High Reliability and Low Reliability Organizations: Findings
(Excerpts from a research report)
- The primary challenge in structures and floating systems is not associated with the traditional engineering technologies that have been employed in the creation of these structures. History has shown that the main challenge is associated with the human and organizational aspects of these systems.
- Human organization factors (HOF) are fundamentally important in development of offshore structures with acceptable and desirable quality and reliability during their life cycles. Design engineers have a fundamental and primary responsibility in addressing HOF as an integral part of the design engineering process.
- The threats to adequate quality and reliability in offshore structures in the design office emerge slowly. It is this slow emergence that generally masks the development of the threats to quality and reliability. Often, the participants do not recognize the emerging problems and hazards. They become risk habituated and lose their wariness. Emerging threats not clearly recognized because the goals of quality and reliability are subjugated.
- System reliability assessment of offshore structures, including human and organizational effects, during the design phase provide important benefits.
- Drives for greater productivity and efficiency need to be aligned with sufficient protections to assure adequate quality and reliability.
- The important thing in achieving desirable quality and reliability is organizing the "right stuff" for the "right job." This is much more than job design. It is selecting those able to perform the daily tasks of the job within the daily organization required to perform that job. Yet, these people must be able to reorganize and re-deploy themselves and their resources as the pace of the job changes from daily to unusual. Given most systems, they must be team players. This is no place for "superstars" or "aces." The demand for highly developed cognitive talents and skills is great for successful crisis management teams. In its elegant simplicity, Crew Resource Management has much to offer in helping identify, train, and maintain the right stuff. If properly selected, trained and motivated, even "pick-up ball teams" can be successful design engineering teams.
- The 15-year stream of research and development on which these insights is based addressed the issues associated with implementation.
- Case studies of 7 implementation efforts
| Organization |
Commitment |
Cognizance |
Competence |
Culture |
Financial Incentives |
Success |
| A |
yes |
yes |
yes |
yes |
yes |
yes |
| B |
some |
yes |
some |
no |
no |
no |
| C |
yes |
yes |
yes |
yes |
yes |
yes |
| D |
no |
no |
no |
no |
no |
no |
| E |
no |
some |
some |
no |
no |
no |
| F |
no |
yes |
yes |
no |
no |
no |
| G |
|
yes |
yes |
no |
no |
no |
Successful implementation involved five elements.
- There must be definitive, measurable, and long-term financial incentives associated with the execution of implementation programs; accounting systems must be developed to allow recognition of the financial gains associated with successful implementation.
- Implementation must be both top-down (commitment of upper management) and bottom-up (commitment of engineers, operators and lower middle management).
- Implementation must be knowledgeable, skilled, trained, structured, and managed (competent).
- The organization must have a clear understanding of the risks that it faces; this is heedful awareness; constant caution is the price of quality and reliability (cognizance).
- Implementation has to be institutionalized so that it becomes an inherent part of the organization; the objective of improving quality and reliability must be aligned with the objective of improving productivity and profitability (culture).
The experiences clearly show that if properly motivated and implemented, programs to improve the human organization aspects of marine systems pay dividends. Definitive decreases in costs and increases in production, resulting in increases in profitability, sustain such programs.
The other side of this coin is LRO (Lower-Reliability Organizations).
- LRO are characterized by a focus on success rather than failure, and efficiency rather than reliability. In LRO the cognitive infrastructure is underdeveloped, failures are localized rather than generalized, and highly specified structures and processes are put in place that develop inertial blind spots that allow failures to accumulate and produce catastrophic outcomes.
- LRO efficient organizations practice stable activity patterns and unpredictable cognitive processes that often result in errors. They do the same things in the face of changing events; these changes go undetected because people are rushed, distracted, careless, or ignorant.
- In LRO, expensive and inefficient learning and diversity in problem solving are not welcomed. Information, particularly "bad" or "useless" information, is not actively sought, failures are not taken as learning lessons, and new ideas are rejected.
- Communications are regarded as wasteful in LRO and hence the sharing of information and interpretations between individuals is stymied. Divergent views are discouraged, so that there is a narrow set of assumptions that sensitize it to a narrow variety of inputs.
- In LRO, success breeds confidence and fantasy. Managers attribute success to themselves, rather than to luck, and they trust procedures to keep them apprised of developing problems.
- Under the assumption that success demonstrates competence, LRO drift into complacency, inattention, and habituated routines which they often justify with the argument that they are eliminating unnecessary effort and redundancy.
- Slashing downsizing and thoughtless outsourcing in LRO further the drives of efficiency, and insensitivity is developed to overloading and its effects on judgment. Cross checks are eliminated, and there is unequivocal dependence on claimed levels of competence. With outsourcing, it is now the supplier, not the buyer that must become preoccupied with failure. But the supplier is preoccupied with success, not failure, and because of low-bid pricing, often is concerned with the lowest possible cost. The buyer now becomes more mindless and if novel forms of failure are possible, the buyer becomes more vulnerable.
- LRO tend to lean toward anticipation of "expected surprises," risk aversion, and planned defenses against foreseeable accidents and risks; unforeseeable accidents and risks are not recognized or believed.
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