3 Lessons from High Reliability Organizations
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The document presents lessons learned from high reliability organizations, particularly the nuclear navy, emphasizing that safety should be an expectation rather than a goal. It advocates for simpler management systems and highlights the importance of organizational culture in maintaining safety and operational efficiency. The text also notes that traditional risk management often fails in complex systems, making proactive management and cultural change essential.
3 Lessons from High Reliability Organizations
- 1. 1 3 Lessons from High Reliability Organiza7ons Presenta*on to the Canadian Na*onal Energy Board at the 2015 Pipeline Safety Forum
- 2. The world has changed! 2 www.wilsonperumal.com “Individual produc7vity” Volume Cost Pre-‐Industrial Age Driven by variable costs “Economies of Scale” Volume Industrial Age Driven by fixed costs “Complexity” Complexity Post-‐Industrial Age Driven by complexity costs
- 3. Complexity is stretching the capabilities of most organizations 3 www.wilsonperumal.com TECHNOLOGY PRODUCTS & SERVICES PROCESSES ORGANIZATIONS REGULATIONS MARKETS X XX X XCOMMUNICATIONS
- 4. Complexity grows exponentially 4 #Items #links 1 0 2 1 3 3 4 6 5 10 … 10 45 $ Complexity
- 5. 5 Characteristics of complex systems 1. Non-linear reactions 2. Emerging properties 3. Feedback loops 4. Unknown interactions
- 6. Many companies are passing a complexity threshold 6 Level of complexity you can support VALUE (diminishing returns) COST & RISK (exponen*al growth) $ Complexity Few companies are s.ll here Many companies are here An increasing number of companies are here
- 7. 7 www.wilsonperumal.com Increased complexity Poor execution Loss of process control Poor performance Added processes Vicious Complexity Cycle The typical response to complexity is to add even more complexity
- 8. Catastrophic incidents are becoming more frequent and more severe 8 1979 – Three-‐Mile Island core meltdown 1988 – Piper Alpha explosion 2005 – Texas City Refinery explosion 2010 – San Bruno Pipeline explosion 2010 – BP Deepwater Horizon oil spill 2011 – Fukushima Daiichi disaster 2013 – West Fer7lizer plant explosion
- 9. 9 www.wilsonperumal.com Traditional risk management doesn’t address these “normal accidents” well Too complex to anticipate Too fast to address Too infrequent to understand
- 10. 10 www.wilsonperumal.com The Pessimist’s View “Regardless of the effec*veness of management and opera*ons, accidents in systems that are characterized by *ght coupling and interac*ve complexity will be normal or inevitable as they oTen cannot be foreseen or prevented.”
- 11. Wilson Perumal & Company, Inc. 11 Yet a few High Reliability Organizations seem to defy the Pessimistic View!
- 12. Birth of the Nuclear Navy 50+ year history 150 mobile nuclear reactors 6,000+ years of reactor plant opera*on 12 www.wilsonperumal.com The Nuclear Navy has never had a reactor accident over its
- 13. 13 Three Lessons from the Nuclear Navy #1 Safety is not a GOAL! #2 Simplify your management system #3 Culture kills!
- 14. 14 Lesson #1 Achieving zero incidents should not be a GOAL! It should be an EXPECTATION!
- 15. 15 This has important implications for what we reward
- 16. 16 Lesson #2: Keep your management system as simple as possible, but no simpler
- 17. 17 www.wilsonperumal.com The Nuclear Navy simplifies with one management system for all outcomes People Process Equipment Change Key Controls Safety People Process Equipment Change Key Controls Environ-‐ mental People Process Equipment Change Key Controls Quality People Process Equipment Change Key Controls Reliability People Process Equipment Change Key Controls Cost Common Management System Approach Nuclear Navy Management System People Process Equipment Change Increased performance Accelerated learning Reduced cost and overhead Safety Quality Environmental Reliability Compliance Cost Key Controls
- 18. 18 www.wilsonperumal.com Don’t manage the outcomes... …manage the sources of risk! Examples Procedures Training/ cer*fica*on Performance mgmt Engineering disciplines Maintenance planning/ scheduling MOC process Culture Risk ID Examples No expecta*ons Lack of knowledge Wrong incen*ves Equipment not capable Process not capable Inadequate MOC Leadership Employee Accountability Risk ID Risk Control Knowledge Sharing Change Management Con7nuous Improvement Safety Environment Compliance Quality Produc7vity Yield Cost Outcomes Sources of Risk Causes of Failure Key Controls Mgmt. System Elements People Processes Equipment Change
- 19. Wilson Perumal & Company, Inc. 19 The Nuclear Navy’s proactive management system allows it to learn faster Reactive risk management Proactive risk management Proac7ve Reac7ve Proac7ve Reac7ve
- 20. Lesson #3: Culture is the key! 20
- 21. Opera*onal Discipline is essen*al to the Navy’s superb safety and opera*onal record 21 www.wilsonperumal.com Human performance is the Nuclear Navy’s last layer of defense RobustEquipment RigorousProcedures OperationalDiscipline
- 22. 22 The culture required was a vast departure from traditional military culture Tradi7onal Military Culture Follow orders Do what you are told Don’t ask ques*ons Never ques*on your superiors Rickover’s Cultural Pillars Have a higher level of understanding Follow procedures Ques*on procedures when things don’t seem right Back each other up Do it all with integrity
- 23. The Nuclear Navy’s OD DNA Level of Knowledge Formality Ques7oning Actude Forceful Watch Team Backup Integrity LEVEL OF KNOWLEDGE FORMALITY QUESTIONING ATTITUDE FORCEFUL BACKUP INTEGRITY CONTINUITY OF POWER REACTOR SAFETY Safety and reliability depend on specific operator behaviors 23 www.wilsonperumal.com The “Pillars of the Program”
- 24. The Pillars are self-reinforcing Ques:oning A=tude enhances Level of Knowledge Integrity Level of Knowledge Ques7oning Actude Formality Forceful Watch Team Backup Level of Knowledge allows ID of out-‐of-‐ the-‐ordinary condi:ons Ques:oning A=tude supports process improvement, not work arounds Ques:oning A=tude helps you spot what others may have missed Level of Knowledge allows you to back up others Integrity means you can be relied upon to support your team Backup drives procedural compliance Formality ensures backup is professional & produc:ve
- 25. 25 Changing culture requires more than posters and training Beliefs Consequences Behaviours Leaders can’t force people to believe something……. ……or to behave in a certain way. But they can change what is rewarded!
- 26. 26 Three Lessons from the Nuclear Navy #1 Safety is not a GOAL! #2 Simplify your management system #3 Culture kills!
- 28. Thank You 28 Chris Seifert Partner, Opera:onal Excellence Prac:ce cseifert@wilsonperumal.com (972) 800-‐3618 www.wilsonperumal.com Sign up for our blog at wilsonperumal.com/blog