1
Falling objects: Engaging the ”man-
in-the-loop” to achieve real safety
improvement
Agenda
•  Introduction
•  Foreign Object Damage – An aviation
perspective
•  Health, Safety and Environment – a
holistic a...
Eric Arne Lofquist
eric.lofquist@bi.no
•  PhD from NHH studying “The effects of strategic
change on safety in High Reliabi...
USS Nimitz CVN-68
6
Foreign Object Damage
(FOD) in Aviation
*FOD costs the civil aviation industry 3-4 Billion dollars each year
7
Civil aviation describes the FOD program
as a two phase process:
• Avoidance of foreign objects
•  Removal of foreign ob...
8
The FOD program today is an integrated
part of the overall safety management
system
•  Safety culture/climate
But what a...
9
What are foreign objects?
Indian Ocean
3 May 1980
11
Concorde 2000
Columbia Space Shuttle 2003
From engineering to behavior
Technology, technical engineering
Safety Management Systems
Behavior
Number of
accidents
Tren...
A systems perspective
•  ”Since both failures and successes are the
outcome of normal performance variability,
safety cann...
Understanding the nature of systems
•  How systems are designed and developed to
operate in an ”expected” environment
•  H...
The problem with models
•  ”All models are wrong” – Jay Forrester
•  All models are simplifications of reality
•  Includes...
Safety Management Systems
•  Based on an ideal or rational view of an
organization
•  Where functions, roles and responsib...
Swiss Cheese Model – Reason (1990)
•  Focus and the Man-in-the-loop in MTO and on HSE-
culture.
•  Need to involve those w...
HSE Management Systems
(Lofquist, 2008:2010)
Proactive
Phase
Interactive
Phase
Reactive
Phase
System Design System Operati...
HSE Management Systems
(Lofquist, 2010)
Proactive
Phase
Interactive
Phase
Reactive
Phase
System Design System Operation Sy...
Proactive activities
  System design/redesign
  Processes, routines and procedures
  Creation of barriers
  Rules and ...
HSE Management Systems
(Lofquist, 2008:2010)
Proactive
Phase
Interactive
Phase
Reactive
Phase
System Design System Operati...
Reactive activities
  System outcomes
  Unplanned and undesired outcomes occur
  Incident and accident reporting
  Per...
HSE Management Systems
(Lofquist, 2008:2010)
Proactive
Phase
Interactive
Phase
Reactive
Phase
System Design System Operati...
Engaging the ”man-in-the-loop”
  Socio-technical systems
  Understanding the nature of the human
element in a systems co...
HSE Management Systems
(Lofquist, 2008:2010)
Proactive
Phase
Interactive
Phase
Reactive
Phase
System Design System Operati...
Organizational culture (Schein, 2004)
•  Culture – a dynamic phenomenon that
surrounds us at all times
•  Constantly enact...
Culture and leadership
•  Two sides of the same coin
•  Culture decides what defines leadership but
leaders create and man...
Culture drives our thinking and actions
•  Observed behavioral regularities when people
interact
•  Group norms
•  Espouse...
Double-loop learning
(Argyris & Schön, 1974)
Real world
Information
feedback
Mental models of
real world
Strategy, structu...
Zohar, 2010
•  Conceptual attributes of the construct of
safety climate
•  Relative priorities
•  Alignment between espous...
How do leaders embed their beliefs, values
and assumptions
•  Primary embedding:
•  What leaders pay attention to, measure...
High Reliability Organizations (HROs)
•  Creating a supporting organizational culture
•  Creating a ”learning environment”...
34
Key points
•  Targeting human error no longer target
•  Safety is the presence of something not the
absence of something
•...
Using the operators
•  Operators, and their deep understanding of an
application area is an important source of
resilience...
Takk for meg
37
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

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

  1. 1. 1 Falling objects: Engaging the ”man- in-the-loop” to achieve real safety improvement
  2. 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. 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. 4. USS Nimitz CVN-68
  5. 5. 6 Foreign Object Damage (FOD) in Aviation *FOD costs the civil aviation industry 3-4 Billion dollars each year
  6. 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. 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. 8. 9 What are foreign objects?
  9. 9. Indian Ocean 3 May 1980
  10. 10. 11 Concorde 2000 Columbia Space Shuttle 2003
  11. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 21. Reactive activities   System outcomes   Unplanned and undesired outcomes occur   Incident and accident reporting   Performance measurement
  22. 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. 23. Engaging the ”man-in-the-loop”   Socio-technical systems   Understanding the nature of the human element in a systems context
  24. 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. 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. 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. 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. 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. 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. 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. 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. 32. 34
  33. 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. 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. 35. Takk for meg 37

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