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Copyright 2010 Muschara Error Management Consulting, LLC Human Performance On the Horizon: HROs, Resilience Engineering, and Black Swans Tony Muschara,

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Presentation on theme: "Copyright 2010 Muschara Error Management Consulting, LLC Human Performance On the Horizon: HROs, Resilience Engineering, and Black Swans Tony Muschara,"— Presentation transcript:

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2 Copyright 2010 Muschara Error Management Consulting, LLC Human Performance On the Horizon: HROs, Resilience Engineering, and Black Swans Tony Muschara, CPT January 25, 2010 The 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 16th Annual HPRCT Conference June · Sheraton Baltimore Inner Harbor co-sponsored by Constellation Energy and INPO

3 Copyright 2010 Muschara Error Management Consulting, LLC BP Deepwater Horizon 2

4 Copyright 2010 Muschara Error Management Consulting, LLC 3

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6 Key Points 1.Black Swans are rare, unpredictable, very severe events. 2.High Reliability Organizations (HRO) enhance safety through optimizing reliability. 3.Resilience Engineering (RE) improves safety by improving the occurrence of success. 4.Safety is what an organization does. 5.Reducing human failures is not the most efficient and effective way to improve human performance. 6.Recognize system health as a primary means to improving the safety state of an organization. 5

7 Copyright 2010 Muschara Error Management Consulting, LLC Black Swan* Rare outside the bounds of known likelihoods Rare outside the bounds of known likelihoods Unpredictable unable to anticipate Unpredictable unable to anticipate Severe unprecedented impact Severe unprecedented impact Event good or bad Event good or bad 6 * Taleb, N. (2007), The Black Swan.

8 Copyright 2010 Muschara Error Management Consulting, LLC Challenger (7) / Columbia (7) Challenger (7) / Columbia (7) Deepwater Horizon (11) Deepwater Horizon (11) Texas City (15) Texas City (15) Chernobyl (>56) Chernobyl (>56) United 232 (108) United 232 (108) Kansas City Hyatt (114) Kansas City Hyatt (114) Piper Alpha (167) Piper Alpha (167) Herald of Free Enterprise (186) Herald of Free Enterprise (186) Tenerife (583) Tenerife (583) Bhopal (>2200) Bhopal (>2200) Notable Black Swan Disasters* * Numbers in parentheses denote number of fatalities on each occasion. 7

9 Copyright 2010 Muschara Error Management Consulting, LLC High 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 Roberts U.C. Berkeley U.C. Berkeley Roberts, K. (2003), HRO has Prominent History, Anesthesia Patient Safety Foundation Newsletter, Vol. 18, No. 1, pp

10 Copyright 2010 Muschara Error Management Consulting, LLC Resilience 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 circumstances Resilience – the ability to adjust its functioning to sustain operations during expected conditions and in the face of escalating demands, disturbances, and unforeseen circumstances Resilience Engineering – the tools that promote resilience: anticipate, monitor, respond, learn Resilience Engineering – the tools that promote resilience: anticipate, monitor, respond, learn Erik 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

11 Copyright 2010 Muschara Error Management Consulting, LLC 1. Preoccupation with Failure 2. Reluctance to Simplify 3. Sensitivity to Operations 4. Commitment to Resilience 5. Deference to Expertise Five HRO Principles* 10 * Weick K. and Sutcliffe, K. (2007), Managing the Unexpected, 2 nd ed. p. Karl Weick Co-author: Managing the Unexpected

12 Copyright 2010 Muschara Error Management Consulting, LLC Anticipate – knowing what to expect; long-term threats and opportunities Anticipate – knowing what to expect; long-term threats and opportunities Monitor – knowing what to look for; near-term developments and threats (critical steps) Monitor – knowing what to look for; near-term developments and threats (critical steps) Respond – knowing what to do; capable of addressing expected and unexpected conditions Respond – knowing what to do; capable of addressing expected and unexpected conditions Learn – knowing what has happened (experience) and what to change (improvement) Learn – knowing what has happened (experience) and what to change (improvement) RE Cornerstones* * Source: Hollnagel, et al., Resilience Engineering, (2006), p.350, and Resilience Engineering Perspectives, Vol. 2, (2009), pp

13 Copyright 2010 Muschara Error Management Consulting, LLC 1. Limitations of Six Sigma and Lean manufacturing processes to adequately address inherent human variabilityrandom and often unpredictable 2. Difficulty in identifying and controlling the effects of social forces on information, its interpretation, knowledge, and action 3. The inability to specify all threats, combinations, and responses, and the occurrence of human failures in all phases of the plants life cycle 4. Multiple, concurrent human activities; dynamic, ambiguous environment; confounding number of system interdependencies 5. Incomplete or inaccurate knowledge about the state of the system and the uncertain nature of resources, information, and time 6. Impossible to chase and eliminate all latent weaknesses in a system. 7. Entropy – things wear out Serendipity 12

