rescas fundamentals of resilient organisational performance · © erik hollnagel, 2014 chief...

© Erik Hollnagel, 2014

Chief ConsultantCenter for Quality, RSD (DK)

Erik Hollnagel

[email protected]

ProfessorUniversity of Southern Denmark

The fundamentals of resilient organisational performance


AB

Making sense of socio-technical systems

The performance of modern socio-technical systems is emergent rather than resultant. They must be described in terms of functions rather than structures.

The conditions for successful functioning are created by the interaction

between social and technical factors.


The causality credo

(1) Adverse outcomes happen because something has gone wrong (causes). (2) Causes can be found and treated.(3) All accidents are preventable (zero harm).

Find the component that failed by reasoning

backwards from the final consequence.

Accidents result from a combination of active

failures (unsafe acts) and latent conditions (hazards).

Find the probability that components “break”, either alone or in simple combinations.

Look for combinations of failures and latent conditions that may constitute a risk.

Accident investigation Risk analysis


Safety = Zero harm

The Anglo American Safety Principles set out the foundation of the desired culture, expected behaviours and performance standards within the organisation. Each Principle has two supporting elements which, we believe, will assist us in leading us on the journey towards Zero Harm.


Increasing safety by reducing failures

Success (no adverse

events)

Failure (accidents, incidents)

Function (work as imagined)

Malfunction, non-compliance,

errorUnacceptable

outcomes

Acceptable outcomes

“Identification and measurement of adverse events is central to safety.”

“Find-and-fix”


Safety-I – when nothing goes wrong

Safety-I: Safety is the condition where the number of adverse outcomes (accidents / incidents / near misses) is as low as possible.

We focus on the events where safety is absent, rather on

those where safety is present.

We focus on the events where safety is absent, rather on

those where safety is present.

Safety is defined by its opposite – by the lack of safety

(accidents, incidents, risks).

Safety is defined by its opposite – by the lack of safety

(accidents, incidents, risks).

If we want something to INCREASE, why do we use a proxy measure that DECREASES?

Why is a HIGHER level of safety measured by a LOWER number of adverse outcomes?


Performance adjustments are necessary

Availability of resources (time, manpower, materials,

information, etc.) may be limited and uncertain.

People adjust what they doto match the situation.

Performance variability is inevitable, ubiquitous, and necessary.

Because of resource limitations, performance adjustments will always be approximate.

Performance variability is the reason why things sometimes go wrong.

Performance variability is the reason why everyday

work is safe and effective.


Increase safety by facilitating work

Success (no adverse

events)

Failure (accidents, incidents)

Everyday work (performance

variability)

Unacceptable outcomes

Acceptable outcomes

Function (work as imagined)

Malfunction, non-compliance,

error

Understanding the variability of everyday performance is the basis for safety.

Constraining performance variability to remove failures will also remove successful everyday work.


Individuals and organisations must adjust everything they do to match the current conditions. Everyday performance must

be variable in order for things to work.

Safety II – when everything goes right

Performance variability

Unacceptable outcomes

Acceptable outcomes

Safety-II: Safety is a condition where the number of successful outcomes (meaning everyday work) is as high as possible. It is the ability to succeed under varying conditions.

Safety-II is achieved by trying to make sure that things go right, rather than by preventing them from going wrong.

The focus is on everyday situations where things go

right – as they should.

The focus is on everyday situations where things go

right – as they should. Safety is defined by its

presence.Safety is defined by its

presence.


What is resilience?

In order to be resilient, the organisation must have four basic abilities.

Learn from past events, understand correctly

what happened and why

Monitor short-term developments and threats; revise risk models

Anticipate long-term threats and opportunities

Respond to regular and irregular conditions in an effective, flexible manner,

A system is resilient if it can adjust its functioning prior to, during, or following changes and disturbances, and thereby sustain required operations under both expected and unexpected conditions.

AnticipateMonitorLearn

Respond


AnticipateMonitorLearn

Respond

Four resilience abilities

Knowing what to do, being capable of doing it.

Knowing what to look for (indicators)

Imagining what to expect

Knowing what has happened


RMLA dependencies

Prototype RMLA model built by the FRAM Model Builder (FMB)

Graphical rendering generated by the FRAM Model Visualiser (FMV)

Both tools available from www.functionalresonance.com


Measuring resilience

Ability to respond(actual)

Ability to respond(actual)

Ability to monitor(critical)

Ability to monitor(critical)

Ability to anticipate(potential)

Ability to anticipate(potential)

Ability to learn

(factual)

Ability to learn

(factual)

Set of questions for ability to

respond

Set of questions for ability to

monitor

Set of questions for ability to anticipate

Set of questions for ability to learn

Rating scale + evaluation criteria





Roads to resilience

Respond + Learn

Respond + Anticipate

Respond + Monitor + Anticipate

Dysfunctional Resilient

Dys

func

t ion

alRe

silien

t

The development towards resilient performance takes place by improving the four abilities differentially – but not independently!

There are no upper bounds on resilience: performance (abilities) can always be improved


Thank you for your attention

rescas fundamentals of resilient organisational performance · © erik hollnagel, 2014 chief...

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