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Practicing High Reliability: Organizations Designed for Humans. W. Earl Carnes – U.S. Department of Energy Richard S. Hartley - B&W Pantex. Why High Reliability? Avert the danger not yet arisen … -- Vedic Proverb Reason 1: Practice-relevant management research

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Presentation Transcript
slide1

Practicing High Reliability:

Organizations Designed for Humans

W. Earl Carnes – U.S. Department of Energy

Richard S. Hartley - B&W Pantex

slide2

Why High Reliability?

Avert the danger not yet arisen …

-- Vedic Proverb

Reason 1: Practice-relevant management research

Reason 2: Defacto state of the art for accident investigation and prevention

High Reliability Practicality

High Reliability Theory

nuclear energy performance trends 1985 2008

Nuclear Energy Performance Trends1985-2008

Rx Trips/ Scrams

Capacity Factor (% up)

Cost (¢/kwh)

Significant

Events/Unit

slide4

LRO

HRO

Safety Culture Continuum

Mindlessness

• Early warning signs of danger go

unnoticed

• Acting with rigidity

• Operating on automatic pilot

• Outdated diagnosis of problems goes

unnoticed

• Underlying style of mental functioning

in which people try to address safety

by following recipes

• Imposing old categories to classify

what people see

• Changes in context go unnoticed

• Mislabeling unfamiliar new contexts

as familiar ones

Mindfulness

• Ongoing scrutiny of existing

expectations

• Continuous refinement and

differentiation of expectations based

on new experiences

• Willingness and capability to invent

new expectations that make sense of

unprecedented events

• A nuanced appreciation of context

and ways to deal with it

• Identification of new dimensions of

context that improve foresight & current

functioning

slide5

Knowing what is not enough!

Jeffrey K. Liker

U. of Michigan

Jeffery Pfeffer & Robert Sutton - Stanford

What we do – the specific techniques and practices …is not as important as why we do it – the underlying philosophy

Example .. the Toyota Production System … observers see the tools and practices not the principles – improvement is made in accordance with the scientific method, under the guidance of a teacher, at the lowest possible level in the organization.

Steven Spear & H. Kent Bowen – Harvard Business School

wylfiwyf
*WYLFIWYF*

The framework you use determines what you learn:

  • Basic view: Equipment failures and human errors
  • Complex view: Above plus underlying failures
    • (Includes latent organizational weaknesses)
  • High Reliability view: Both of above plus work processes, recovery mechanisms, and resilience

*What you look for is what you find*

slide7

HRO Meta Model *

Core properties

*Meta model defines the language and processes from which to form a domain specific model

slide8

“Our ability to manage a technology, rather than our ability to conceive it may be the limiting factor …”

Poole R. “Beyond Engineering: How Society Shapes Technology” 1997.