HRO Perspectives on Interdependence in and across Organizations

HRO Perspectives on Interdependence in and across Organizations Peter M. Madsen Marriott School of Management, Brigham Young University Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Organizational Disaster • Disaster: 1: “A sudden calamitous event bringing great damage, loss, or destruction; ” 2: “A sudden or great misfortune or failure. ” Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Fukushima I Nuclear Power Plant Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Deepwater Horizon Explosion & Oil Spill Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Upper Big Branch Mine Explosion, 2010 Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Imperial Sugar Explosion, 2008 Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Spinach Recall, 2006 Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Systems View of Organizations • Organizations as socio-technical systems – People, groups & units – Technological components, information networks • Complexity in organizations – Combinatorial complexity: large numbers of potential interactions, tight coupling – Dynamic complexity: delayed effects, feedback loops, feedforward loops Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

System Accidents • Distinct from simple component failures – Including human error • Driven by unplanned and unexpected interactions between system components – Non-independence – Combinatorial and dynamic complexity • Extremely difficult to predict and prepare for – “Normal accidents” • Examples – Three Mile Island – Petrobras P 36 Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Fukushima I Nuclear Power Plant Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

System Accidents • Distinct from simple component failures – Including human error • Driven by unplanned and unexpected interactions between system components – Non-independence – Combinatorial and dynamic complexity • Extremely difficult to predict and prepare for – “Normal accidents” • Examples – Three Mile Island – Petrobras P 36 Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Combinatorial Complexity & System Accidents Number of System Components Number of Possible Pairwise Interactions 2 1 3 3 5 10 10 45 100 5000 1000 500, 000 10, 000 50, 000 Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

System Accidents • Distinct from simple component failures – Including human error • Driven by unplanned and unexpected interactions between system components – Non-independence – Combinatorial and dynamic complexity • Extremely difficult to predict and prepare for – “Normal accidents” • Examples – Three Mile Island – Petrobras P 36 Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

TMI 2 Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Petrobras P 36 Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Petrobras P 36 Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Prevention of System Accidents • HRO strategies for managing system accidents – Learning from non-events – Resiliency • HRO requirements – Vigilance – Shared Cognition – Constrained Improvisation – Safety Culture Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Inter-Organizational System Accidents • Inter-organizational systems • Interdependencies cross organizational boundaries – – – Contractors Suppliers/Vendors Unions Regulators Customers Competitors • Inter-organizational system accident examples – Avianca flight 52 – Mumbai High North – Deepwater Horizon Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Avianca flight 52 Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Mumbai High North Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Mumbai High North Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Deepwater Horizon Explosion & Oil Spill Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Inter-Organizational System Accident Prevention • HRO strategies are the same – Learning from non-events – Resiliency • HRO requirements are the same – Vigilance – Shared Cognition – Constrained Improvisation – Safety Culture • But challenges are much greater Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Challenges to HRO in Inter. Organizational Systems • Vigilance – Warning signs in multiple organizations – Need for rapid, rich information sharing • Shared Cognition – Need for shared mental models across organizations • Constrained Improvisation – Coordination of activities across groups with no history of joint action • Examples: Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

9/11 Attacks Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Challenges to HRO in Inter. Organizational Systems • Vigilance – Warning signs in multiple organizations – Need for rapid, rich information sharing • Shared Cognition – Need for shared mental models across organizations • Constrained Improvisation – Coordination of activities across groups with no history of joint action • Examples: Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Oakland Hills Fire of 1991 Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

HRO Implementation in Inter. Organizational Systems • Cultural compatibility – Cultural consideration in partner selection – Long-term relationships – Development of trust • Rich information sharing – Accident and near-miss reporting – Contracts with economic incentives for “safety” are counterproductive • Joint training and planning – Build relationships – Develop shared cognition – Establish parameters for constrained improvisation Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

U. S. Air Force and Aerospace Corporation Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Grand Teton Dam Failure Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

Conclusion • System errors occur in inter-organizational systems • Inter-organizational HRO implementation is challenging • HRO may be introduced through: – Development of compatible safety cultures – Norms of rich information sharing – Joint training Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020

HRO Perspectives on Interdependence in and across Organizations Peter M. Madsen Marriott School of Management, Brigham Young University Center for Catastrophic Risk Management, University of California, Berkeley 11/25/2020