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High Reliability Organizations (HROs) and High Performance
Karlene H. RobertsHaas School of Business
Canter for Catastrophic Risk ManagementUniversity of California, Berkeley
[email protected] (fax)
Agenda
• Causes of catastrophic accidents
• Defining High Reliability Organizations
• Five elements of a process model of HROs
• How these elements can come together
• Businesses targeting HRO
• Government agencies targeting HRO
• Performance outcomes of HRO implementation
The Arrow
Work
Management
Operational Staff
Company
Regulators
Government
Actions
Accident
What is an HRO ?
• An organization
– conducting relatively error free operations
– over a long period of time
– and making consistently good decisions resulting in
– high quality and reliability operations
A HRO IS ALSO AN ORGANIZATION THAT SOLVES THE RIGHT PROBLEMS
AN EXAMPLE OF AN ORGANIZATION THAT SOLVED THE WRONG PROBLEM PRECISELY
Before its Texas City refinery accident BPs safety metric for its refineries was:SlipsTripsFalls
Slips, trips, and falls have nothing to do with the kind of process accident that happened at Texas City*
Hopkins, A. (2010) Failure to Learn
1. Process Auditing:
• An established system for ongoing checks designed to spot expected as well as unexpected safety problems.
• Safety drills are in this category, as is equipment testing.
• Follow-ups on problems revealed in prior audits are critical.
2. Reward System:
• The reward system is the payoff an individual or organization receives for behaving one way or another.
• Organizational theory points out that organizational reward systems have powerful influences on the behavior of individuals in them.
• Similarly, inter-organizational reward systems also influence behavior in organizations.
3. Quality Degradation:
• Avoiding degradation of quality and/or developing inferior quality: This refers to the essential quality of the system as compared to a referent generally regarded as the standard for quality in the industry.
4. Perception of Risk:
•There are at least two elements of risk perception; (1) Whether or not there is knowledge that risk exists, and(2) If there is knowledge that risk exists, the extent to which it is acknowledged and appropriately mitigated and/or minimized
•Part two is a logical outgrowth of part one.
5. Command and Control Elements:
• Migrating decision making: (the person with the most expertise makes the decision).
• Redundancy: (people and/or hardware), i.e., backup systems exist.
• Senior managers who see the “big picture”: i.e., they don’t micromanage.
• Formal rules and procedures: A definite existence of hierarchy but not necessarily bureaucracy in the negative sense.
• Training.
High Reliability Organizations
Process auditing- spot the expected and unexpected
Reward & Recognition-Drive the correct behaviors
-Value contribution of the line
Quality Systems
Risk Perception– Knowledge that risks exist?–Extent to which risk is acknowledged and mitigated
Training- High technical
competence
Formal rules and procedures
Senior managers who see the big
picture
Depth/Org. Capacity
Migrate decision making to the
appropriate person
Businesses Targeting High Reliability
• Commercial Aviation (e.g. United Airlines, Qantas)
• Commercial Banking (e.g. S.W.I.F.T.)
• Healthcare (e.g. Kaiser Permanente perinatal units)
• Commercial Nuclear Power (e.g. INPO, Diablo Canyon Nuclear Power Plant)
Government Agencies Targeting High Reliability
• U.S. Navy carrier aviation
• U.S. Navy submarine service
• U.S. Department of Energy Laboratories
• Community Emergency Services (e.g. U.S. Forest Service, San Bernardino County and City Fire)
• Deep Underground Science and Engineering Laboratory (under design)
0
10
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50 65 80 95
Angled DecksAviation Safety Center
Naval Aviation Maintenance ProgramRAG (FRS) Concept Initiated
NATOPS ProgramSquadron Safety Program
System Safety Aircraft DesignCRM Aircrew reviews
ORMSafety culture
776 aircraftdestroyed in
1954
Naval Aviation Class AFlight Mishap Rate
FY50-03
Fiscal Year
24 aircraftdestroyed in
FY03-all in flightmishaps
96-2003
• Aircraft catapult off every 30 seconds
• Aircraft are catapulted from 0 –160 mph in 2 seconds down a runway 460 ft long
• One person sets the controls for each launch individually (with many verbal and automatic backups)
• Aircraft approach at 150 mph and are ‘hooked’ on landing to a halt within 2 seconds and 300 ft
• The hooking mechanism must again be set by a single person based on the weight of the plane
> …..and it’s >>> >>>> >> >>>>>> >>> >>> >> >>>>>>> 20
>>>>> >>>> >>> >>>>>>> >>>>>>>>>> >> 2> 3 >>>>>
HRO operation –the USS Nimitz
Keys to their success•No hierarchy during operations. Everyone has a DUTY to interrupt if they have a concern. There is no punishment for this
•Training is constant and relentless. There is healthy challenge to constantly improve, resulting in an active learning society.
•Communication throughout the team is far in excess of the norm
•Turnover of people helps stop operations becoming stale
–‘the worst type of employee in an HRO is one whois too confident or stubborn’
64 63
41
128
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Supervisory Aircrew Material Maintenance Fac Pers
Cause Factors of Aviation MishapsNavy & Marine Class A Flight Mishaps
FY 95 - 99
1002C3
155 mishaps131 (85%) involved human error
percent
99 97 64 19 12
Nuclear Energy Institute Data1985-2008
Rx Trips/ Scrams
Cost (¢/kwh)
SignificantEvents/Unit
Capacity Factor (% up)
What I Talked About
• Causes of catastrophic accidents
• Defining High Reliability Organizations
• Five elements of a process model of HROs
• How these elements can come together
• Businesses targeting HRO
• Government agencies targeting HRO
• Performance outcomes of HRO implementation
