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)

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.

Page 3

For internal use only / © Siemens AG 2010. All rights reserved.

Siemens Leadership Excellence

15 mm

The Arrow

WorkWork

ManagementManagement

Operational Operational StaffStaff

CompanyCompany

Government / Government / RegulatorsRegulators

General environmental General environmental conditionsconditions

ActionsActions

IncidentIncident

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

It is our contention that reliability enhancement is

fast execution enhancement

HRO and Fast Execution

What HRO theory does for youProvides 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

Angled DecksAviation Safety Center

Naval Aviation Maintenance ProgramRAG (FRS) Concept Initiated

NATOPS ProgramSquadron Safety Program

System Safety Aircraft DesignCRM Aircrew reviews ORM Safety culture

776 aircraftdestroyed in

1954

Naval Aviation Class ANaval Aviation Class AFlight Mishap RateFlight Mishap Rate

FY50-03FY50-03

Fiscal Year

24 aircraftdestroyed in

FY03-all in flightmishaps

96-2003

Nuclear Energy Institute Data1985-2008

Rx Trips/ Scrams

Cost (¢/kwh)

SignificantEvents/Unit

Capacity Factor (% up)

An HRO must sustain a “mindful infrastructure” which

1. Observes and tracks small failures and anomalies

2. Resists oversimplification

3. Remains sensitive to operations

4. Maintains capabilities for resilience

5. Looks to expertise not rank to inform decisions

An HRO must sustain a “mindful infrastructure” which

1. Observes and tracks small failures and anomalies

2. Resists oversimplification

3. Remains sensitive to operations

4. Maintains capabilities for resilience

5. Looks to expertise not rank to inform decisions

Principles of anticipation

Principles of containment

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.”

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.

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.

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

5) Look to expertise not rank to inform decisions

• Let decisions “migrate” to those with expertise to make them.

• Avoid rigid hierarchies.

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)

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)

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 degradationSource: Weick and Sutcliffe

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

Is your organization an HRO?

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.

HRO – High Reliability Organizations

Statoil Experience

Siemens 20 May 2010

Why the HRO initiative ?

• Statfjord field – Statfjord B ,A and C

Statoil’s experience

• The HRO journey startet with inviting the PSA and OLF together with Statoil Managers

• HRO Workshop at University of California, Berkeley

The Norwegian Oil Industry Association

Statoil’s HRO experience

• What happened when back in business and introducing HRO?

− Great enthusiasm in the group

− Realized that the process needed maturation and time

− Not the great buy-in, but not rejection either!

Gjøa Development - topside facility on the move

Statoil What we do – and how we do it

•A values based performance culture

•Firm commitment to health, safety and environment (HSE)

•Stringent ethical requirements and a code of conduct which promotes personal integrity

Is Statoil a high or low reliability organization?

Elementary versus advanced DenialHRO’s

• Leadership training

• Good structures

• Value based organisation

• Emergency preparedness

LRO’s

• Consensus culture

• Focus on success

• Expertise focusNumber of Denials

HRO – High Reliability Organizations

LRO- Low Reliability OrganizationsCri

sis

Ma

na

ge

me

nt

Pre

pa

red

ne

ss

Culture/HRO step-change

• Cultural / HRO step-change is not triggered by magic bullet or directive

Rather

• Culture / HRO is changed by series of small steps taken by the leading members of the organization at all levels

• Leadership is standing up and leading the way

• Changing the way business is conducted requires people at all levels to lead by personal example

Recommendations

• Start at the Top Management

• Use time to implement

• Training, training, training and discussions

• External inspiration

• Establish network / forum meetings

“Troll A Platform shaft

HRO – Statoil Experience

Ståle Tungesvik

Senior Vice President, Reserve and Business Development

Exploration and Production Norway

sttu@statoil.com

www.statoil.com

Thank you

An HRO must sustain a “mindful infrastructure” which

1. Observes and tracks small failures and anomalies

2. Resists oversimplification

3. Remains sensitive to operations

4. Maintains capabilities for resilience

5. Looks to expertise not rank to inform decisions

Exercise on 5 HRO leadership principles