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.
Speakers at High Reliability Organizing conferences, workshops and training sessions have served high-risk communities of practice with inter-industry education in HRO principles and special skills enhancement in life threatening occupations.
Presentation - RAMP Tool (Risk Analysis and Mitigation Prioritization)
Greg Alston is currently the Safety Sigma Program Manager for CSSI, Inc. He came to CSSI from the aerospace and defense industry, where he was the Corporate VP for Mission Assurance for Raytheon. In that role, he led the Raytheon corporate enterprise mission assurance program, and was responsible for corporate quality and Six Sigma (R6σ). Before going to industry, he was a member of the Government Senior Executive Service as Director of the Air Force Safety Center and Deputy Chief of Safety for the Air Force. As such, he led all facets of the Air Force Safety Center to include strategic planning, day-to-day operations, publishing all Air Force safety policies, and managing mishap investigations. He also oversaw analysis for safety data in Aviation, Ground and Industrial, Explosives, Space Operations, and Directed Energy. Prior to his SES service, Greg served as an officer in the Air force and a fighter pilot for 28 years... He is a published author, and wrote, How Safe Is Safe Enough? Leadership, Safety, and Risk Management. In 2005, Greg was honored to win an Honorary Life Member Award from the SAFE Association. He is currently a doctoral candidate in business administration and holds a Master’s Degree in Aerospace Science. Download Short Bio
Presentation- Overcoming dysfunctional momentum: organizational safety as a social achievement
Michelle Barton is a doctoral candidate at the Ross School of Business, University of Michigan. Her research explores how individuals and groups organize to manage uncertainty in real time, particularly in highly dynamic and complex contexts. She focuses on the ways in which dynamic organizing practices affect awareness of unfolding events and the capacity for flexible and adaptive performance. Her work spans several contexts including wildland firefighting, nursing units and high technology entrepreneurial ventures. Prior to her doctoral work, Michelle spent ten years with Harvard Business School Publishing where she was an original founder of their eLearning business. In her most recent role there as Product Director, she was responsible for the vision, strategy and management of the Leadership and Management Development product lines, globally. Prior to her work at HBSP, Michelle was an Associate at the Boston Consulting Group. She has a B.A. in Psychology from Pomona College, Claremont, California. Download Short Bio
Presentation - Imagining Fail-Safe Schools
Dr. Thomas Bellamy has published on the theoretical advantages of an HRO orientation to school improvement over multiple, currently dominant ways to thinking through school improvement.
Presentation - HRO-Spiritual Leadership that Runs Toward the Fire
The Problem With Deferring To Experts
Preoccupation with the Costs of Preoccupation with Failure
Bill Brown is a Human Factors Scientist at Brookhaven National Laboratory (BNL), where he has conducted research on human performance in complex, high-consequence systems for nearly twenty years. Much of this work was sponsored by the Nuclear Regulatory Commission and was principally concerned with the design and operation of nuclear power plants; however, more recently he has investigated human error and human reliability in the context of medical and industrial uses of radioactive material, especially in advanced types of radiotherapy. He is currently working in BNL’s Quality Management Office, serving as technical lead for the Laboratory’s Human Performance Improvement efforts.
Bill is a member of the Human Factors Society and an associate member of the American Society of Safety Engineers. He received his PhD in Experimental Psychology from the State University of New York at Stony Brook, and has earned an Advanced Graduate Certificate in Occupational and Environmental Safety and Health, also from Stony Brook.
Presentation - The Reflective Practitioner Revisited: Promoting High Reliability though Affirmative Engagement Download Abstract
W. Earl Carnes, BS, MA, is a Senior Advisor for High Reliability for the U.S. Department of Energy (DOE) and also serves as the DOE liaison with the Institute of Nuclear Power Operations (INPO). His principal function is to support the DOE Research and Development, Environmental and Defense missions with improving performance and safety through adopting HRO principles and practices. Mr. Carnes coordinates with other U.S. federal government agencies, international agencies, industry and the academic community on HRO application. Prior to joining DOE Mr. Carnes worked as a management consultant and with INPO as a specialist in emergency management. His academic work includes a Bachelor of Science in Chemistry, a Masters of Arts in Communications and additional graduate studies in Systems Engineering focusing on the management of scientific and technical knowledge.
