High Reliability Organizing in High Risk Industries Banner - Artwork by E. Steele, for the Wildland Fire Lessons Learned Center

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Feb 22, 2009:
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Our Approach

 

We Have a Problem Here

Situations and problems come upon us, as individuals, missing information, incompletely developed, or with an uncertain or unknown future.  Despite these shortcomings we must act to contain the events before they further evolve into a crisis. 

The accelerating risk and the limitation of time press us to resolve the situation or solve the problem before irreversible damage can occur.  We may not have sufficient time to search for the correct or perfect principle, something a supervisor or an outside observer might do.  We, acting as individuals, look at the specifics of the case and use our past experience or what we can immediately recall to begin containment. 

The system, when designed for reliability, will begin the flow of information toward the right people while the individual commences engagement.  In these circumstances, individuals do not act as sentries to notify management or supervisors but as actors to begin engagement of the events. 

If the individual sees the situation as a problem to solve then that part of the brain called theBrain Structures and Stress prefrontal cortex takes over.  If the individual sees or experiences the situation as a threat then the emergency part of the brain, the amygdala, initiates the physiological fear responses and perceptions bypass thought and rapidly turn into action. 

Unfortunately, the actions of fight, flight, or freeze cannot be blocked and may quickly result in self-reinforcing anger, avoidance, or confused states.  But fortunately, training and experience can redirect these actions into self-sustaining collaboration, trust, and team formation.

Our approach is to study that first big bang when the individual realizes that a problem has come.

"Sometimes the most effective use of overwhelming force is the conspicuous decision not to use it." Tony Hare, PhD

 

The Triad of the Complex Problem: Technology, Human Performance, Social Interactions

Confounding the utility of planning is the complexity of the interactions between technology, human performance, and social interactions. 

Technology refers to the control for human use of energy in its five forms: kinetic, potential, chemical, ionizing radiation (nuclear), and thermal.  Energy extends the productivity of mankind but must be controlled.  A consequential error in the use of energy, that is, an error in the process, can result in degradation of quality if it affects the process or product and degradation of safety if it affects a person. 

Human performance is the total functionality of a person which is an interaction of the physiological and psychological.  Human factors research is the study of human performance in specific situations.  Human performance contributes to adaptability and resilience but must be protected.  Consequential error to a human will result in degradation of safety.

Physiology is the function of the person’s body which can be affected by illness, fatigue, or organ system deficits.  In the most extreme case where death can result it refers to oxygen delivery to the cells (the cardiac output multiplied by the oxygen content of the blood) and relates to either illness or performance decrements under physiological stress (e.g., dehydration leading to hypovolemia or low blood volume). 

Psychology refers to cognition and emotion as it applies to the person’s function toward the organization’s goals.  While it may be viewed as mental illness, in performance situations, it is the normal reactions to abnormal situations.  Emotion as a physiological state is processed through specific brain regions with physiological effects.  It differs from the feelings of emotion that we commonly discuss in everyday situations.   

Social interactions occur between individuals working in pairs and within groups or between different groups.  They may be planned or extemporaneous, have a rigid or fluid hierarchy, and may be formal or informal.  When positive they increase satisfaction and reduce isolation placing the individual in the “good hormones.” 

The Environment, to a great degree, has the final audit on the plans and performance of both the individual and the organization.  The organization may successfully prevent the environment from acting on the organization’s values, beliefs, and behaviors.  When this happens leaders and members of the organization may misattribute their success to maladaptive values, beliefs, and behaviors leaving the organization in a precarious situation when it comes to uncertain or unexpected events.  This can lead to a final and severe environmental audit. 

In the learning organization the environment and its complexity can strengthen and invigorateNucleus Accumbens an organization as it adapts successfully to a changing world.  On an individual level such successful problem solving stimulates a specific region of nerve cells in the brain, the nucleus accumbens, to bring rewards and feelings of satisfaction.  In the final result, people develop a drive to identify and engage problems producing a resilient, learning organization. 

 

Quality is absence of harm to the process or product.

Safety is absence of harm to a person.

Reliability is absence or reduction of harm in extreme, uncertain, or unexpected environments.