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DARWIN Webinar 'The sharp end' by Anders Ellerstrand

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On 26 February 2019, the DARWIN Community of Practitioners (DCoP) hosted a webinar with Anders Ellerstrand, Watch Supervisor at the Malmö ATC Centre in Sweden, entitled 'Don't Forget the Sharp End When Improving Resilience'.

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DARWIN Webinar 'The sharp end' by Anders Ellerstrand

  1. 1. Let’s not forget The Sharp End when improving Resilience Anders Ellerstrand
  2. 2. Anders Ellerstrand Sweden Air Traffic Control DCOP member
  3. 3. The Resilience Abilities: A - The ability to anticipate L - The ability to learn and evolve M - The ability to monitor R - The ability to respond and adapt
  4. 4. DRMG: • “The DRMGs are intended for /directly addressed to policy makers, decision makers and managers at different levels in an organization. They can only indirectly affect the activities of front line operators or first responders in crisis management.”
  5. 5. DRMG: • “The DRMGs are not directly addressed to front line operators or first responders in crisis management (although their activities will be indirectly impacted by the DRMGs, if their practices and procedures have been revised or designed based on the DRMGs).”
  6. 6. You can divide an operational system - into a sharp end and a blunt end…
  7. 7. The Blunt End: Control and support Low Risk and High Power
  8. 8. The Sharp End: First responders High Risk and Low Power
  9. 9. M - The ability to monitor • “Knowing what to look for or being able to monitor that which is or could seriously affect the system’s performance in the near term – positively or negatively. The monitoring must cover the system’s own performance as well as what happens in the environment.” • “One type of indicators are called ‘leading’ indicators, because they can be used as valid precursors for changes and events that are about to happen. ‘Leading’ indicators are generally seen as very attractive (Hopkins, 2009). The main difficulty with ‘leading’ indicators is that the interpretation requires an articulated description, or model, of how the system functions.” Reference: Hollnagel, E. (2015) Introduction to the Resilience Analysis Grid (RAG)
  10. 10. Work-as-Imagined (WAI)/ Work as Prescribed (WAP)
  11. 11. Work-as-Done (WAD)
  12. 12. WAI – WAD The knowledge is at the sharp end…
  13. 13. M - The ability to monitor
  14. 14. L - The ability to learn and evolve • “Knowing what has happened, or being able to learn from experience, in particular to learn the right lessons from the right experience.” • “Counting how often something happens is not learning. Knowing how many accidents have occurred, for instance, says nothing about why they have occurred, nor anything about the many situations when accidents did not occur. And without knowing why something happens, as well as knowing why it does not happen, it is impossible to propose effective ways to improve safety.” Reference: Hollnagel, E. (2015) Introduction to the Resilience Analysis Grid (RAG)
  15. 15. Reference: Hollnagel, E., Wears, R.L. and Braithwaite, J. (2015) From Safety-I to Safety-II: A White Paper. The Resilient Health Care Net: Published simultaneously by the University of Southern Denmark, University of Florida, USA, and Macquarie University, Australia.
  16. 16. Drifting… On April 14, 1994, two U.S. Air Force F-15 fighters accidentally shot down two U.S. Army Black Hawk Helicopters over Northern Iraq, killing all twenty-six peacekeepers onboard. In response to this disaster the complete array of military and civilian investigative and judicial procedures ran their course. After almost two years of investigation with virtually unlimited resources, no culprit emerged, no bad guy showed himself, no smoking gun was found. This book attempts to make sense of this tragedy--a tragedy that on its surface makes no sense at all.
  17. 17. General conditions: • ”…the tendency to overdesign, and a bias to overcontrol…” • ”A long enough period to loosely coupled time sufficient to generate substantial gaps between globally synchronized rules and local subgroup practice…” • ”A reasonable chance that isolated subgroups would become tightly coupled at some point in the future.” Reference: Snook, S. A. (2000) Friendly Fire. Princeton University Press
  18. 18. L - The ability to learn and evolve
