HIGH RELIABILITY ORGANIZATIONS HROS JOHN GROUT BERRY COLLEGE

HIGH RELIABILITY ORGANIZATIONS (HRO’S) JOHN GROUT BERRY COLLEGE

SFO

• … Imagine that it’s a busy day, and you shrink San Francisco airport to only one short runway and one ramp and one gate. Make planes take off and land at the same time, at half the present time interval, rock the runway from side to side and require that everyone who leaves in the morning returns that same day. Make sure the equipment is so close to the edge of the envelope that it’s fragile. Then turn off the radar to avoid detection, impose strict controls on radios, fuel the aircraft in place with their engines running, put an enemy in the air and scatter live bombs and rockets around. Now wet the whole thing down with seawater and oil and man it with 20 year-olds, half of whom have never seen an airplane close-up. Oh and by the way, try not to kill anyone.

Karl E. Weick and Karlene H. Roberts. Administrative Science Quarterly Vol. 38, No. 3 (Sep. 1993), pp. 357 -381.

HRO CHARACTERISTICS 1. Preoccupation With Failure 2. Reluctance to Simplify 3. Sensitivity to Operations 4. Deference to Expertise 5. Commitment to Resilience

1. PREOCCUPATION WITH FAILURE • Everyone is aware of and thinking about the potential for failure. People understand that new threats emerge regularly from situations that no one imagined could occur, so all personnel actively think about what could go wrong and are alert to small signs of potential problems. The absence of errors or accidents leads not to complacency but to a heightened sense of vigilance for the next possible failure. Near misses are viewed as opportunities to learn about systems issues and potential improvements, rather than as evidence of safety.

NORMAL ACCIDENTS • Perrow identifies three conditions that make a system likely to be susceptible to Normal Accidents: 1. Complex 2. Tightly coupled 3. Catastrophic potential

JAMES REASON’S SWISS CHEESE MODEL

1. PREOCCUPATION WITH FAILURE • Everyone is aware of and thinking about the potential for failure. People understand that new threats emerge regularly from situations that no one imagined could occur, so all personnel actively think about what could go wrong and are alert to small signs of potential problems. The absence of errors or accidents leads not to complacency but to a heightened sense of vigilance for the next possible failure. Near misses are viewed as opportunities to learn about systems issues and potential improvements, rather than as evidence of safety.

NEAR MISS REPORTING • https: //www. youtube. com/watch? v=nw_bg. L 1 Mw. UQ • Watch 12: 50 to 13: 33 • Different signals to cross flight deck • Near miss occurs • See Air Boss and explain situation • Naval safety center elevated situation to appropriate team to make corrective action • Procedure standardized

RATE YOUR PREOCCUPATION WITH FAILURE • Regard close calls and near misses as a kind of failure that reveals potential danger rather than as evidence of our success and ability to avoid danger • We treat near misses and errors as information about the health of our system and try to learn from them • (1 = not at all, 2 = to some extent, 3 = a great deal)

2. RELUCTANCE TO SIMPLIFY • People resist simplifying their understanding of work processes and how and why things succeed or fail in their environment. People in HROs understand that the work is complex and dynamic. They seek underlying rather than surface explanations. While HROs recognize the value of standardization of workflows to reduce variation, they also appreciate the complexity inherent in the number of teams, processes, and relationships involved in conducting daily operations.

RATE YOUR RELUCTANCE TO SIMPLIFY • People around here take nothing for granted • People are encouraged to express different points of view • (1 = not at all, 2 = to some extent, 3 = a great deal)

3. SENSITIVITY TO OPERATIONS • Based on their understanding of operational complexity, people in HROs strive to maintain a high awareness of operational conditions. This sensitivity is often referred to as "big picture understanding" or "situational awareness. " It means that people cultivate an understanding of the context of the current state of their work in relation to the unit or organizational state—i. e. , what is going on around them—and how the current state might support or threaten safety.

RATE YOUR SENSITIVITY TO OPERATIONS • During an average day, people come into enough contact with each other to build a clear picture of the situation. • People are familiar with operations beyond one’s own job. • (1 = not at all, 2 = to some extent, 3 = a great deal)

4. DEFERENCE TO EXPERTISE • People in HROs appreciate that the people closest to the work are the most knowledgeable about the work. Thus, people in HROs know that in a crisis or emergency the person with greatest knowledge of the situation might not be the person with the highest status and seniority. Deference to local and situation expertise results in a spirit of inquiry and de-emphasis on hierarchy in favor of learning as much as possible about potential safety threats. In an HRO, everyone is expected to share concerns with others and the organizational climate is such that all staff members are comfortable speaking up about potential safety problems.

RATE YOUR DEFERENCE TO EXPERTISE • If something out of the ordinary happens, people know who has the expertise to respond • People in this organization value expertise and experience over hierarchical rank • (1 = not at all, 2 = to some extent, 3 = a great deal)

5. COMMITMENT TO RESILIENCE • Commitment to resilience is rooted in the fundamental understanding of the frequently unpredictable nature of system failures. People in HROs assume the system is at risk for failure, and they practice performing rapid assessments of and responses to challenging situations. Teams cultivate situation assessment and cross monitoring so they may identify potential safety threats quickly and either respond before safety problems cause harm or mitigate the seriousness of the safety event.

RATE YOUR COMMITMENT TO RESILIENCE • There is a concern with building people’s competence and response repertoires. • People have a number of informal contacts that they sometimes use to solve problems. • (1 = not at all, 2 = to some extent, 3 = a great deal)

HIGH RELIABILITY ORGANIZATIONS (HROs) • operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures. • high reliability is not just effective standardization of processes. • high reliability is better described as a condition of persistent heedful interrelating within an organization. • High reliability organizations cultivate resilience by relentlessly prioritizing safety over other performance pressures.

HEEDFUL INTERRELATING MEANS TO PAY ATTENTION IN A DIFFERENT WAY • Teams with members who show greater dispersion of attention and more responsive communication are more effective in coordinating effort and feel more sense of belonging. • You STOP concentrating on those things that confirm your hunches, are pleasant, feel certain, seem factual, are explicit, and that others agree on. • You START concentrating on things that disconfirm, are unpleasant, feel uncertain, seem possible, are implicit, and are contested.

TO HEEDFULLY INTERRELATE IS TO “SEE MORE CLEARLY” NOT TO THINK HARDER AND LONGER • See where your model didn’t work, or see indicators you missed that signaled expectations weren’t being filled (failure) • Strip away labels, stereotypes that conceal differences among details (simplification) • Focus on what is happening here and now (operations) • See new uses for old resources through improvisation and making do (resilience) • Discover people who understand a situation better than you do and defer to them (expertise)

QUESTIONS AND DISCUSSION • Thank you for inviting me! I am sorry I can’t be there in person.