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

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Presentation on theme: "High Reliability Organization A Practical Approach This presentation was produced under contract number DE-AC04-00AL66620 with Richard S. Hartley, Ph.D.,"— Presentation transcript:

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

2 2 Pantex has no choice except to be a High Reliability Organization!

3 SYSTEM ACCIDENT TIMELINE 1979 - 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 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 couldnt happen to them 10 BP Gulf Who is Next?

4 4 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 "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 6

7 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 organizations mistakes Aka a learning organization 7

8 Many organizations have demonstrated, great safety stats dont 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). 8

9 CAIB: The unexpected became the expected, which became the accepted. 9 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.

10 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 10 All rights reserved © B&W Pantex 2011

11 11 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 All rights reserved © B&W Pantex 2011 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.

12 12

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

14 14 All rights reserved © B&W Pantex 2011 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

15 15 Work-as-Imagined Work-as-Done All rights reserved © B&W Pantex 2011

16 Where you want to be 16 Work-as-Imagined Work-as-Done All rights reserved © B&W Pantex 2011 Underlying Assumptions Espoused Beliefs and Values Artifacts and Behaviors Becoming an HRO Becoming an HRO Desire to be 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 Youre Going To Do What You Do

17 Work-as-Imagined Work-as-Done Non-HRO Wg Why Where you probably are 17 All rights reserved © B&W Pantex 2011 What

18 18 Demings Theory of Profound Knowledge (TPK) provides a foundation for the systems approach W. Edwards Deming We used Demings Theory of Profound Knowledge to develop a process to attain those HRO attributes identified by the High Reliability Theorists

19 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 19 Demings Theory of Profound Knowledge (TPK) used to provide foundation for the systems approach

20 Knowledge of Psychology Knowledge of Knowledge Knowledge of Variation Knowledge of Systems 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 20 Knowledge of Systems Knowledge of Variation Knowledge of Knowledge Knowledge of Psychology

21 Knowledge of Knowledge Knowledge of Variation Knowledge of Systems 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 21

22 Provide capability to make conservative decisions Make judgments based on reality Openly question & verify system Generate decision- making info Tiered approach Refine HRO system Deploy system Evaluate operations – meas. variability Adjust processes Ensure system provides safety Manage system, evaluate variability Foster culture of reliability Model organizational learning 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 22

23 Provide capability to make conservative decisions Make judgments based on reality Openly question & verify system Generate decision- making info Tiered approach Refine HRO system Deploy system Evaluate operations – meas. variability Adjust processes Ensure system provides safety Manage system, evaluate variability Foster culture of reliability Model organizational learning 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 23

24 Provide capability to make conservative decisions Make judgments based on reality Openly question & verify system Generate decision- making info Tiered approach Refine HRO system Deploy system Evaluate operations – meas. variability Adjust processes Ensure system provides safety Manage system, evaluate variability Foster culture of reliability Model organizational learning 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 24

25 Provide capability to make conservative decisions Make judgments based on reality Openly question & verify system Generate decision- making info Tiered approach Refine HRO system Deploy system Evaluate operations – meas. variability Adjust processes Ensure system provides safety Manage system, evaluate variability Foster culture of reliability Model organizational learning 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 25

26 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. 26 Authors: Hartley, Tolk, Swaim Available through GPO http://bookstore.gpo.gov/collections/hro.jsp

27 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. 27 CAUSAL FACTORS ANALYSIS An Approach for Organizational Learning Learn from Information Rich Events Authors: Hartley, Swaim, Corcoran Available through GPO http://bookstore.gpo.gov/collections/hro.jsp

28 cannot recover 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. 28

29 cannot recover 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

30 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 wont improve performance Sustain behavior – account for organizational culture Long-term, sustained performance improvement 30 Work-as-imagined Work-as-done Artwork courtesy of Marshall Clemens of Idiagram. All rights reserved. mclemens@idiagram.com

31 31 All rights reserved © B&W Pantex 2011 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

32 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 32

33 Want to learn more? Richard S. Hartley, Ph.D., P.E. Principal Engineer 806-477-6480 rhartley@pantex.com B&W Pantex P.O. Box 30020 Amarillo, TX 79120-0020 Bld 12-6, Rm 126


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