  19. 19. A - The ability to anticipate • “Knowing what to expect or being able to anticipate developments further into the future, such as potential disruptions, novel demands or constraints, new opportunities, or changing operating conditions.” • “Many present day systems where industrial safety is a concern are … underspecified. For such systems the principles of functioning are only partly known, descriptions contain (too) many details and take a long time to make, and the systems keep changing so that descriptions must be frequently updated.” Reference: Hollnagel, E. (2015) Introduction to the Resilience Analysis Grid (RAG)
  20. 20. Competence – Lagging or Leading? • Erik Hollnagel; Eurocontrol Hindsight magazine No 27: • “Indeed, an almost universal response to failures and accidents is to analyse them in order to identify the competence that would have prevented them.” • “Although some part of competence must be lagging, it would clearly be interesting and useful if competence also could be leading.” • “A complementary and more constructive approach is to consider what is needed for a system to function as required in expected and unexpected conditions alike – or in other words to perform in a resilient manner.” • “The requisite competence could, for instance, be derived from the set of cognitive and interpersonal skills that are the focus of CRM – such as communication, decision making, and leadership.”
  21. 21. CRM / Non-technical skills 1. Cooperation: Cooperation is the ability to work effectively in a crew. 2. Leadership and managerial skills: Effective leadership and managerial skills help to achieve joint task completion within a motivated, fully functioning team through coordination and persuasiveness. 3. Situation awareness: Situation awareness relates to one’s ability to accurately perceive what is in the flight crew compartment and outside the aircraft. It is also one’s ability to comprehend the meaning of different elements in the environment and the projection of their status in the near future. 4. Decision-making: Decision-making is the process of reaching a judgement or choosing an option. Reference: European Aviation Safety Agency; Acceptable Means of Compliance (AMC) and Guidance Material (GM) to Annex III – Part-ORO
  22. 22. Threat and Error Management There are basically three categories of individual and team countermeasures: • Planning countermeasures: essential for managing anticipated and unexpected threats; • Execution countermeasures: essential for error detection and error response; • Review countermeasures: essential for managing the changing conditions of a flight. Reference: Maurino, D. (2005) Threat and error management (TEM). Vancouver: Canadian Aviation Safety Seminar (CASS)
  23. 23. Threat and Error Management There are basically three categories of individual and team countermeasures: • Planning countermeasures: essential for managing anticipated and unexpected threats; • Briefings, plans, workload assignment, contingency • Execution countermeasures: essential for error detection and error response; • Review countermeasures: essential for managing the changing conditions of a flight. Reference: Maurino, D. (2005) Threat and error management (TEM). Vancouver: Canadian Aviation Safety Seminar (CASS)
  24. 24. A - The ability to anticipate
  25. 25. R - The ability to respond and adapt • “Knowing what to do or being able to respond to regular and irregular changes, disturbances, and opportunities by activating prepared actions or by adjusting current mode of functioning.” • “In order to respond, the system must therefore first detect that something has happened, then recognise what it is and determine whether a response is necessary, and finally know how to respond, when to begin, and when to stop.” Reference: Hollnagel, E. (2015) Introduction to the Resilience Analysis Grid (RAG)
  26. 26. DRMG 3.2. Establishing conditions for adapting plans and procedures during crises and other events that challenge normal plans and procedures.
  27. 27. DRMG 3.2. ”Often, crises challenge the plans and procedures in place. As a result, organisations need to support and maintain a clear and legitimate space of manoeuvre relative to normative plans and procedures.”
  28. 28. DRMG 3.2. ”Such space is important for actors engaged in crisis response in order to adapt to unusual (unanticipated) circumstances.”
  29. 29. R - The ability to respond and adapt
  30. 30. The Darwin Resilience Management Guidelines (DRMG) are not directly addressed to front line operators or first responders in crisis management… …but let’s not forget the sharp end…
  31. 31. Thanks – any questions?

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