Human and organizational factors in the achievment of high reliability

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Human and organizational factors in the achievment of high reliability

  1. 1. High reliability organizations (HRO’s) • Nuclear power stations, commercial aviation, nuclear submarines, air traffic control • Potentially hazardous, highly complex systems Katharine Parkes Design and manufacture of complex equipment School of Psychology, UWA for which failure is expensive and/or hazardous • Deepwater subsea equipment, space exploration, satellite deployment • Also, medical equipment, software design, electronics, automobile engineering. 8 June 2009 Engineers Australia / SPE “Reliability is the probability that a Organizational culture device, system, or process will perform its prescribed duty without failure for a given Organizational structure time when operated correctly in a specified Organizational l O i i l learning i environment” Capability of companies to meet reliability requirements (CMM models) Reliability-oriented HR policies “The Organizational culture is shaped by the beliefs, values, attitudes, assumptions, norms, an d behaviours, which are widely shared throughout philosophy, values, skills and leadership the organization, and are expressed through qualities of the top management personnel. rules, structures, decision-making processes, and To build and support a high reliability reward mechanisms” culture, managers need to - , g • Culture defines how an organization operates • develop a clear vision and provide a coherent sense internally, and how it adapts and interacts with of direction. customers, suppliers, regulatory bodies, and other • make a strong and consistent commitment to external organizations reliability, and ensure adequate resources • Strong vs. weak cultures • identify and communicate reliability goals • Defensive vs. constructive cultural styles throughout the company and its suppliers in a way that engages and inspires employees 1
  2. 2. Face-to-face • High levels of communication foster trust and good working relationships, the sharing of Video conference information, and the opportunity to develop new Telephone Decreasing skills. E-mail richness • Constraints on communication: remote sites; Letter language barriers; engineers as ‘smart people who don’t talk’ Memo • The means of communication influences its Numerical computer printout effectiveness . . . The right information must be conveyed to the right person at the right time, to communicate all necessary implications and consequences without overloading the recipient • Encourage and reward reporting of errors; treat errors as learning • In the organization as a whole, high opportunities; avoid a ‘blame’ culture. levels of alertness and vigilance are directed at identifying possible problems and errors, and using • Fear of a blame culture and possible experience to anticipate future financial penalties may affect the honesty and transparency of feedback through the problems. supply chain (Roberts, Strutt et al, 2001) Reliability Management Framework 1. Leadership and direction Refers to the way responsibility and authority is • Setting goals and objectives distributed within the organization: the number • Corporate Project Processes of hierarchical levels, reporting lines, and how 2. Consistency work tasks are allocated among employees. • Vertical alignment of goals/ processes • Allocation of goals and requirements Better company performance is associated with: 3. Coherence • Fewer layers in the organizational hierarchy • Common processes and practices • Decentralizing decisions to the lowest possible level • Alignment of goals across disciplines • Allowing authority to flow to those with relevant expertise 4. Feedback • How the organization learns, and • Frequent and open communication within and across communicates its experience in work groups projects and operations Strutt and Brookes (2007) 2
  3. 3. Capturing individual knowledge (e.g. lessons “The way firms build, supplement, and learned, root cause analyses) organize knowledge and routines around ◦ Systematically storing and organizing knowledge their activities and within their cultures, and ◦ Regularly updating records adapt and develop organizational efficiency Transferring knowledge by improving the skills of their workforce” ◦ Information needs to be widely disseminated y ◦ Readily accessible to potential users; ‘user-friendly’ • Organizational learning depends on sharing ◦ Shared among individuals and groups knowledge and experience Mobilizing knowledge; integrating information • Facilitated by a ‘constructive’ organizational from different sources culture which places high value on participation ◦ to create new knowledge, and to solve problems and co-operation ◦ to prevent the recurrence of past errors Provide a means of assessing the level of maturity of the practices within organizations that contribute to reliability, safety, and effective risk management. CMM models have been applied in software development, electronics, offshore oil/gas industry, subsea engineering, maintenance activities, marine construction, and water services. (Garvin et al. 2008) Level Maturity