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Business Case for High Reliability. HPRCT Workshop June 21-25, 2010 Richard S. Hartley, Ph.D., P.E. This presentation was produced under contract number DE-AC04-00AL66620 with. What is a High Reliability Organization?.

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business case for high reliability

Business Case for High Reliability

HPRCT Workshop

June 21-25, 2010

Richard S. Hartley, Ph.D., P.E.

This presentation was produced under contract number DE-AC04-00AL66620 with

what is a high reliability organization
What is a High Reliability Organization?
  • An organization that repeatedly accomplishes its high hazard mission while avoiding catastrophic events, despite significant hazards, dynamic tasks, time constraints, and complex technologies
  • A key attribute of being an HRO is to learn from the organization’s mistakes
    • Aka a learning organization
slide4

SYSTEM ACCIDENT TIMELINE

What is Next?

Who is Next?

1979 - Three Mile Island

1984 – Bhopal India

1986 – NASA Challenger

1986 – Chernobyl

1989 – Exxon Valdez

1996 – Millstone

2001 – World Trade Center

2005 – BP Texas City

2007 – Air Force B-52

2008 – Stock Market Crash

why is being an hro so important
Why Is Being an HRO So Important?

Some types of system failures are so punishing that they must be avoided at almost any cost.

These classes of events are seen as so harmful that they disable the organization, radically limiting its capacity to pursue its goal, and could lead to its own destruction.

Laporte and Consolini, 1991

Some types of system failures are so punishing that they must be avoided at almost any cost.

These classes of events are seen as so harmful that they disable the organization, radically limiting its capacity to pursue its goal, and could lead to its own destruction.

Laporte and Consolini, 1991

Some types of system failures are so punishing that they must be avoided at almost any cost.

These classes of events are seen as so harmful that they disable the organization, radically limiting its capacity to pursue its goal, and could lead to its own destruction.

Laporte and Consolini, 1991

slide7

Does a Systems Approach Make Sense?

Department of Energy Safety Improvement from 1993-2008

Contractor ISM deployed

Data as of 7/7/2009

DOE injury rates have come down significantly since Integrated Safety Management (ISM) was adopted

does a systems approach make sense u s nuclear industry performance 1985 2008

Does a Systems Approach Make Sense?U.S. Nuclear Industry Performance 1985-2008

Capacity Factor (% up)

Cost (¢/kwh)

Rx Trips/ Scrams

Significant

Events/Unit

Nuclear Energy Institute (NEI) Data

what is the focus of an hro

What is the Focus of an HRO?

Individual Accidents OR Systems Accidents?

individual accident
Individual Accident
  • An accident occurs wherein the worker is not protected from the plant and is injured (e.g. radiation exposure, trips, slips, falls, industrial accident, etc.)
  • Focus:
  • Protect the worker from the plant

Plant

(hazard)

Human Errors

(receptor)

systems accident
Systems Accident
  • An accident wherein the system fails allowing a threat (human errors) to release hazard and as a result many people are adversely affected
    • Workers, Enterprise, Surrounding Community, Country

Plant

(hazard)

Human Errors

(threat)

  • Focus:
  • Protect the plant from the worker

The emphasis on the system accident in no way degrades the importance of individual safety , it is a pre-requisite of an HRO

strive to avoid a systems accident
Strive To Avoid A Systems Accident!
  • Goal of a High Reliability Organization
    • Strive daily for High Reliability Operations
  • A systems approach
    • Every individual is not going to have a perfect day every day
    • To avoid the catastrophic accident a systems approach is required
fundamentals of systems approach

Fundamentals of Systems Approach

Reality Engineering

Understanding Socio-Technical Systems to Improve Bottom-Line

central theme of an hro
Central Theme of an HRO

Not a New Initiative

Logical, Defensible Way to Think

Based on Logic & Science

Logic & Science are Time and New Initiative Invariant

The most important thing,

is to keep the most important thing,

the most important thing.