Presentation - Leading Connection Development and Knowledge Flow to Increase High Reliability Organizing Implementation Effectiveness
David Christenson is the Acting Center Manager of the U.S. Wildland Fire Lessons Learned Center. He has focused on promoting organizational learning, implementing high reliability organizing, and creating a widely used knowledge management system for the nation’s wildland fire community. He coaches incident management teams on practical HRO implementation and is a co-chair of the French/USA HRO in IMTs Project. He has given presentations in Spain, Greece, Sweden and France in addition to the U.S. on these subjects. He earned a Masters of Applied Geography with honors from New Mexico State University in 2000 after a career in the US Air Force developing teams working with jet fighter aircraft. He began working with HRO while assigned at Soesterberg AB, Holland in 1980. Download Short Bio
Presentation - Overcoming Organizational Communication Barriers for Medical Students
Rebecca is currently in her first year at Tulane University’s School of Medicine where she also volunteers as a Basic Life Support certification instructor. She completed her B.S. degree at Mills College with a major in Biopsychology. She has worked as an Emergency Medical Technician for a private ambulance company between 2004 and 2006. She was recently a Research Associate for California’s Alameda County Emergency Medical Services. There she co-managed several research projects including a study to determine the optimal age group for disseminating CPR skills to the community. Additionally, she performed studies assessing the safety of pre-hospital interventions of airway devices. Rebecca also performed quality improvement projects, one of which was developing a pre-hospital airway management “checklist” which is currently being used in a pilot quality improvement program in Alameda County. Her current medical academic interests are Emergency Medicine and Pediatric Cardiology. Download Short Bio
Presentation - Mapping the Failure Landscape:
Process Deviations, System Breakdowns and Unsuccessful Trials as Sources of Improvement, Problem Solving and Innovation in Teams
Amy C. Edmondson is the Novartis Professor of Leadership and Management and Co-Unit Head of the Technology and Operations Management Unit at Harvard Business School. The Novartis Chair was established to enable the study of human interactions that lead to the creation of successful business enterprises for the betterment of society. Edmondson joined the Harvard faculty in 1996. Her research examines leadership influences on learning, collaboration and innovation in teams and organizations, reported in over 60 articles published in academic journals, management periodicals, and books. In 2003, the Academy of Management's Organizational Behavior Division selected Professor Edmondson for the Cummings Award for outstanding achievement in early mid-career, and in 2000 selected her article, "Psychological safety and learning behavior in work teams," for its annual award for the best published paper in the field. Her article (with Anita Tucker), "Why Hospitals Don't Learn from Failures: Organizational and Psychological Dynamics That Inhibit System Change" received the 2004 Accenture Award for a significant contribution to management practice. Download Short Bio
Presentation - High Reliability Organizing to develop managers and organizational capabilities
Annette is a senior consultant for management and organizational development as well as cultural change. Her mission is to translate HRO thinking to classical industries like production, banking, services and technology etc. Annette runs her own consultancy in Berlin (Beratung für Corporate Learning) serving large DAX-companies like ThyssenKrupp, Sabic, Deutsche Telekom, SAP etc. Beratung für Corporate Learning collaborates with Apollo 13 as well as Management Zentrum Witten. Annette is member of the program committee of the first European HRO conference that will take place in autumn 2011.