Description Characterized as Lack of written procedures. No real Ad hoc, 1 Uncontrolled understanding of reliability or how solely reactive Optimized 5 Proactive to achieve it. Can consistently repeat what it has 2 Repeatable done before, but does not address Prescriptive Managed 4 or control reliability Understands reliability and the 3 Defined factors that influence it. Written it Measured, Measured design procedures. Limited open-loop Defined 3 feedback of lessons from failures. Can meet reliability targets; 4 Managed products are adapted and reliability Single-loop improved in response to feedback learning Repeatable 2 from observed failures. ‘Best practice’. Uses experience and Adaptive 5 Optimized testing not only to correct product processes, Ad hoc 1 Reactive problems but also to change the way it operates. double-loop learning 3
  4. 4. Mean capability scores of subsea supplier companies on 13 CMM dimensions (Williams et al, 2003) Setting and allocating reliability requirements Research and development in 1 risk and reliability 4 Risk and reliability analysis 13 2 in design. Setting reliability requirements 3 4 Education and training in risk 12 3 Reliability assurance and reliability 2 Reliability Training and 3 improvements development 1 2 Feedback and Verification, validation and organizational learning g g 11 4 bench-marking g 0 1 Verification and 0 Reliability analysis Customer validation Reliability improvement and risk reduction in design 10 5 Project risk management. Management of change 9 6 Failure data tracking Reliability setting in design Reliability testing and life-cycle transitions and development and analysis 8 7 Failure reporting, tracking Supply chain management. and analysis. Supply chain management Subsea equipment suppliers were at a level of 2.2 – 2.75 (c.f. aeronautical Tiku et al (2007) and automotive industry, 4 – 4.5) Setting reliability Implement policies that serve to create a stable requirements 4 workforce, and reinforce and support employee Reliability Training and engagement and commitment (e.g. provision of 3 improvements development training, good pay, job security) 2 1 Verification and Supplier Develop selection procedures that successfully Reliability analysis identify, recruit, and promote people whose 0 validation Customer personal characteristics predispose them to conscientious, vigilant and consistent performance. Failure data tracking Reliability testing and analysis Supply chain management Tiku et al (2007) Ensure that all communications reinforce some aspect of reliability Individual characteristics that promote team Reward reliability over and above productivity or work, positive interaction, co- efficiency operation, communication, sharing of information, and learning among employees Create clear lines of responsibility; instil accountability t bilit • e g Emotional stability, extraversion and emotional e.g. stability extraversion, intelligence Select and promote people on the basis of their adherence to organizational values ‣ Diligence: conscientious, purposeful, attentive, and Facilitate development, provide training vigilant behaviour Encourage employment security; reduce turnover Ability to respond effectively to unexpected problems and events, and to anticipate possible future difficulties 4
  5. 5. Leadership and a strong commitment to Reliability-enhancing reliability from senior managers HR strategies An organizational culture that encourages frequent and open communication throughout the company and its supply chain Reliability oriented Reliability-oriented Devolving d i i D l i decision-making t l ki to lowest possible t ibl employee behaviours levels ‘Trying conditions’ Positive error management culture Organizational Encouraging organizational learning reliability Use of CMM models to assess capability Implementing reliability-oriented HR policies Ericksen & Dyer (2005) Obstacles to communication caused by hierarchy and consequent power that managers wielded over engineers, stifling their input to critical decisions . . Cultural traits and organizational practices detrimental to safety were allowed to develop, including reliance on past success as a substitute for sound engineering practices; organizational barriers that prevented effective Melinda Hodkiewitz, School of communication of critical safety information and stifled professional differences of opinion; Dave Morrison, School of Psychology A flawed decision-making process – managers tended to solve problems John Cordery, UWA Business School internally not forwarding them to all hierarchical levels The evolution of an informal chain of command of decision-making thatg operated outside the organization’s rules ‘NASA’s organizational culture had as much to do with this accident (the Gledden Trust, UWA Columbia disaster) as foam did’ . . . The hierarchical, protocol-oriented management culture that failed to decentralize and defer to engineering expertise after the foam hit. Cultural belief that the problems were not a threat to flight safety – a belief reinforced by the safe return of each mission. Flying with these flaws became normal and acceptable, not deviant. 5

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