High Reliability Organizing Karlene H. Roberts Haas School of Business Center for Catastrophic Risk Management University of California, Berkeley [email protected] 510.642.4700 (fax)

Agenda •  Defining High Reliability Organizations (HROs) •  Need for HROs •  We often solve the wrong problem precisely rather than having HROs •  Theory addresses a number of HRO processes •  Implementation •  Rewards for successful implementation

What is an HRO ? •  An organization or system of organizations – conducting relatively error free operations – over a long period of time – and making consistently good decisions resulting in – high quality and reliability operations

The Arrow

Poole, R. Beyond Engineerng: How Society Shapes Technology, 1997, p.276

•  In a generation or two, the world will likely need thousands of high-reliability organizations running not just nuclear power plants, space flight, and air traffic control, but also chemical plants, electrical grids, computer and telecommunication networks, financial networks, genetic engineering, nuclear-waste storage, and many other complex, hazardous technologies. Our ability to manage a technology, rather than our ability to conceive and build it, may be the limiting factor in many cases (1997, p. 276).

Solving the Wrong Problem Precisely •  If they can get you to ask the wrong questions, then they don’t have to worry about the answers. Thomas Pynchon •  The worst and most corrupting lies are problems wrongly stated. Georges Bernanos •  We know…that when you cannot get an answer there is something wrong with the question Joan Robinson

Two Examples of Solving the Wrong Problem Precisely • 

Coca Cola in Belgium 1999 –  Children in six schools complained coke tasted bad and smelled funny –  Coke forced to withdraw 30 million cans and bottles of its products –  Governments of France , Netherlands and Luxembourg also banned coke products –  Coke engineers concluded nothing toxic in the product –  Also said the children were victims of mass hysteria –  Solution made things worse by insulting the consumers –  Coke defined the problem as technical not psychological

• 

BP in its refineries prior to 2005 –  Safety metric was number of slips, trips and falls over some time period –  Slips, trips and falls have absolutely nothing to do with process accidents such as the Texas City Refinery fire.

Work Began in 1985 by Examining Organizing Processes in: •  U.S. Navy Aircraft Carrier Operations •  U.S. Federal Aviation Administration’s Air Traffic Control Operations •  Diablo Canyon Commercial Nuclear Power Plant •  All are organizations in which errors can have catastrophic consequences

The Kinds of Organizations Studied in This Body of Research •  U.S. Navy carrier aviation •  Federal Aviation Administration’s Air Traffic Control System •  Commercial nuclear power plants •  Banks •  Health care organizations •  School reform •  California’s electrical grid •  Wild land and urban fire fighting

Organizations Studied, cont. •  •  •  •  •  •  •  • 

Aviation Columbia space shuttle Manufacturing Military armored brigade Offshore oil platforms A police force Submarines United Kingdom train operators

Some Organizational Processes HRO Theory Addresses: •  The necessity of simultaneously considering systems of organizations as well as the organizations in those systems. •  How to design organizations and systems of organizations •  Mindfulness •  Latent errors •  Coordination •  Decentralized decision making

Processes HROs Have Implemented •  •  •  •  • 

Process auditing Appropriate Reward Systems Improved quality Risk Perception Command and Control –  Migrating decision making –  Redundancy –  Senior manager with “big picture” –  Formal rules and procedures –  Training!!!!!!!!!!!!

Implementation of HRO Processes •  With varying degrees of success •  Sometimes attempts are made with little understanding of HRO processes •  Such attempts always fail •  Where successful it requires great understanding and constant effort •  Where successful the entire organization is behind HRO

Some Examples of Implementation •  U.S. Department of Energy and some organizations related to it •  Commercial aviation •  Health care (e.g. Kaiser perinatal) •  Energy Company •  Wildland/urban fire fighting (U.S. and France) •  U.S. Department of State (in Diplomacy)

While the Effort May be High the Rewards are Great

24 aircraft destroyed in FY03all in flight mishaps

776 aircraft destroyed in 1954

Angled Decks Aviation Safety Center Naval Aviation Maintenance Program RAG (FRS) Concept Initiated NATOPS Program Squadron Safety Program System Safety Aircraft Design CRM Aircrew reviews ORM

Safety culture 96-2003

Fiscal Year

Nuclear Energy Institute Data 1985-2008 Rx Trips/ Scrams Cost (¢/kwh)

Significant Events/Unit

Capacity Factor (% up)

What we Talked About •  Defining High Reliability Organizations (HROs) •  Need for HROs •  How we often solve the wrong problem precisely rather than having HROs •  Discussed theory that addresses a number of HRO processes •  Implementation •  Rewards for successful implementation