Christopher A. Hart is the Vice Chairman of the National Transportation Safety Board, having been nominated by President Obama and confirmed by the Senate in 2009. The NTSB investigates major transportation accidents in all modes of transportation, determines probable cause, and makes recommendations in an effort to prevent recurrences. He was previously a Member of the NTSB in 1990, having been nominated by (the first) President Bush. Download short BIO
Presentation- Pantex Implementation of High Reliability Download Abstract
Richard S. Hartley, Ph.D., P.E. is a principal engineer in the Emergency, Safety, and Health Division for B&W Pantex in Amarillo, Texas.
Dr. Hartley is currently the primary lead for developing High Reliability Organization (HRO) training for his organization's senior management and for developing an improved Causal Factors Analysis process for organizationally rich, yet non-consequential events for the General Manager.
Dr. Hartley received his Ph.D. in Nuclear Engineering from the University of Texas at Austin, his M.S. in Nuclear Weapons Effects from the Air Force Institute of Technology, and his B.S. in Physics from Texas A&M University. He holds Professional Engineering Licenses in Environmental Engineering in Ohio and Texas. Download short bio
Presentation- High Reliability Theory to High Reliability Practice
Barry Hill is the manager of the Nuclear Explosive Safety Department at the National Nuclear Security Administrations (NNSA’s) Pantex Plant, managed by the Babcock and Wilcox Technical Services Group. This Department is responsible for the management and oversight of Nuclear Explosive Safety, Explosive Safety, Criticality Safety, and Nuclear Safety at the Pantex Plant.
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Presentation - The Medical Crisis in California Prisons: A Cautionary Case Study
Terry Hill, M.D., is a geriatrician with longstanding interests in leadership, healthcare redesign, and organizational development. From 2006 to 2009 he was Chief Medical Officer, then CEO for Medical Services, at the California Prison Receivership, which removed control of prison medical care from the state. Dr. Hill was previously Senior Medical Director for Quality Improvement at Lumetra, which was the Medicare Quality Improvement Organization for California. He is an Assistant Clinical Professor in the Department of Medicine, UC San Francisco. From 1999-2004 Dr. Hill was medical director of Laguna Honda Hospital. He is past-president of the California Association of Long Term Care Medicine. His experience in palliative care includes serving on the National Quality Forum’s Palliative and Hospice Care Review Committee and serving as co-chair of the California Coalition for Compassionate Care. Dr. Hill was in private practice in Oakland from 1994-1999. He has led program development for hospitals and managed care organizations, and he has been medical director of retirement communities, nursing facilities, adult day health centers, and a hospitalist program. Download Bio
Jim Holbrook is a Professor of Emergency Services in the Department of Public Safety at Crafton Hills College. He currently serves as the Chair of the Department and as the Chair of the San Bernardino County Emergency Medical Care Committee. Jim is also adjunct faculty at Loma Linda University School of Allied Health.
Presentation- High Reliability in Dentistry: Effects of Pain on Patient, Caregiver, and Healthcare
Presentation- Expanding the Reach of HRO Ideas and Practice: Lessons from the 2009 Steelworkers Union Safety Conference
Bill Hoyle was Investigations Manager for the U.S. Chemical Safety and Hazard Investigation Board (CSB) for ten years before retiring in 2008. He directed the investigation of more than 30 major incidents including the 2005 BP Texas City Refinery disaster. This was the most comprehensive workplace incident investigation in U.S. history. He designed CSB’s urgent recommendation that resulted in the formation of the Baker Panel, which studied the safety culture at five BP oil refineries in the U.S. Prior to joining the CSB he worked for Amoco Oil Company for 15 years.
Dan has 35 years of wildland fire and all hazards experience. His experience includes Engines, Fire Prevention, Fuels Management, and Hotshots. He was a member of the Fulton Hotshots for 13 years with 8 years as Superintendent, was promoted to Battalion Chief (AFMO) in 1995, Division Chief (DFMO) in 2000, and NIMO Operation Section Chief in August of 2006.
