This is an experiment in collaborative content development. A High Reliability community of interest has emerged within DOE. Members of this community have volunteered to collaborate in developing a description of what high reliability means in their science and technology contexts. Cindy Caldwell, the High Reliability Champion at Pacific Northwest National Laboratory volunteered to take the lead in developing a first draft; our thanks to Cindy for bravely leading the way. Those of you not in the DOE community are welcome and encouraged to contribute your comments. Here’s Cindy’s opening offering:
At a recent HRO working meeting of DOE contractors at Y-12 in Oak Ridge I volunteered to initiate a discussion on high reliability. The following is a white paper that briefly discusses the history of high reliability, its attributes, practical use and potential benefits to DOE contractors. It integrates discussion from last week and my own thoughts and is not intended to be a comprehensive discourse. Please use it as a starting point to for expanded critical group think!
High reliability (HR) is not new. The study of HR theory began with a high-reliability organization project at the University of California in Berkeley in the 1980’s. A small group of researchers began studying a distinct and special class of organizations where the potential for error and disaster was over whelming and could result in thousands of lives lost both inside and outside the organization. Specifically, they studied how individuals organized for high performance within nuclear aircraft carriers, air traffic control systems, and nuclear power generating plants. These specialized industries had a record of success at managing high risk and shared a single minded attention to safety. Since then, the application of reliability concepts has expanded to preventing systems failure in other industries such as pharmaceutical, healthcare, financial and rail transport. HR is increasingly being employed as a reflective framework to improve operational performance in businesses where an error could impact a corporation’s survival. Examples of serious operational incidents beyond the tradition process safety risks include as loss of market competitiveness, failure of a unique mission critical system (supercomputing) and compromise of classified information.
High reliability performance principles are based on risk management and a change in thinking from predicting and preventing error to resilience. The paradigm of blame shifts from the traditional view that people are the cause of accidents to a new view that human intervention can prevent accidents. HR organizations do not punish people for making mistakes when they are trying to do the right thing. Resilience in the organizational context means that people make things go right by adjusting to demands and detecting and correcting errors.
Resilience and reliability are achieved at both the meso and macro level through the core properties of systems, culture and cognition. Figure 1 is an HRO meta model (modified) that was presented by Earl Carnes at the March HRO workshop. The core properties and application of those properties are outlined below.
Processes are in place that supports
- Reporting: well developed systems for reporting near misses, small and localized failures
- Risk assessment: Risk profiling to understand what is really important
- Lessons learned
- Investigation and Causal analysis
- Reward and recognition
The organization embodies attributes of a just culture, reporting culture and learning culture by emphasizing
- Organizational Learning
Mental models influence reasoning and decision making and encourage systems thinking
- Increased situational awareness
Reducing organizational incidents has many potential benefits to Department of Energy contractors including:
- less time spent in critiques and accident investigation
- improved staff engagement and reduced presenteeism in the workplace
- healthier relationship with regulators
- less oversight
- understanding risks (what is important) and working collaboratively with the customer to accept those areas as the primary focus
- less distraction and more organizational focus on accomplishing our collective missions