Presentation on theme: "27 March 2017 16th Annual HPRCT Conference"— Presentation transcript:
127 March 201716th Annual HPRCT ConferenceJune · Sheraton Baltimore Inner Harbor co-sponsored by Constellation Energy and INPOHuman Performance On the Horizon: HROs, Resilience Engineering, and Black SwansTony Muschara, CPTJanuary 25, 2010The Certified Performance Technologist (CPT) designation is awarded by the International Society for Performance Improvement (ISPI) to experienced practitioners in the field of organizational performance improvement whose work meets both the performance-based Standards of Performance Technology and application requirements. For more information, visit
5Key Points Black Swans are rare, unpredictable, very severe events. 27 March 2017Key PointsBlack Swans are rare, unpredictable, very severe events.High Reliability Organizations (HRO) enhance safety through optimizing reliability.Resilience Engineering (RE) improves safety by improving the occurrence of success.Safety is what an organization does.Reducing human failures is not the most efficient and effective way to improve human performance.Recognize system health as a primary means to improving the safety state of an organization.
6Black Swan* Rare outside the bounds of known likelihoods 27 March 2017Black Swan*Rare outside the bounds of known likelihoodsUnpredictable unable to anticipateSevere unprecedented impactEvent good or bad* Taleb, N. (2007), The Black Swan.
7Notable Black Swan Disasters* 27 March 2017Notable Black Swan Disasters*Challenger (7) / Columbia (7)Deepwater Horizon (11)Texas City (15)Chernobyl (>56)United 232 (108)Kansas City Hyatt (114)Piper Alpha (167)Herald of Free Enterprise (186)Tenerife (583)Bhopal (>2200)* Numbers in parentheses denote number of fatalities on each occasion.
8High Reliability Organization (HRO) 27 March 2017High Reliability Organization (HRO)HROs are “Organizations [that] operate under trying conditions yet perform relatively event-free over a long period of time, making consistently good decisions that result in high quality and reliable operations.”-- Karlene RobertsU.C. BerkeleyRoberts, K. (2003), “HRO has Prominent History,” Anesthesia Patient Safety Foundation Newsletter, Vol. 18, No. 1, pp.1-16.
9Resilience Engineering (RE)* Resilience – the ability to adjust its functioning to sustain operations during expected conditions and in the face of escalating demands, disturbances, and unforeseen circumstancesResilience Engineering – the tools that promote resilience: anticipate, monitor, respond, learnErik Hollnagel Editor: Resilience Engineering Perspectives Volume 1: Remaining Sensitive to the Possibility of Failure* Nemeth, C. et al. (2009), Resilience Engineering Perspectives, Volume 2: Preparation and Restoration, p.117.
10Karl Weick Co-author: Managing the Unexpected 27 March 2017Five HRO Principles*Preoccupation with FailureReluctance to SimplifySensitivity to OperationsCommitment to ResilienceDeference to ExpertiseKarl Weick Co-author: Managing the Unexpected* Weick K. and Sutcliffe, K. (2007), Managing the Unexpected, 2nd ed. p.