He has been actively involved with Incident Management Teams in the positions of Division/Group Supervisor, Operations Branch Director, Operations Section Chief, and Incident Commander since 1990. Complex incident management experience includes many wildland fires, several missions of national significance including the 9/11 attack on the Pentagon, Columbia Shuttle Recovery, Greensburg Kansas Tornado, and four Hurricanes. Dan also performed as an Operations Section Chief Type 1 on wildfires in Australia in 2007.
During his career, he has been actively involved as an instructor in wildland fire suppression, incident management, and leadership. Currently he is a member of the NWCG Leadership Committee working on the development and delivery of Advanced Leadership programs. He is a student of High Reliability Organizations, Human Factors, Decision Making, and Leadership Development. Download short bio
Presentation - Paranoid Sensemaking: On psychological pressures in dynamically complex environments
Dorothy Leonard, the William J. Abernathy Professor of Business Administration Emerita, joined the Harvard faculty in 1983 after teaching for three years at the Sloan School of Management, Massachusetts Institute of Technology. She has taught MBA courses in managerial leadership, corporate capabilities, new product and process design, technology strategy and innovation management. At Harvard, M.I.T., and for corporations such as Hewlett-Packard, AT&T, and 3M, Professor Leonard has conducted executive courses on a wide range of innovation-related topics such as cross-functional coordination during new product development, technology transfer and knowledge management. She has initiated and served as faculty chair for executive education programs such as Leveraging Knowledge for the 21st Century, Leading Product Development, and Enhancing Corporate Creativity.
She is also the author of a book considered seminal in her field: Wellsprings of Knowledge: Building and Sustaining the Sources of Innovation and co-author (with Walter Swap) of When Sparks Fly: Igniting Group Creativity.
Peter M. Madsen is an assistant professor in the Department of Leadership and Strategy at the Marriott School of Management at Brigham Young University. He received a PhD in Organizational Behavior and Industrial Relations from the Haas School of Business at the University of California Berkeley in 2006. His research focuses on how organizations and their members learn about and attempt to manage uncertainty and risk (including safety, environmental, and financial risks). His recent work focuses specifically on organizational strategies for learning from failure, especially catastrophic failure, including: the effective use of accident investigations, the identification of near-miss events, and the development of organizational safety culture. Peter also studies the interplay between safety, environmental, and finanical goals in organizations. His work has been published in top management and safety journals, including: Academy of Management Journal, Organization Science, Quality and Safety in Health Care, and Engineering Management Journal.
Presentation - High Reliability in Serious Accident Review
Thomas A. Mercer, MS, Rear Admiral (ret.) was Superintendent of the Naval Postgraduate School at Monterey, California. He was also Executive Director of the Center for Risk Mitigation at the University of California, Berkeley. Before that he was on the Joint Chief’s Staff for interoperability, strategy, connectivity and operational planning. Mercer received BS from the U.S. Naval Academy and his MSAE from the Naval Postgraduate School. He also graduated from the Navy’s nuclear propulsion school. Mercer was an A-7 carrier pilot.
Presentation - Staff Rides to provoke urgency for change
Presentation - Work incidents information diffusion and training as practices to learning and safety performance development: an exploratory study
Presentation - TRANSFER OF EXPERTISE: THE LONG AND WINDING ROAD TO FOOTBALL SAFETY AND SECURITY
Presentation - An Oil and Gas operator’s journey to improving reliability in the organisation
Presentation - The Effect of Accident Investigations on Organizational Culture
Ivan Pupulidy is the Human Performance Specialist for the US Forest Service, a position earned through a multi-faceted career path. After receiving a Geology B.S. Degree in 1984, Ivan worked as a mine geologist and exploration geophysicist (for companies such as Newmont Exploration, Ltd. and Quintana Minerals Corp.). With a desire to go from the earth to the sky, Ivan joined the Coast Guard and progressed from Officer Candidate School to Flight School, where he was winged as a Naval Aviator in 1987.
