High Reliability Organizations (HROs) and High Performance

1. High Reliability Organizations (HROs) and High Performance Karlene H. Roberts Haas School of Business University of California, Berkeley karlene@haas.berkeley.edu 510.642.4700 (fax)

2. December 29, 2001 - As the sun rises on the deck of USS John C. Stennis (CVN 74), the ship is readied for flight operations. Stennis and her embarked Carrier Air Wing Nine (CVW-9) are supporting Operation Enduring Freedom. U.S. Navy photo by Photographer's Mate 3rd Class Jayme Pastoric.

4. General environmental conditions Government / Regulators Company The Arrow Management Operational Staff Work Actions Incident

5. What is a High Reliability Organization (HRO) ? An organization • Conducting relatively error free operations • Over a long period of time • Making consistently good decisions resulting in • High quality and reliability operations

6. It is our contention that reliability enhancement is fast execution enhancement HRO and Fast Execution

7. What HRO theory does for you Provides a common language Recognizes principles and practices shared by high reliability firms Permits you to communicate lessons learned with other High Reliability Organizations Enables executives to share HRO concepts with managers and workers who will develop detailed plans Changes attitudes about reporting important information Establishes and supports a safety culture

8. Naval Aviation Class AFlight Mishap Rate 24 aircraft destroyed in FY03- all in flight mishaps FY50-03 776 aircraft destroyed in 1954 Angled Decks Aviation Safety Center Naval Aviation Maintenance Program RAG (FRS) Concept Initiated NATOPS Program Squadron Safety Program System Safety Aircraft Design CRM Aircrew reviews ORM Safety culture 96-2003 Fiscal Year

10. Nuclear Energy Institute Data1985-2008 Rx Trips/ Scrams Capacity Factor (% up) Cost (¢/kwh) Significant Events/Unit

11. An HRO must sustain a “mindful infrastructure” which Observes and tracks small failures and anomalies Resists oversimplification Remains sensitive to operations Maintains capabilities for resilience Looks to expertise not rank to inform decisions

12. An HRO must sustain a “mindful infrastructure” which Observes and tracks small failures and anomalies Resists oversimplification Remains sensitive to operations Maintains capabilities for resilience Looks to expertise not rank to inform decisions Principles of anticipation Principles of containment

13. 1) Observe and track small failures and anomalies Worry chronically about errors. Assume each day is a bad day. Difficult to do. “Collective bonds among suspicious people.”

14. 2) Resist oversimplification All organizations must ignore many things. Doing so may force them to ignore key sources of problems. Restrain temptations to simplify. Through checks and balances, adversarial reviews, and multiple perspectives.

15. 3) Remain sensitive to operations Pay close attention to operations. Everyone values organizing to maintain situational awareness. Use resources so people can see and comprehend what is happening.

16. 4) Maintain capabilities for resilience Anticipate trouble spots. Capability to improvise. Improve capacity to Do quick studies Develop swift trust Engage in just‐in‐time learning

17. 5) Look to expertise not rank to inform decisions Let decisions “migrate” to those with expertise to make them. Avoid rigid hierarchies.

18. Businesses Targeting High Reliability Commercial Aviation (e.g. United Airlines) Commercial Banking (e.q. S.W.I.F.T.) Healthcare (e.g. Loma Linda Hospital, Totally Kids, Kaiser Permanente, AHRQ hospital consortium) Nuclear Power (e.g. Diablo Canyon Power Plant, INPO) Commercial Maritime Petroleum and chemical Industries (e.g. Chevron, Shell, Gard Services)

19. Government Agencies Targeting High Reliability US Naval Carrier Aviation US Navy Submarine Service (e.g., Admiral Rickover) US Department of Energy Laboratories Community Emergency Services (U.S. Forest Service, Orange County California Fire Authority, San Bernardino County and City Fire) Manned Space Flight (Columbia Accident Investigation Board) Deep Underground Science and Engineering Laboratory - DUSEL (under design)

21. Non-HROs Focus on success Underdeveloped cognitive infrastructure Focus on efficiency Inefficient learning (episodic) Lack of diversity (focused conformity) Information & communications filtering Reject or excuse early warning signs of quality degradation Source: Weick and Sutcliffe

22. Characteristics of a Non-HRO Attend meetings and solve nothing Catch airplanes and miss ‘connections’ Conduct briefings and persuade no one Evaluate proposals and miss the winners Meet deadlines for projects on which the plugs have been (or should be) pulled Organizations in which people shuffle papers and lose a few Source:Weick and Sutcliffe

23. Is your organization an HRO?

24. Is your organization an HRO? How do you get there? How do you stay there? HRO is not a one time change like adopting a currency or language, it is a way of conducting business and a continual effort.