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Practicing High Reliability: Organizations Designed for Humans

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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Practicing High Reliability: Organizations Designed for Humans

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  1. Practicing High Reliability: Organizations Designed for Humans W. Earl Carnes – U.S. Department of Energy Richard S. Hartley - B&W Pantex

  2. 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

  3. Nuclear Energy Performance Trends1985-2008 Rx Trips/ Scrams Capacity Factor (% up) Cost (¢/kwh) Significant Events/Unit

  4. 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Mindlessness • Early warning signs of danger go unnoticed • Acting with rigidity • Operating on automatic pilot • Outdated diagnosis of problems goes unnoticed • Underlying style of mental functioning in which people try to address safety by following recipes • Imposing old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

  5. 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

  6. *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*

  7. HRO Meta Model * Core properties *Meta model defines the language and processes from which to form a domain specific model

  8. “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.

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