Flying HU-25 Falcon Fan-Jets at Coast Guard Air Station Corpus Christi, Texas, Ivan engaged in rescue and law enforcement missions until the Coast Guard selected him for a very competitive Maintenance Officer and Pilot position. Assigned to the HC-130 Hercules aircraft (at Coast Guard Air Station Sacramento) Ivan flew one of the most challenging humanitarian missions in the military, often taking him directly into the eye of a hurricane, or low over stormy water to rescue ships in distress.
Following a successful ten year career with the Coast Guard, Ivan traded water for fire and became a Lead Plane Pilot for the US Forest Service. Flying low level over forest fires across the United States, Ivan was led to develop safety programs that would impact all levels of his organization.
Ivan also remained active in the US Air Force Reserves and has flown the Hercules in combat missions in Iraq and Afghanistan and humanitarian support missions throughout central Africa. Ivan completed a Master’s of Science Degree in Human Factors and Systems Safety at Lund University, Sweden and is currently working on a PhD in System Safety. Download Short Bio
Gary Provansal, Division Chief, Special Operations, San Bernardino County (CA) Fire Department, is responsible for counter-terrorism, Emergency Medical Services, Urban Search and Rescue, Hazardous Materials, and training for the county fire department that covers 20,000 square miles, the largest county in the United States. He serves on the Joint County Terrorism Oversight Committee for Riverside and San Bernardino Counties. He also administers the Federal Aviations Administration’s (FAA) Western Region Air Crash Rescue Training School. He served on a Federal advisory group for counter-terrorism training for the national fire service. He represents San Bernardino County for the low-level nuclear waste program for the US Department of Energy (DOE). He was the Director of the San Bernardino County Emergency Operations Center for the fire siege of 2003 where, with a staff of 500, he directed the evacuation of 155,000 citizens from mountain communities and several hospitals. He also acted as Operations Chief for the Emergency Operations Center (EOC) during the subsequent floods that killed 14 people. He started his career with the department as a firefighter and paramedic.
Presentation - HRO Designs for Health Care
Roger Resar, MD is Senior Fellow at the Institute for Healthcare Improvement where he functions as faculty and a member of the R&D Team. He is a retired Assistant Professor of Medicine at the Mayo Clinic School of Medicine and former Change Agent for Mayo Foundation. Dr. Resar has contributed to the development and national spread of key safety and improvement strategies. Several of notable mention include Medication Reconciliation, the Global Trigger Tool, “bundle science”, reliable process design, and basic work and design in hospital flow. Dr. Resar is boarded in Pulmonary and Critical Care Medicine and graduated from the University of Wisconsin Medical School in 1972.
Presentation - Nuclear Self-Assessment as a High Reliability Organization (HRO) Tool
Karlene H. Roberts is a Professor at the Walter A. Haas School of Business, at the University of California at Berkeley. She is also Chair of the Center for Catastrophic Risk Management at Berkeley. Roberts earned her bachelor’s degree in Psychology from Stanford University and her Ph.D. in Industrial Psychology from the University of California at Berkeley. She also received the docteur honoris causa from the Universite Paul Cezanne (Aix Marseilles III). Since 1984 Roberts has investigated the design and management of organizations and systems of organizations in which error can result in catastrophic consequences. She has studied both organizations that failed and those that succeed in this category. Some of the industries Roberts has worked in are the military, commercial marine transportation, healthcare, railroads, petroleum production, commercial aviation, banking, and community emergency services.
Roberts has consulted in the areas of human resource management, staffing policies, organizational design, and the development of cultures of reliability. Recently she has consulted with the military, in the healthcare industry, in software development, and in the financial industry. She testified before the Columbia Accident Investigation Board. Roberts is a Fellow in the American Psychological Association, the Academy of Management, and the American Psychological Society. She has contributed to policy formation for the Federal Aviation Administration, the U.S. Coast Guard, the U.S. Navy, the Department of Energy, and the Mineral Management Service of the U.S. Department of Interior. Download Short Bio
Presentation - Toward the Creation of Highly Reliable Public Education in the U.S. and the U.K.
