HRO Perspectives on Interdependence in and across Organizations

1. HRO Perspectives on Interdependence in and across Organizations Peter M. Madsen Marriott School of Management, Brigham Young University Center for Catastrophic Risk Management, University of California, Berkeley

2. Center for Catastrophic Risk Management, University of California, Berkeley

3. Organizational Disaster • Disaster: 1: “A sudden calamitous event bringing great damage, loss, or destruction;” 2: “A sudden or great misfortune or failure.” Center for Catastrophic Risk Management, University of California, Berkeley

4. Fukushima I Nuclear Power Plant Center for Catastrophic Risk Management, University of California, Berkeley

5. Deepwater Horizon Explosion & Oil Spill Center for Catastrophic Risk Management, University of California, Berkeley

6. Upper Big Branch Mine Explosion, 2010 Center for Catastrophic Risk Management, University of California, Berkeley

7. Imperial Sugar Explosion, 2008 Center for Catastrophic Risk Management, University of California, Berkeley

8. Spinach Recall, 2006 Center for Catastrophic Risk Management, University of California, Berkeley

9. Systems View of Organizations • Organizations as socio-technical systems • People, groups & units • Technological components, information networks • Complexity in organizations • Combinatorial complexity: large numbers of potential interactions, tight coupling • Dynamic complexity: delayed effects, feedback loops, feedforward loops Center for Catastrophic Risk Management, University of California, Berkeley

10. System Accidents • Distinct from simple component failures • Including human error • Driven by unplanned and unexpected interactions between system components • Non-independence • Combinatorial and dynamic complexity • Extremely difficult to predict and prepare for • “Normal accidents” • Examples • Three Mile Island • Petrobras P36 Center for Catastrophic Risk Management, University of California, Berkeley

11. Fukushima I Nuclear Power Plant Center for Catastrophic Risk Management, University of California, Berkeley

12. System Accidents • Distinct from simple component failures • Including human error • Driven by unplanned and unexpected interactions between system components • Non-independence • Combinatorial and dynamic complexity • Extremely difficult to predict and prepare for • “Normal accidents” • Examples • Three Mile Island • Petrobras P36 Center for Catastrophic Risk Management, University of California, Berkeley

13. Combinatorial Complexity & System Accidents Center for Catastrophic Risk Management, University of California, Berkeley

14. System Accidents • Distinct from simple component failures • Including human error • Driven by unplanned and unexpected interactions between system components • Non-independence • Combinatorial and dynamic complexity • Extremely difficult to predict and prepare for • “Normal accidents” • Examples • Three Mile Island • Petrobras P36 Center for Catastrophic Risk Management, University of California, Berkeley

15. TMI 2 Center for Catastrophic Risk Management, University of California, Berkeley

16. Petrobras P36 Center for Catastrophic Risk Management, University of California, Berkeley

17. Petrobras P36 Center for Catastrophic Risk Management, University of California, Berkeley

18. Prevention of System Accidents • HRO strategies for managing system accidents • Learning from non-events • Resiliency • HRO requirements • Vigilance • Shared Cognition • Constrained Improvisation • Safety Culture Center for Catastrophic Risk Management, University of California, Berkeley

19. Inter-Organizational System Accidents • Inter-organizational systems • Interdependencies cross organizational boundaries • Contractors • Suppliers/Vendors • Unions • Regulators • Customers • Competitors • Inter-organizational system accident examples • Avianca flight 52 • Mumbai High North • Deepwater Horizon Center for Catastrophic Risk Management, University of California, Berkeley

20. Avianca flight 52 Center for Catastrophic Risk Management, University of California, Berkeley

21. Mumbai High North Center for Catastrophic Risk Management, University of California, Berkeley

22. Mumbai High North Center for Catastrophic Risk Management, University of California, Berkeley

23. Deepwater Horizon Explosion & Oil Spill Center for Catastrophic Risk Management, University of California, Berkeley

24. Inter-Organizational System Accident Prevention • HRO strategies are the same • Learning from non-events • Resiliency • HRO requirements are the same • Vigilance • Shared Cognition • Constrained Improvisation • Safety Culture • But challenges are much greater Center for Catastrophic Risk Management, University of California, Berkeley

25. Challenges to HRO in Inter-Organizational Systems • Vigilance • Warning signs in multiple organizations • Need for rapid, rich information sharing • Shared Cognition • Need for shared mental models across organizations • Constrained Improvisation • Coordination of activities across groups with no history of joint action • Examples: Center for Catastrophic Risk Management, University of California, Berkeley

26. 9/11 Attacks Center for Catastrophic Risk Management, University of California, Berkeley

27. Challenges to HRO in Inter-Organizational Systems • Vigilance • Warning signs in multiple organizations • Need for rapid, rich information sharing • Shared Cognition • Need for shared mental models across organizations • Constrained Improvisation • Coordination of activities across groups with no history of joint action • Examples: Center for Catastrophic Risk Management, University of California, Berkeley

28. Oakland Hills Fire of 1991 Center for Catastrophic Risk Management, University of California, Berkeley

29. HRO Implementation in Inter-Organizational Systems • Cultural compatibility • Cultural consideration in partner selection • Long-term relationships • Development of trust • Rich information sharing • Accident and near-miss reporting • Contracts with economic incentives for “safety” are counterproductive • Joint training and planning • Build relationships • Develop shared cognition • Establish parameters for constrained improvisation Center for Catastrophic Risk Management, University of California, Berkeley

30. U.S. Air Force and Aerospace Corporation Center for Catastrophic Risk Management, University of California, Berkeley

31. Grand Teton Dam Failure Center for Catastrophic Risk Management, University of California, Berkeley

32. Conclusion • System errors occur in inter-organizational systems • Inter-organizational HRO implementation is challenging • HRO may be introduced through: • Development of compatible safety cultures • Norms of rich information sharing • Joint training Center for Catastrophic Risk Management, University of California, Berkeley

33. HRO Perspectives on Interdependence in and across Organizations Peter M. Madsen Marriott School of Management, Brigham Young University Center for Catastrophic Risk Management, University of California, Berkeley