14 Copyright 2010 Muschara Error Management Consulting, LLC Intangibles – Sources of Uncertainty TrustCompassion CaringDedication FortitudeCuriosity HonestyWisdom InsightCourage ConsensusEmpathy PrideInterpretation ThoughtsMotives PerceptionsFeelings CollaborationPassion UnderstandingCreativity CraftsmanshipValues ForgivenessUnity PerseveranceInitiative Follow-throughIntegrity MeaningEffort AssumptionsBeliefs InterpretationsFears 13

15 Copyright 2010 Muschara Error Management Consulting, LLC Accumulation Accumulation Inconspicuous and seemingly harmless buildup of unusual conditions, hazards, threats, and system weaknesses without warning Drift and Accumulation* 14 Safety Danger Hi Lo Time Drift Expectations Current Practice Real Margin for Error * Adapted from Dekker, S. (2007), The Field Guide to Understanding Human Error. Hidden hazards, threats, unusual conditions, & system weaknesses Expectations: Desired approach to work (as imagined) Practices: Work as actually performed (allowed by mgmt!) Error Violation

16 Copyright 2010 Muschara Error Management Consulting, LLC Be Aggressive! The causes of tomorrows events exist today! 15 Latent System Weaknesses Accumulate Latent System Weaknesses Accumulate!

17 Copyright 2010 Muschara Error Management Consulting, LLC Safety Space – Where am I?* 16 Boundary: Economic Failure Boundary: Unacceptable Workload Administrative Safety Limit Boundary: System Failure Operating Point * Rasmussen, J. (1997), Risk Management in a Dynamic Society: A Modeling Problem, Safety Science, 27(2/3),

18 Copyright 2010 Muschara Error Management Consulting, LLC Commercial nuclear power Commercial nuclear power Air traffic control Air traffic control Wildland fire fighting Wildland fire fighting Aircraft carrier operations Aircraft carrier operations Healthcare Healthcare Armored military brigade Armored military brigade Space shuttle Space shuttle Offshore platforms Offshore platforms Rail and train operations Rail and train operations Manufacturing Manufacturing Submarine operations Submarine operations Studies on HROs and RE 17

19 Copyright 2010 Muschara Error Management Consulting, LLC Principal Features of an HRO* High-Hazard and Complex Activities High-Hazard and Complex Activities High Technical Competence High Technical Competence Hazard-Driven Adaptations Hazard-Driven Adaptations Positive Design-Based Redundancy Positive Design-Based Redundancy High Performance and Close Oversight High Performance and Close Oversight Constant Search for Improvement Constant Search for Improvement High Pressures and Expectations for Reliability High Pressures and Expectations for Reliability No Substitutes for Reliability No Substitutes for Reliability Limitations on Trial-and- Error Learning Limitations on Trial-and- Error Learning Culture of Reliability Culture of Reliability Flexible Authority during Emergencies Flexible Authority during Emergencies Mindfulness Mindfulness 18 * Roe, E. and Schulman, P. (2008), High Reliability Management: Operating on the Edge, p

20 Copyright 2010 Muschara Error Management Consulting, LLC Principal Features of RE Adaptability, Flexibility, and Capacity Adaptability, Flexibility, and Capacity Dynamic Nature of System and Multiple Interdependencies among Components Dynamic Nature of System and Multiple Interdependencies among Components Dependency on Functioning of the Whole System Dependency on Functioning of the Whole System Preparation and Sustainability Preparation and Sustainability Learning from Successes Learning from Successes Sustaining Normal Functioning, not just Preventing Failures Sustaining Normal Functioning, not just Preventing Failures Resourcefulness and Redundancy Resourcefulness and Redundancy Safety more than Reliability of Individual Components Safety more than Reliability of Individual Components Safety – What an Organization Does Safety – What an Organization Does Minimizing the gap between work-as-imagined and work-as-done Minimizing the gap between work-as-imagined and work-as-done 19

21 Copyright 2010 Muschara Error Management Consulting, LLC RE emphasizes adapting – to maintain success. RE emphasizes adapting – to maintain success. HRO emphasizes reliability – avoiding failure. HRO emphasizes reliability – avoiding failure. Fundamentally, the only difference is PERSPECTIVE! Fundamentally, the only difference is PERSPECTIVE! There are advantages from both. There are advantages from both. Are there any REAL Differences between HRO and RE? 20

22 Copyright 2010 Muschara Error Management Consulting, LLC Thanksgiving Turkey Days Benefits Surprise!

23 Copyright 2010 Muschara Error Management Consulting, LLC Accumulation Accumulation Inconspicuous and seemingly harmless buildup of unusual conditions, hazards, threats, and system weaknesses without warning Drift and Accumulation* 22 Safety Danger Hi Lo Time Drift Expectations Normal Practice Real Margin for Error * Adapted from Dekker, S. (2007), The Field Guide to Understanding Human Error. Hidden hazards, threats, unusual conditions, & system weaknesses Expectations: Desired approach to work (as imagined) Normal Practices: Work as actually performed (allowed by mgmt!)