Steven Covey, 8thHabit

  • Focus on what is important
  • Measure what is important
hros think and act differently
HROs Think and Act Differently
  • Take a physics-based system approach
  • Measure gaps relative to physics-based system
  • Explicitly account for people
    • People are not the problem, they are the solution
    • People are not robots, pounding won’t improve performance
    • People provide safety, quality, security, science etc.
  • Sustain behavior – account for culture
    • Improve long-term safety, security, quality
slide16

Spectrum of Safety

Spectrum of Safety

  • Hard Core Safety Physics
  • Physics invariant
  • Prevent flow of unwanted energy
  • Delta function
  • Squishy People Part of Safety
  • Average IQ of the organization
  • It is a systems approach
  • Gaussian curve

As Engineers Write

As People Do

slide17

Spectrum of Safety

Spectrum of Safety

  • Hard Core Safety Physics
  • Physics invariant
  • Prevent flow of unwanted energy
  • Delta function
  • Squishy People Part of Safety
  • Average IQ of the organization
  • It is a systems approach
  • Gaussian curve

Old Mind-Set

Compliance-based safety

  • High Reliability Organization
  • Explicitly consider human error
  • Take into account org. culture
  • Maximize delivery of procedures
  • Improve system safety
steps to deploy hro
Steps To Deploy HRO
  • Step #1: Ensure the operation has a defined and justified safety basis
  • Step #2: Develop and deploy HRO framework to use strengths of organization to maintain safety
  • Step #3: Measure performance of organization to safety basis
  • Step #4: Leverage organizational learning to reduce variability to following safety basis
steps to deploy hro19
Steps To Deploy HRO
  • Step #1: Ensure the operation has a defined and justified safety basis
    • Understand physics and chemistry of processes
      • Unsafe Zone
      • Do not Operate Zone (DOZ)
slide20

In the red part of the unsafe zone and as delineated by the deterministic line, there are some levels of physics beyond which the outcomes (consequences) are certain.

Zones of Safety

Unsafe Zone

Violates physics of safety

High consequence event

Unsafe Zone

Violates physics of safety

High consequence event

20

slide21

The orange cloud signifies the DOZ (don’t operate zone). It extends to the unsafe zone (red circle) and signifies that area which because of uncertainty we try to stay out of by establishing conservative margins of safety.

Zones of Safety

Unsafe Zone

Violates physics of safety

High consequence event

DOZ

(don’t operate zone -

signified by orange cloud)

Region noted by DOZ should provide safety but can’t prove

21

steps to deploy hro22
Steps To Deploy HRO
  • Step #1: Ensure the operation has a defined and justified safety basis
    • Understand physics and chemistry of processes
      • Unsafe Zone
      • Do not Operate Zone (DOZ)
    • Define and justify safety basis relative to Unsafe Zone and DOZ
      • Ensure individual processes are within safety basis
      • Ensure collective processes are within safety basis
      • Determine margin of safety
slide23

Zones of Safety

Unsafe Zone

Violates physics of safety

High consequence event

The safe zone/safety basis (green oval) represents a physics-based zone bounded with hazard analyses and defined using operating procedures.

DOZ

(don’t operate zone -

signified by orange cloud)

Safe Zone - Safety Basis

Assured safety based on physics

Processes if followed (i.e. stay within safety basis) assures safety

Region noted by DOZ should provide safety but can’t prove

23

slide24

Zones of Safety

Unsafe Zone

Violates physics of safety

High consequence event

DOZ

(don’t operate zone -

signified by orange cloud)

Safe Zone - Safety Basis

Assured safety based on physics

Processes if followed (i.e. stay within safety basis) assures safety

The Margin of Safety represents the gap between the established safety basis and the unsafe zone.

Margin of Safety (i.e. safety factors)

24

steps to deploy hro25
Steps To Deploy HRO
  • Step #2: Develop and deploy HRO framework to use strengths of organization to maintain safety
    • Compliance-based safety
      • Work-as-imagined equals work-as-done, except
      • Bad apples
slide26

Compliance-Based Safety

Engineer’s Field of Dreams

Build it and they will come

Unsafe Zone

Violates physics of safety

High consequence event

Based on assumption that most people will follow established safety rules.

