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High Reliability Organization A Practical Approach

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1 High Reliability Organization A Practical Approach
Richard S. Hartley, Ph.D., P.E. This presentation was produced under contract number DE-AC04-00AL66620 with

2 High Reliability Organization!
U.S. Nuclear Weapon Assembly- Disassembly Plant Pantex has no choice except to be a High Reliability Organization!

3 SYSTEM ACCIDENT TIMELINE
10 BP Gulf Who is Next? Commonalities High 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 Three Mile Island 1984 – Bhopal India 1986 – NASA Challenger 1986 – Chernobyl 1989 – Exxon Valdez 2001 – World Trade Center 2005 – BP Texas City 2007 – Air Force B-52 2008 – Stock Market Crash 2010 – BP Deepwater Horizon

4 Why Is Being an HRO So Important?
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

5 SYSTEM ACCIDENT TIMELINE
10 BP Gulf

6 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

7 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

8 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).

9 NASA & Columbia Jan 16, 2003 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. CAIB: “The unexpected became the expected, which became the accepted.” * Criticality 1/1R component failures result in loss of the orbiter and crew.

10 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.) Focus: Protect the worker from the plant Plant (hazard) Human Errors (receptor) Rick’s note: Think about this slide and the system event slide to think about indicators to individual and system accidents with the intent of trying to determine if there is something fundamentally wrong with focusing on individual accidents vs. system accidents (i.e. does it set you up for system failure?) Preventing (and for that matter, causing individual accidents) are all based on the individual, equipment controls, and human behavior. There is no system per se (except the desire by management to be safe  i.e. the safety management system). Therefore if the focus is on preventing individual accidents, you are not looking at the major system (ISM, AB, etc.) and hence they can degrade and your individual safety statistics will stay good. So if you want leading indicators of system safety, individual safety stats tell you NOTHING! It does give you an indication your safety management system is not working if you get beyond blaming the worker for not following your perfect system. In fact, the focus on individual safety (i.e. reducing TRC etc.) takes an organization’s focus from the system safety. Indicators of system safety require looking at those systems and resulting processes and barriers put in place (i.e. designed right, implemented, verified before work) because the outcome of system safety is the (hopefully) null-set (unless you get near misses and actually investigate and learn from them) until the black swan occurs. This approach is nothing but your BTC framework using the six steps. All rights reserved © B&W Pantex 2011 10

11 Fundamental HRO Focus  Prevent System Accident
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 Human Errors (threat) Equipment, tooling, facility malfunctions (threat) Plant (hazard) Focus: Protect the plant from the threats Natural Disasters (threat) Rick note: This is your revised system accident slide to include all threats to the hazard. Whether this view is grander than just the focus on human errors or not is discussed in your recognize how system accidents and BTC slide. Food for thought: The typical focus on human error are those errors (active) that occur immediately before the event Your additional focus on equipment, tooling, and facility malfunctions are more focused on latent errors that are put into the system well before work is begun that day. Some are a result of human error, but by humans well upstream of the event. Natural disasters are just those things that occur that you have no control over, you only try to mitigate their impact on your consequence. Note this slide depends on organizations taking a system approach to safety. That is, they recognize that they cannot depend on individuals to be perfect everyday based on the consequences that may occur, therefore they have put systems (protection) in place to prevent the human screw up. The problem is most companies put these in place and assume they will be implemented as designed and maintained to the same level of fidelity after many years of abuse as they were when originally implemented. Evidence shows (NAT) that this is not the case. Note your side note on individual safety as a pre-requisite, does it go in the face of what you discussed on the individual accident slide? 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. All rights reserved © B&W Pantex 2011

12 Building a Practical High Reliability Organization

13 Ultimate Goal of an HRO Non-HRO HRO ∆Wg Work-as-Imagined
Work-as-Done Work-as-Imagined “What” ∆Wg “Why” HRO Goal: Align, tighten, and sustain spectrum of performance. Work-as-Done Where you want to be Where you probably are ∆Wg = gap in work as done vs. as imagined 13

14 To Become an HRO Work-as-Imagined Work-as-Done
(Take a System Approach) 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-Imagined Work-as-Done Where you want to be All rights reserved © B&W Pantex 2011

15 To Implement HRO Practices
(Break the Chain Between Threat and Hazard) Work-as-Imagined Work-as-Done Where you want to be All rights reserved © B&W Pantex 2011

16 What You Say You’re Going To Do What You Really Feel You Should Do
To Sustain an HRO (Align Each Culture Level) Underlying Assumptions Espoused Beliefs and Values Artifacts and Behaviors Becoming an HRO Desire to be What You Do Work-as-Imagined Work-as-Done What You Say You’re Going To Do What You Really Feel You Should Do Where you want to be Adapted from Schein, Organizational Culture and Leadership, 2004 All rights reserved © B&W Pantex 2011

17 To Learn as an HRO Non-HRO ∆Wg Work-as-Imagined Work-as-Done
(Learn from Small Mistakes) Tier 4: Learn From Others’ Mistakes Tier 3: Causal Factors Analysis Tier 2: Tracking & Trending Tier 1: Daily Supervisor-Worker Interactions Tier 0: Startup Work-as-Imagined Work-as-Done Non-HRO ∆Wg “Why” Where you probably are “What” All rights reserved © B&W Pantex 2011

18 Construct of the HRO Systems Approach to Avoid Catastrophic Accidents
We used Deming’s Theory of Profound Knowledge to develop a process to attain those HRO attributes identified by the High Reliability Theorists Deming’s Theory of Profound Knowledge (TPK) provides a foundation for the systems approach W. Edwards Deming