24 Copyright 2010 Muschara Error Management Consulting, LLC Chronic Sense of Uneasiness An attitude of mindfulness regarding ones capacity to err and the presence of hidden threats; preoccupation with failure When you stop being scared, you start making mistakes. -- unknown 23 --how you perceive, think, feel, and behave toward hazards--

25 Copyright 2010 Muschara Error Management Consulting, LLC 1. 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. 2. If demands for productivity are high, thoroughness is reduced until productivity goals are met. 3. If demands for safety are high, efficiency is reduced until the safety goals are met. Efficiency/Thoroughness Trade-Off* * Hollnagel. E. (2009), The ETTO Principle, Efficiency-Thoroughness Trade-Off. 24

26 Copyright 2010 Muschara Error Management Consulting, LLC 1. Performance conditions are always imperfect: resources and time are finite, training and procedures are incomplete, and planning is approximate. 2. The reliability of individual components or subsystems cannot always effectively predict how they combine to create novel pathways to failure. 3. Safety is what you do, not what you have (continuous adaptation to changes and disruptionscore business). 4. People create safety within inherently imperfect systems. 5. It is difficult to do safety and production at the same time (trade-offs between time to think vs. time to do). 6. Identifying and eliminating latent system weaknesses continuously offers the best route to improving system health. 7. Organizations cultivate a capacity to adapt – preserve capacity, flexibility, reserves, and options and reduce volatile work situations. Key Conclusions about HRO and RE 25

27 Copyright 2010 Muschara Error Management Consulting, LLC Suggestions Make boundaries explicit, and build a preoccupation with failure. 2. Give people coping skills (adaptive capacities) at boundaries. 3. 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). 4. Pay attention to: 1) avoiding human failures at critical steps, and 2) improving system health (arresting the accumulation of latent system weaknesses) 5. Expand Hu management perspective from a myopic operational focus to an organizational focus. 6. Monitor how you monitor system health and safety. 7. Learn continuously – learn from successes, not just failures. 8. Anticipate – Monitor – Respond – Learn

28 Copyright 2010 Muschara Error Management Consulting, LLC 1. Reporting 2. Observation and Coaching 3. Self-Assessment and Trending 4. Operating Experience and Benchmarking 5. Causal Analyses Multi-Tiered Approach – Finding LSWs Eliminating latent [system weaknesses] is the most effective way to manage human error. --Jop Groeneweg Author: Controlling the Controllable 27

29 Copyright 2010 Muschara Error Management Consulting, LLC Improving System Health (RE) Internal Methods Field Observations Field Observations Post-job Reviews Post-job Reviews Reporting Reporting Self-Assessments Self-Assessments Metrics and Trending Metrics and Trending Common Factor Analysis Common Factor Analysis Surveys & Questionnaires Surveys & Questionnaires Cause Analysis Cause Analysis Effectiveness Reviews Effectiveness Reviews External Methods Operating Experience Operating Experience Benchmarking Benchmarking Independent Oversight Independent Oversight 28

30 Copyright 2010 Muschara Error Management Consulting, LLC Organization Local Factors (drivers) Human Performance Human Performance is its goal and its test. --Peter Drucker Management: Tasks, Responsibilities, Practices Management: Tasks, Responsibilities, Practices 29 We cannot change the human condition, but we can change the conditions under which people work. --James Reason Managing the Risks of Organizational Accidents Managing the Risks of Organizational Accidents

31 Copyright 2010 Muschara Error Management Consulting, LLC Effort vs. Importance* Latent System Weaknesses Human Failure Equipment Failure CurrentlyActual * Adapted from Kletz, T. (2001), An Engineers View of Human Error (3 rd ed.); p Effort Expended Importance 30

32 Copyright 2010 Muschara Error Management Consulting, LLC Be skeptical about confirmatory data. Be skeptical about confirmatory data. Worry less about small failures, and more about large, potentially terminal ones. Worry less about small failures, and more about large, potentially terminal ones. Worry more about matters that lie outside beyond our consciousness. Worry more about matters that lie outside beyond our consciousness. Worry about matters you can do something about. Worry about matters you can do something about. Be very conservative when exposed to the threat of a negative Black Swan. Be very conservative when exposed to the threat of a negative Black Swan. Avoiding the Black Swan 31 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 Taleb Author: The Black Swan Author: The Black Swan

33 Copyright 2010 Muschara Error Management Consulting, LLC 4724 Outlook Way Marietta, Georgia Questions and Comments 32


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