S. Hartley, Ph.D., P.E.
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U.S. Nuclear Weapon Assembly- Disassembly Plant
Pantex has no choice except to be aHigh Reliability Organization!
SYSTEM ACCIDENT TIMELINE
1979 - Three Mile Island1984 – Bhopal India1986 – NASA Challenger1986 – Chernobyl1989 – Exxon Valdez
2001 – World Trade Center2005 – BP Texas City2007 – Air Force B-522008 – Stock Market Crash2010 – BP Deepwater Horizon
CommonalitiesHigh tech, no shortage of smart people, lots of tools
A safety management system
Energy flowed from threat to hazard resulting in mega consequence
Lost focus of weak signals, never saw the catastrophe coming, convinced it couldn’t happen to them
10BPGulf
Who is Next?
Why Is Being an HRO So Important?
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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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What is a High Reliability Organization?
An organization that repeatedly accomplishes its high hazard 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
Aka a learning organization
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Feeling Comfortable with a Good Safety Stats?
Many organizations 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.
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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Fundamental HRO Focus Prevent System Accident
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Plant(hazard)
Equipment, tooling, facility malfunctions
(threat)
Natural Disasters
(threat)
Focus:Protect the plant from the threats
Human Errors(threat)
An accident wherein the system fails allowing a threat to release the hazard and as a result many* people are adversely affected
* Workers, Enterprise, Environment, Country
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The emphasis on the system accident in no way degrades the importance of individual safety , it is a pre-requisite of an HRO, but focus on individual accidents is not enough.
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Building a Practical High Reliability Organization
HRO
Where you want to be
Work-as-Imagined
Work-as-Done
Non-HRO
∆Wg “Why”
Where you probably are
“What”
Work-as-ImaginedWork-as-Done
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Ultimate Goal of an HRO
∆Wg = gap in work as done vs. as imagined
HRO Goal: Align, tighten, and sustain spectrum of performance.
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To Become an HRO(Take a System Approach)
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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 and Adapt as an
Organization
Work-as-ImaginedWork-as-Done
Where you want to be
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Where you want to be
To Implement HRO Practices(Break the Chain Between Threat and Hazard)
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HumanPerformance
Error Precursors
(Between Threats and Hazard)
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Work-as-ImaginedWork-as-Done
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Where you want to be
To Sustain an HRO(Align Each Culture Level)
Work-as-ImaginedWork-as-Done
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Underlying Assumptions
Espoused Beliefs and
Values
Artifacts and Behaviors
Becoming an HRO
Desire to be an HRO
Adapted from Schein, Organizational Culture and Leadership, 2004
What You Really Feel
You Should Do
What You Say You’re Going
To Do
What You Do
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Work-as-Imagined
Work-as-Done
Non-HRO
∆Wg “Why”
Where you probably are
To Learn as an HRO(Learn from Small Mistakes)
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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
“What”
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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 U.S. interests.
HRO 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
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CAUSAL FACTORS ANALYSISAn Approach for Organizational Learning
Learn from Information Rich Events
Authors: Hartley, Swaim, CorcoranAvailable through GPOhttp://bookstore.gpo.gov/collections/hro.jsp
Should Your Organization Be High Reliability ?Simply put, if your organization cannot recover from the consequences of a systems accident in your operations, then consider learning and applying the concepts and practical application of high reliability.
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HROs Think and Act Differently
Take a science-based system approachMeasure gaps relative to science-based system
Explicitly account for peoplePeople are not the problem, but the solutionPeople provide safety, quality, security, science etc.Disciplining because of a human error won’t improve performance
Sustain behavior – account for organizational culture
Long-term, sustained performance improvement
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Work-as-imagined
Work-as-done
Artwork courtesy of Marshall Clemens of Idiagram. All rights reserved. [email protected]
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What Can You Expect Out of the HRO Journey?
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Focus on the “Important”Decreases the gap between work-as-imagined and work-as-doneHelps everyone understand their role in the bigger system
Increased Value to Customers and Regulators
Increased Employee Involvement & Buy-inPositive Atmosphere Where Employees Report Errors
EmpowermentFramework to understand
Ability to challenge
Responsibility to engage
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Pantex’s HRO Journey2006 – DEVELOPED FOUNDATION
Human Performance Improvement
2007 – EXPLORED HRO & CFA CONCEPTSSenior Managers initiated HRO journeyDeveloped a new Causal Factors Analysis (CFA) Investigation Process
2008 – TESTED HRO & CFA CONCEPTSPublished HRO and CFA TextsDeveloped Training
2009 – BEGAN HRO DEPLOYMENT
2010 – DEVELOPED TOOLS TO EXPLORE HRO2011 – PLANT-WIDE DEPLOYMENT OF HRO TOOLS
HRO Ambassadors System Mapping
Want to learn more?
Richard S. Hartley, Ph.D., P.E.Principal [email protected]&W PantexP.O. Box 30020Amarillo, TX 79120-0020Bld 12-6, Rm 126