19 Construct of the HRO Systems Approach to Avoid Catastrophic Accidents
Organizations are systems that interact within their internal and external environments Statistical process control is the foundation of process optimization Knowledge of Systems Knowledge of Variation Deming’s Theory of Profound Knowledge (TPK) used to provide foundation for the systems approach Knowledge of Knowledge Knowledge of Psychology Theory, prediction, and feedback as the basis of learning Organizations have cultures that influence the system and desired outcome

20 Fundamental HRO Practices Use a Systems Approach to Avoid Catastrophic Accidents
Manage the System, Not the Parts HRO Practice #1 Knowledge of Systems Reduce Variability in HRO System HRO Practice #2 Knowledge of Variation Foster a Strong Culture of Reliability HRO Practice #3 Knowledge of Psychology Learn & Adapt as an Organization HRO Practice #4 Knowledge of Knowledge Knowledge of Systems Knowledge of Variation Knowledge of Knowledge Knowledge of Psychology

21 Fundamental HRO Practices Use a Systems Approach to Avoid Catastrophic Accidents
Manage the System, Not the Parts HRO Practice #1 Knowledge of Systems Reduce Variability in HRO System HRO Practice #2 Knowledge of Variation Foster a Strong Culture of Reliability HRO Practice #3 Knowledge of Psychology Learn & Adapt as an Organization HRO Practice #4 Knowledge of Knowledge

22 Fundamental HRO Practices Use a Systems Approach to Avoid Catastrophic Accidents
Manage the System, Not the Parts HRO Practice #1 Ensure system provides safety Manage system, evaluate variability Foster culture of reliability Model organizational learning Reduce Variability in HRO System HRO Practice #2 Deploy system Evaluate operations – meas. variability Adjust processes Foster a Strong Culture of Reliability HRO Practice #3 Provide capability to make conservative decisions Make judgments based on reality Openly question & verify system Learn & Adapt as an Organization HRO Practice #4 Generate decision-making info Tiered approach Refine HRO system

23 Fundamental HRO Practices Use a Systems Approach to Avoid Catastrophic Accidents
Manage the System, Not the Parts HRO Practice #1 Ensure system provides safety Manage system, evaluate variability Foster culture of reliability Model organizational learning Reduce Variability in HRO System HRO Practice #2 Deploy system Evaluate operations – meas. variability Adjust processes Foster a Strong Culture of Reliability HRO Practice #3 Provide capability to make conservative decisions Make judgments based on reality Openly question & verify system Learn & Adapt as an Organization HRO Practice #4 Generate decision-making info Tiered approach Refine HRO system

24 Fundamental HRO Practices Use a Systems Approach to Avoid Catastrophic Accidents
Manage the System, Not the Parts HRO Practice #1 Ensure system provides safety Manage system, evaluate variability Foster culture of reliability Model organizational learning Reduce Variability in HRO System HRO Practice #2 Deploy system Evaluate operations – meas. variability Adjust processes Foster a Strong Culture of Reliability HRO Practice #3 Provide capability to make conservative decisions Make judgments based on reality Openly question & verify system Learn & Adapt as an Organization HRO Practice #4 Generate decision-making info Tiered approach Refine HRO system

25 Fundamental HRO Practices Use a Systems Approach to Avoid Catastrophic Accidents
Manage the System, Not the Parts HRO Practice #1 Ensure system provides safety Manage system, evaluate variability Foster culture of reliability Model organizational learning Reduce Variability in HRO System HRO Practice #2 Deploy system Evaluate operations – meas. variability Adjust processes Foster a Strong Culture of Reliability HRO Practice #3 Provide capability to make conservative decisions Make judgments based on reality Openly question & verify system Learn & Adapt as an Organization HRO Practice #4 Generate decision-making info Tiered approach Refine HRO system

26 HRO Guide 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. 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 Authors: Hartley, Tolk, Swaim Available through GPO

27 Causal Factors Analysis Handbook
An Approach for Organizational Learning Learn from Information Rich Events Folded high reliability concepts with systematic root cause investigation techniques to unveil underlying organizational contributors to prevent significant events. 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 Authors: Hartley, Swaim, Corcoran Available through GPO 27

28 Should Other Organizations 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.

29 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.

30 HROs Think and Act Differently
Work-as-imagined Take a science-based system approach Measure gaps relative to science-based system Explicitly account for people People are not the problem, but the solution People 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 Work-as-done Artwork courtesy of Marshall Clemens of Idiagram. All rights reserved.

31 What Can You Expect Out of the HRO Journey?
Focus on the “Important” Decreases the gap between work-as-imagined and work-as-done Helps everyone understand their role in the bigger system Increased Value to Customers and Regulators Increased Employee Involvement & Buy-in Positive Atmosphere Where Employees Report Errors Empowerment Framework to understand Ability to challenge Responsibility to engage All rights reserved © B&W Pantex 2011

32 High Reliability Operations in Nuclear Settings
12 July 2009 Pantex’s HRO Journey 2006 – DEVELOPED FOUNDATION Human Performance Improvement 2007 – EXPLORED HRO & CFA CONCEPTS Senior Managers initiated HRO journey Developed a new Causal Factors Analysis (CFA) Investigation Process 2008 – TESTED HRO & CFA CONCEPTS Published HRO and CFA Texts Developed Training 2009 – BEGAN HRO DEPLOYMENT 2010 – DEVELOPED TOOLS TO EXPLORE HRO 2011 – PLANT-WIDE DEPLOYMENT OF HRO TOOLS HRO Ambassadors System Mapping Michael S. Ford, CHP --

33 Want to learn more? Richard S. Hartley, Ph.D., P.E. Principal Engineer B&W Pantex P.O. Box 30020 Amarillo, TX Bld 12-6, Rm 126


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