Managing the Unexpected
High Reliability develops an organization’s strengths through individual actions.
Shared attitudes fill the gap between organization and the individual to determine High Reliability.
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10/19/2013 4:35 PM
Minutes from a meeting to discuss Weick and Sutcliffe’s Five Principles of HRO
Massive information flow can block the system. Correct information is necessary how do we not lose the weak signal? The question becomes, weak signals, too much filter filters weak signals. This is a delicate balance. What does the group think?
When you assemble the team, you must give them context and your intent. Give expectation, intent, information flow, cross talk in organization regardless of hierarchy, goals, and objectives. When discovery of things that don't seem right matters, this helps maintain the balance. People think they now need to pay attention so they can communicate this and make sure it has reasonable content. Say intelligent things.
Back to STO, when you have a team operating, information is generated somewhere else as part of mechanics of the organization functioning. Weak signals develop from other people around you as well as the system. On the aircraft carrier flight deck there are many things going on at once. The operations of the flight deck must be sensitive to changing operations around you as well as keeping track. Carrier landings, difference between day and night, deck pitching, these stress out the already difficult task of landing, brings up operations risk assessment that need to change when risk increases.
One person, as a company commander in Afghanistan, established a baseline expectation. You are monitoring the information that is flowing and everyone has the authority to make connections. The intelligence officer can pick it apart and review later but sometimes people are dismissive of that. Intelligence officers commonly are criticized for all their wrong calls, but they make connections during dynamic times. It is easy for people to be dismissive when the intelligence person tries to predict what the enemy will do. Having that transparency/breaking down barriers, intelligence plays a critical role. This goes back to expectations. The intelligence officer is trying to predict, maybe not exactly, but he is doing a good job.
We are hoping the workforce will act on the weak signal. In the fire service different fire companies are in charge of different aspects of one incident. In one situation related by this person, one hose team could not obtain information from another hose team in time so one team ran into the inferno and one captain was killed.
None of this is linear or singular. It is a dynamic process. It is hoped workers will take action on weak signals without direction. You have to trust people are going to support one another. It is a good thing when those on the front line can take action on their own and not have to wait for headquarters.
How do we give feedback during the operation when things are not working? Sometimes have divisions or companies take individual action when things are going badly and, not being able to communicate, take risks that only a few can see.
One department started an initiative or improvement program. Line staff must perform sensitivity to operations and their work honored by management. In the operating room they started an operation, put the patient to sleep, but the operation did not get started when they found out the equipment was not ready. You open a pump in and find out that the seal for the replacement is the wrong one. Walkout, tag out, de-energize, the craftsman who did it may not be available at the time of work on the pump. He or she may not be aware of the purpose of the ongoing operation.
Several examples of starting operations (surgery, pump repair in refinery) and find out something was lacking. Were people that prepared feeling part of the program? One discussant noted that everyone on an aircraft carrier can quickly explain how what they do supports flight operations (learned from CVN 70, Carl Vinson, visit). This is easier on carriers because they are closed systems. Ships use closed-circuit television to provide a view of the flight deck during flight operations. Shows people all sorts of information that helps them stay connected to flight operations.
On the aircraft carrier, closed circuit television helps keep everyone sensitive to operations. Everyone on a ship can be keyed to how they are connected two aircraft recovery. The challenge to HRO it is how can we make this applicable two chemical processes or hospitals.
When we discuss operations we are assuming we understand what the operations are for in the system and the organization. The fire service had problems when EMS was added 30 years ago. The majority of calls went from fire suppression to medical aid calls. Now there are new assignments coming to fire service, these include high-angle rescues, swiftwater rescue, and urban search and rescue. Fire service has yet to define what their responsibilities are. Practitioners disagree about what their operations really are. "Operations" can change over time. Practitioners need to be grounded in what your core competencies are.
There is a balance of how much information you to be effective need vs. spending too much effort sending information to upper echelon without information overflow. When people are head down, butt up they do not see what is happening with the primary containment.
Sensitivity to operations is information flow, real-time information flow. This is reliability of information flow across days and for threats.
STO, other operations should not drive us, the balance came up several times, need enough to keep from being negatively impacted, too much and you drown it information.
Information flows happen and different rates and you have to be sensitive to some things that only change slowly. STO should be compared to planning and strategy making (not always the key activities), need to be in contact with what is going on right now.
Weick states that in sensitivity to operations he was comparing sensitivity to operations it to sensitivity to planning. This was to get people out of the mindset of planning and missing what was going on " right now.” So, it was done to counter sensitivity to planning.