Presentation - Retained Surgical Items: An Organizational Commitment to Mindfulness of a Never Event
Slagmolen, Bert, PhD is Managing Partner of a Dutch consultancy firm, IME organization consultants and Apollo13: Managing the Unexpected
IME works primarily for governmental, not-for-profit and professional organizations in the Netherlands. One of his focus areas is High Performance Organizations and the implementation of intervention strategies to make organizations more reliable, more client-oriented and more professional. He studied electronics at the Technical University in Delft and business administration at the Erasmus University in Rotterdam. He finished his PhD on the Analyses of ICT-narratives in organizations and society. He currently consults for Dutch ProRail, the Dutch national rail infrastructure manager, and for the Dutch Labor Offices.
Presentation - Toward the Creation of Highly Reliable Public Education in the U.S. and the U.K.
Daved van Stralen, MD, FAAP, is an Assistant Professor of Pediatrics and a pediatric critical care physician on staff at Loma Linda University Children’s Hospital and Children’s Subacute Center at Community Hospital of San Bernardino (California), Adjunct Professor of Emergency Medical Service at Crafton Hills College, Yucaipa, California, and medical director for American Medical Response, San Bernardino County. He served as Medical Director for San Bernardino County Fire Department (covering 20,000 square miles) for ten years. He worked in South Los Angeles as an ambulance man and fire department rescue ambulance driver for the Los Angeles City Fire Department in the 1970s. By one review, he is the first career paramedic to attend medical school. He has a Bachelor of Arts in Social Ecology and a Bachelor of Science in Biological Science from the University of California, Irvine; an MD degree from University of California at Irvine College of Medicine where he completed his Pediatric Residency. He completed a Pediatric Critical Care Fellowship at Children’s Medical Center and Parkland Memorial Hospital, Dallas, Texas. At Loma Linda University he worked with another Pediatric Intensivist, a Viet Nam combat veteran (Navy A-4 pilot), to create a High Reliability Pediatric Intensive Care Unit. He also developed the pediatric critical care transport service and the nation’s first clinical academic Emergency Medical Care baccalaureate degree for paramedics. Using a fire service/EMS model with critical care principles he developed a subacute care model for profoundly handicapped children that enabled them to play and develop despite dependency on mechanical ventilation for life while cared for in a chronic intensive care unit. He collaborates with safety, risk, and reliability experts from wildland firefighting, business, and healthcare in the US and Europe to identify common approaches the individual uses to ensure safety and reliability. Presentation PDF
Karl E. Weick is the Renis Likert Collegiate Professor of Organizational Behavior and Psychology and professor of psychology at the University of Michigan Business School. Dr. Weick's research interests include collective sensemaking under pressure, medical errors, handoffs in extreme events, high-reliability performance, improvisation and continuous change.
Michele M. Zembo, MD, MBA, is an Associate Professor of Orthopaedic Surgery at Tulane University School of Medicine. She is the Director of the Medical Staff and Graduate Medical Education at the Medical Center of Louisiana at New Orleans. She is currently charged with developing a comprehensive Quality and Safety Program for the School of Medicine and the Tulane Medical Center. She was Director of Compliance for the Louisiana State University School of Medicine and their Faculty Group Practice for eight years. She is a founding Board Member of the Louisiana Emergency Response Network (LERN). The LERN Board is responsible for developing a statewide system to facilitate the treatment of trauma and time sensitive illnesses. She is an active member of the American Academy of Orthopaedic Surgeons having served on numerous committees and is currently a mentor in the Leadership Fellows Program. She has spoken nationally on a variety of topics including pediatric orthopaedic surgery, healthcare compliance, practice management, and health information technology. She received her Bachelor of Science in Biology from Rensselaer Polytechnic Institute, her MD from Penn State College of Medicine, and her Master in Business Administration from the University of New Orleans. She completed her orthopaedic training at the University of Michigan and her fellowship in pediatric orthopaedic surgery at Louisiana State University.