1127 March 2017RE Cornerstones*Anticipate – knowing what to expect; long-term threats and opportunitiesMonitor – knowing what to look for; near-term developments and threats (critical steps)Respond – knowing what to do; capable of addressing expected and unexpected conditionsLearn – knowing what has happened (experience) and what to change (improvement)* Source: Hollnagel, et al., Resilience Engineering, (2006), p.350, and Resilience Engineering Perspectives, Vol. 2, (2009), pp
1227 March 2017SerendipityLimitations of Six Sigma and Lean manufacturing processes to adequately address inherent human variability—random and often unpredictableDifficulty in identifying and controlling the effects of social forces on information, its interpretation, knowledge, and actionThe inability to specify all threats, combinations, and responses, and the occurrence of human failures in all phases of the plant’s life cycleMultiple, concurrent human activities; dynamic, ambiguous environment; confounding number of system interdependenciesIncomplete or inaccurate knowledge about the state of the system and the uncertain nature of resources, information, and timeImpossible to chase and eliminate all latent weaknesses in a system.Entropy – things wear out
13Intangibles – Sources of Uncertainty 27 March 2017Intangibles – Sources of UncertaintyTrust Compassion Caring Dedication Fortitude Curiosity Honesty Wisdom Insight Courage Consensus Empathy Pride Interpretation Thoughts Motives Perceptions FeelingsCollaboration Passion Understanding Creativity Craftsmanship Values Forgiveness Unity Perseverance Initiative Follow-through Integrity Meaning Effort Assumptions Beliefs Interpretations Fears
14Drift and Accumulation* 27 March 2017Drift and Accumulation*Expectations: Desired approach to work (as imagined)HiPractices: Work as actually performed (allowed by mgmt!)ExpectationsDriftViolationCurrent PracticeSafetyReal Margin for ErrorErrorAccumulation Inconspicuous and seemingly harmless buildup of unusual conditions, hazards, threats, and system weaknesses without warningDangerHidden hazards, threats, unusual conditions, & system weaknessesLoTime* Adapted from Dekker, S. (2007), The Field Guide to Understanding Human Error.
15Latent System Weaknesses Accumulate! 27 March 2017Be Aggressive!The causes of tomorrow’s events exist today!Latent System Weaknesses Accumulate!
16Safety Space – Where am I?* 27 March 2017Safety Space – Where am I?*Boundary: System FailureBoundary: Economic FailureOperating PointAdministrative Safety LimitBoundary: Unacceptable Workload* Rasmussen, J. (1997), “Risk Management in a Dynamic Society: A Modeling Problem,“ Safety Science, 27(2/3),
17Studies on HROs and RE Commercial nuclear power Air traffic control 27 March 2017Studies on HROs and RECommercial nuclear powerAir traffic controlWildland fire fightingAircraft carrier operationsHealthcareArmored military brigadeSpace shuttleOffshore platformsRail and train operationsManufacturingSubmarine operations
18Principal Features of an HRO* 27 March 2017Principal Features of an HRO*High-Hazard and Complex ActivitiesHigh Technical CompetenceHazard-Driven AdaptationsPositive Design-Based RedundancyHigh Performance and Close OversightConstant Search for ImprovementHigh Pressures and Expectations for ReliabilityNo Substitutes for ReliabilityLimitations on Trial-and-Error LearningCulture of ReliabilityFlexible Authority during EmergenciesMindfulness* Roe, E. and Schulman, P. (2008), High Reliability Management: Operating on the Edge, p
19Principal Features of RE 27 March 2017Principal Features of REAdaptability, Flexibility, and CapacityDynamic Nature of System and Multiple Interdependencies among ComponentsDependency on Functioning of the Whole SystemPreparation and SustainabilityLearning from SuccessesSustaining Normal Functioning, not just Preventing FailuresResourcefulness and RedundancySafety more than Reliability of Individual ComponentsSafety – What an Organization DoesMinimizing the gap between work-as-imagined and work-as-done
20Are there any REAL Differences between HRO and RE? 27 March 2017Are there any REAL Differences between HRO and RE?RE emphasizes adapting – to maintain success.HRO emphasizes reliability – avoiding failure.Fundamentally, the only difference is PERSPECTIVE!There are advantages from both.
21Surprise! Thanksgiving Turkey Benefits Days 200 400 800 600 1000 27 March 2017Thanksgiving Turkey2004008006001000DaysBenefitsSurprise!
22Drift and Accumulation* 27 March 2017Drift and Accumulation*Expectations: Desired approach to work (as imagined)HiNormal Practices: Work as actually performed (allowed by mgmt!)ExpectationsDrift“Normal” PracticeSafetyReal Margin for ErrorAccumulation Inconspicuous and seemingly harmless buildup of unusual conditions, hazards, threats, and system weaknesses without warningDangerHidden hazards, threats, unusual conditions, & system weaknessesLoTime* Adapted from Dekker, S. (2007), The Field Guide to Understanding Human Error.