Regulation and oversight ensure compliance with established safety basis.

DOZ

(don’t operate zone -

signified by orange cloud)

Safe Zone - Safety Basis

Assured safety based on physics

Processes if followed (i.e. stay within safety basis) assures safety

Management assumes work-as-imagined equals work-as-done

work-as-imagined =

Margin of Safety (i.e. safety factors)

work-as-done

26

slide27

Why do we remove “bad apples?”

They represent the $ M lesson learned!

Compliance-Based Safety

Those that don’t follow established safety systems are just those few bad apples that need to be removed.

Unsafe Zone

Violates physics of safety

High consequence event

DOZ

(don’t operate zone -

signified by orange cloud)

bad-apples

Safe Zone - Safety Basis

Assured safety based on physics

bad-apples

X

X

Processes if followed (i.e. stay within safety basis) assures safety

work-as-imagined =

Margin of Safety (i.e. safety factors)

work-as-done

27

steps to deploy hro28
Steps To Deploy HRO
  • Step #2: Develop and deploy HRO framework to use strengths of organization to maintain safety
    • Compliance-based safety
      • Work-as-imagined equals work-as-done, except
      • Bad apples
    • HRO Approach to safety
      • Reality between work-as-imagined vs. work-as-done
      • Socio-technical systems
        • Explicitconsideration of the affect of organizations on technical safety
slide29

HRO Approach to Safety

Unsafe Zone

Violates physics of safety

High consequence event

Green cloud signifies organizations’ struggles to stay within safety basis.

DOZ

(don’t operate zone -

signified by orange cloud)

Safe Zone - Safety Basis

Assured safety based on physics

Processes if followed (i.e. stay within safety basis) assures safety

work-as-imagined

work-as-done

29

slide30

HRO Approach to Safety

Holes in safety basis because of poor analysis (potentially drops you into the DOZ).

Unsafe Zone

Violates physics of safety

High consequence event

DOZ

(don’t operate zone -

signified by orange cloud)

Safe Zone - Safety Basis

Assured safety based on physics

Processes if followed (i.e. stay within safety basis) assures safety

work-as-imagined

work-as-done

30

slide31

HRO Approach to Safety

Unsafe Zone

Violates physics of safety

High consequence event

DOZ

(don’t operate zone -

signified by orange cloud)

Safe Zone - Safety Basis

Assured safety based on physics

.

Every excursion into DOZ decreases margin of safety.

Processes if followed (i.e. stay within safety basis) assures safety

work-as-imagined

Reduced Margin of Safety

work-as-done

31

slide32

HRO Approach to Safety

HROs:

Explicitly consider how the organizational behavior affects ability to buy-in to the established safety basis.

Attempt to leverage this to improve the margin of safety.

Unsafe Zone

Violates physics of safety

High consequence event

DOZ

(don’t operate zone -

signified by orange cloud)

Safe Zone - Safety Basis

Assured safety based on physics

Processes if followed (i.e. stay within safety basis) assures safety

work-as-imagined

work-as-done

32

how do hros do this

How Do HROs Do This?

Builiding a High Reliability Organization

recommended reading material
Recommended Reading Material
  • The Limits of Safety, Scott D. Sagan
  • Normal Accidents – Living with High-Risk Technologies, Charles Perrow
  • Managing the Unexpected, Karl E. Weick& Kathleen M. Sutcliffe
  • Managing the Risks of Organizational Accidents, James Reason
  • Organizational Culture and Leadership, 3rd ed., Edgar Schein
  • Field Guide to Human Error Investigations, Sidney Dekker
  • The 8th Habit, From Effectiveness to Greatness, Stephen Covey
  • Pantex High Reliability Operations Guide
  • Pantex Causal Factors Analysis Handbook