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Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
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Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement

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Introduction …

Introduction

Foreign Object Damage
– An aviation perspective
Health, Safety and Environment – a holistic approach

Engaging the human element

Culture

Leadership’s role

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  • 1. 1 Falling objects: Engaging the ”man- in-the-loop” to achieve real safety improvement
  • 2. Agenda •  Introduction •  Foreign Object Damage – An aviation perspective •  Health, Safety and Environment – a holistic approach •  Engaging the human element •  Culture •  Leadership’s role
  • 3. Eric Arne Lofquist eric.lofquist@bi.no •  PhD from NHH studying “The effects of strategic change on safety in High Reliability Organizations (HROs)” - Avinor •  Associate Professor Handelshøyskole BI Bergen •  Health, Safety and Environment (HSE) 5 November 2010
  • 4. USS Nimitz CVN-68
  • 5. 6 Foreign Object Damage (FOD) in Aviation *FOD costs the civil aviation industry 3-4 Billion dollars each year
  • 6. 7 Civil aviation describes the FOD program as a two phase process: • Avoidance of foreign objects •  Removal of foreign objects FOD program activities: •  FOD walkdowns •  ”Good housekeeping” activities •  Reporting and investigation •  Compiling data and trend analysis
  • 7. 8 The FOD program today is an integrated part of the overall safety management system •  Safety culture/climate But what about identification of foreign objects? •  Everyone’s responsibility
  • 8. 9 What are foreign objects?
  • 9. Indian Ocean 3 May 1980
  • 10. 11 Concorde 2000 Columbia Space Shuttle 2003
  • 11. From engineering to behavior Technology, technical engineering Safety Management Systems Behavior Number of accidents Trend in practice over time Pre-1960 1960s-1970s 1980’s +
  • 12. A systems perspective •  ”Since both failures and successes are the outcome of normal performance variability, safety cannot be achieved by constraining – or eliminating it.” •  Normal Accident Theory – (Perrow, 1984) •  High Reliability Organizations (Rochlin et al., 1987) •  Resilience Engineering (Hollnagel et al., 2006) •  Safety management cannot be based on a reactive approach alone
  • 13. Understanding the nature of systems •  How systems are designed and developed to operate in an ”expected” environment •  How they evolve in response to the environment •  Based on our limited mental models – why a particular risk assessment might be limited •  Instead, expecting that challenges to system performance will occur – because systems evolve
  • 14. The problem with models •  ”All models are wrong” – Jay Forrester •  All models are simplifications of reality •  Includes our system of rules and regulations •  Models are based on our limited cognative capacity •  Short-cuts •  Rules-of-thumb
  • 15. Safety Management Systems •  Based on an ideal or rational view of an organization •  Where functions, roles and responsibilities are clearly defined ”for people” according to specified organizational goals, and as a result, the organization is designed to ”behave” in a rational way •  A prescriptive approach ending up with a normative organization against which practices can be measured or assessed
  • 16. Swiss Cheese Model – Reason (1990) •  Focus and the Man-in-the-loop in MTO and on HSE- culture. •  Need to involve those who feel the problem in the bodies – those on the shop floor. •  Last line of defence 17 Latent conditions Hazards Losses Man Technology Organization
  • 17. HSE Management Systems (Lofquist, 2008:2010) Proactive Phase Interactive Phase Reactive Phase System Design System Operation System Outcomes Time Organizational Culture Environment Socio-technical system
  • 18. HSE Management Systems (Lofquist, 2010) Proactive Phase Interactive Phase Reactive Phase System Design System Operation System Outcomes Time Organizational Culture Environment Socio-technical system
  • 19. Proactive activities   System design/redesign   Processes, routines and procedures   Creation of barriers   Rules and regulations   Risk analysis (based on incomplete and/or changing assumptions)   Personnel selection   Personnel training/retraining
  • 20. HSE Management Systems (Lofquist, 2008:2010) Proactive Phase Interactive Phase Reactive Phase System Design System Operation System Outcomes Time Organizational Culture Environment Socio-technical system
  • 21. Reactive activities   System outcomes   Unplanned and undesired outcomes occur   Incident and accident reporting   Performance measurement
  • 22. HSE Management Systems (Lofquist, 2008:2010) Proactive Phase Interactive Phase Reactive Phase System Design System Operation System Outcomes Time Organizational Culture Environment Socio-technical system
  • 23. Engaging the ”man-in-the-loop”   Socio-technical systems   Understanding the nature of the human element in a systems context
  • 24. HSE Management Systems (Lofquist, 2008:2010) Proactive Phase Interactive Phase Reactive Phase System Design System Operation System Outcomes Time Organizational Culture Environment Socio-technical system
  • 25. Organizational culture (Schein, 2004) •  Culture – a dynamic phenomenon that surrounds us at all times •  Constantly enacted and created by our interaction with others and shaped by leadership behavior •  Creates a set of social structures, routines, rules and norms that guide and constrain behavior •  The dynamic processes of culture creation and management are the essence of leadership 05-11 -10 Eric Arne Lofquist26
  • 26. Culture and leadership •  Two sides of the same coin •  Culture decides what defines leadership but leaders create and manage culture •  Leadership creates and changes culture, while management and administration act within culture •  Culture is the result of complex group learning processes that are only partly influenced by leader behavior 05-11 -10 Eric Arne Lofquist27
  • 27. Culture drives our thinking and actions •  Observed behavioral regularities when people interact •  Group norms •  Espoused values •  Informal ”rules of the game” •  Habits of thinking, mental models and linguistic paradigms – cognitive frameworks 05-11 -10 Eric Arne Lofquist28
  • 28. Double-loop learning (Argyris & Schön, 1974) Real world Information feedback Mental models of real world Strategy, structure, decision rules Decisions Single- loop Double- loop
  • 29. Zohar, 2010 •  Conceptual attributes of the construct of safety climate •  Relative priorities •  Alignment between espousals and enactments •  Internal consistency •  Shared cognitions or social consensus •  Motivation for climate perceptions: social verification 05-11 -10 Eric Arne Lofquist31
  • 30. How do leaders embed their beliefs, values and assumptions •  Primary embedding: •  What leaders pay attention to, measure and control •  How leaders react to critical incidents and organizational crisis •  How leaders allocate resources •  Deliberate role modeling, teaching and coaching •  How leaders allocate rewards and status •  How leaders recruit, select, promote and excommunicate 05-11 -10 32
  • 31. High Reliability Organizations (HROs) •  Creating a supporting organizational culture •  Creating a ”learning environment” •  Mindfulness •  Knowing (Education and training) •  Sensemaking •  Seeing (Noticing) •  Responding (Reporting) •  Taking action
  • 32. 34
  • 33. Key points •  Targeting human error no longer target •  Safety is the presence of something not the absence of something •  Attempting to fix unreliable human behavior by: •  Automation •  More procedures and barriers •  Increased monitoring •  Only people have adaptive capacity
  • 34. Using the operators •  Operators, and their deep understanding of an application area is an important source of resilience – expertise in action •  Two main sources of resilience •  Picking up the faint signals when ”things are going wrong” •  Being able to develop resources that can adapt ”on the fly” •  Identify potential dangers
  • 35. Takk for meg 37

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