23Chronic Sense of Uneasiness An attitude of mindfulness regarding one’s capacity to err and the presence of hidden threats; preoccupation with failure--how you perceive, think, feel, and behave toward hazards--“When you stop being scared, you start making mistakes.”-- unknown
24Efficiency/Thoroughness Trade-Off* 27 March 2017Efficiency/Thoroughness Trade-Off*People routinely make a choice between being efficient (productive / less effort) and being thorough (safe / reliable), since it is rarely possible to be both at the same time.If demands for productivity are high, thoroughness is reduced until productivity goals are met.If demands for safety are high, efficiency is reduced until the safety goals are met.* Hollnagel. E. (2009), The ETTO Principle, Efficiency-Thoroughness Trade-Off.
25Key Conclusions about HRO and RE 27 March 2017Key Conclusions about HRO and REPerformance conditions are always imperfect: resources and time are finite, training and procedures are incomplete, and planning is approximate.The reliability of individual components or subsystems cannot always effectively predict how they combine to create novel pathways to failure.Safety is what you do, not what you have (continuous adaptation to changes and disruptions—core business).People create safety within inherently imperfect systems.It is difficult to do safety and production at the same time (trade-offs between time to think vs. time to do).Identifying and eliminating latent system weaknesses continuously offers the best route to improving system health.Organizations cultivate a capacity to adapt – preserve capacity, flexibility, reserves, and options and reduce volatile work situations.
2627 March 2017SuggestionsMake boundaries explicit, and build a “preoccupation with failure.”Give people coping skills (adaptive capacities) at boundaries.When introducing change, 1) avoid introduction of local factors that intensify volatility for the front-line worker, (control) and 2) preserve local factors that support flexibility in off normal conditions (adaptability).Pay attention to: 1) avoiding human failures at critical steps, and 2) improving system health (arresting the accumulation of latent system weaknesses)Expand Hu management perspective from a myopic operational focus to an organizational focus.Monitor how you monitor system health and safety.Learn continuously – learn from successes, not just failures.Anticipate – Monitor – Respond – Learn
27Multi-Tiered Approach – Finding LSWs 27 March 2017Multi-Tiered Approach – Finding LSWsReportingObservation and CoachingSelf-Assessment and TrendingOperating Experience and BenchmarkingCausal Analyses“Eliminating latent [system weaknesses] is the most effective way to manage human error.”--Jop GroenewegAuthor: Controlling the Controllable
28Improving System Health (RE) 27 March 2017Improving System Health (RE)Internal MethodsExternal MethodsField ObservationsPost-job ReviewsReportingSelf-AssessmentsMetrics and TrendingCommon Factor AnalysisSurveys & QuestionnairesCause AnalysisEffectiveness ReviewsOperating ExperienceBenchmarkingIndependent Oversight
29Local Factors (drivers) 27 March 2017“Human Performance is its goal and its test.”--Peter Drucker“Management: Tasks, Responsibilities, Practices”OrganizationManagement SystemsLeadership Practices“We cannot change the human condition, but we can change the conditions under which people work.”--James Reason“Managing the Risks of Organizational Accidents”Local Factors (drivers)Human Performance
30Effort vs. Importance* Effort Expended Importance Currently Actual 27 March 2017Effort vs. Importance*Effort ExpendedImportanceLatent System WeaknessesHuman FailureEquipment FailureCurrentlyActual* Adapted from Kletz, T. (2001), An Engineer’s View of Human Error (3rd ed.); p.127..
31Avoiding the Black Swan 27 March 2017Avoiding the Black SwanBe skeptical about confirmatory data.Worry less about small failures, and more about large, potentially terminal ones.Worry more about matters that lie outside beyond our consciousness.Worry about matters you can do something about.Be very conservative when exposed to the threat of a negative Black Swan.“It is more difficult to be a loser in a game you set up yourself. …this means that you are exposed to the improbable only if you let it control you. You always control what you do.”--Nassim TalebAuthor: The Black Swan
32Questions and Comments 27 March 2017Questions and Comments4724 Outlook WayMarietta, Georgia 30066