School of Social Science and Public Policy: Risk Management - Essay Example

SCHOOL OF SOCIAL SCIENCE & PUBLIC POLICY POLITICAL ECONOMY Master of Arts Public Policy stephen427927@hotmail.com Table of Contents 1.0 Introduction 3 2.0 What are the Key Features of ‘High-Reliability Organisations’? 5 2.1 Preoccupation with Failure 5 2.2 Reluctance to Simplify 5 2.3 Situational Awareness 6 2.4 Commitment to Resilience 6 2.5 Deference to Expertise 6 3.0 What sets the high reliability organisation apart from other organisations? 7 4.0 HRO Perspective 9 5.0What are the limits and criticisms of HRO Theory? 10 6.0 Conclusion 11 7.0 Bibliography 16 Introduction Organisations which have the possibility for harm or that are in high risk industries are considered high reliability organisations. The most common definition for a high reliability organisation is one that is consistently reliable and operates in a complex environment where accidents could possibly be expected and is also an organisation which through actions avoids and minimizes catastrophes (Health Foundation, 2011). More emphasis has been placed on reliability seeking organisations versus reliability achieving organisations. Industries where extensive study has been conducted on risk management include energy, transport and aviation, military and space exploration, fires and natural disasters, health care and education. These organisations are characterized by the serious demand for reliability and the need to avoid operational failures. Learning processes do not include trial and error due to the cataclysmic consequences of possible failure. Theories in HRO point out the importance of redundancy, requisite variety and information richness (Karina and Torstein, 2012, p 2). These organisations strive for continuous improvement and leadership must be managed by strong individuals and teams must be creative in their response to failures. Mistakes are guarded against through systems of checks and rechecks, counter checks and redundancy (Health Foundation, 2011). Collective mindfulness is demonstrated through a sensitivity to operations, constant thought to the possibility of failure, the seeking of all possible expertise and the reluctance to simplify issues and risks. High reliability organisations have histories of safe operations and demonstrate reliability, flexibility, effectiveness, and efficiency (Muhren, Eede and Walle, 2012, p 577). These environments pursue the image of a tightly coupled organisation and the absence of trial and error is what is attributed to the success of high reliability organisations. Organisations systems of defense are thought of as layers in James Reason’s Swiss Cheese Model. Some defenses may not be operating optimally, allowing holes to occur in the system. Latent failures can occur through incomplete procedures, regulatory narrowness, inadequate training, responsibility shifting, attention distractions, clumsy technology or deferred maintenance. These many variables occur at one time and any triggers can be responsible for an accident. In order to be an effective HRO’s it is not necessary to be completely error free; however, it is necessary to be able to recover quickly and to ensure that the errors do not disable the organisation. What are the key features of ‘high-reliability organisations’? How confident should we be that they are ‘highly reliable’? There are many key features that are agreed upon by experts in the literature regarding high reliability organisations. They each operate in a complex environment which can be physical, political and or social environments. These environments can be and are unforgiving in major catastrophes. Processes and technologies used in these environments have high potential for errors and are considered high risk environments. Consequences for errors would be considered significant which makes it impossible for these environments to learn through trial and error. Learning through experimentation is not possible in these environments Preoccupation with Failure Preoccupation with failure means that HRO’s are successful in avoiding accidents yet do not boast about their success. They are wary of common failures and are on the alert for restricted searches, inattention, inertia, risk aversion and homogeneity. Minute errors are treated with extreme importance and members remain prepared for surprises, expecting them as much as is possible in an organisation. Members are constantly in fear of analytical errors and aware that these errors are easily amplified. Reluctance to Simplify Reluctance to simplify means that HRO’s create more complicated and differentiated pictures of what is going on in order to avoid the possibility of blind spots. Few assumptions are made and members are trained to notice more. The law of requisite variety suggests that an increased amount of suggestions available to a system will generate an increased amount of compensations that a system is able to create. The more diverse a group is the more information there is available. It is important that communication patterns are created in an efficient manner so that all information available is shared with the group or team. Situational Awareness Situational awareness and sensitivity to operations allows a team to signal errors when they are still able to be traced. Situational awareness can be defined as the perception of elements within an environment, comprehension of their meaning, and the ability to project their future status (Muhren, Eede and Walle, 2012, p 579). This sensitivity can be reached through shared mental images, roundtable story building, and knowledge of the organisations systems and the diagnosis of the limitations of procedures that have been preplanned. Commitment to Resilience Commitment to resilience requires the teams to keep errors small and ensure the system remains functional. To protect against unexpected hazards you must have the capacity to learn, to act and to act without advance knowledge of what the situation will be. There must be a broad range of actions that the organisation is able to choose from when a dangerous situation occurs. Deference to Expertise Deference to expertise allows decisions to be made by people on the front line who have the most expertise, despite rank. Expertise and experience are more important than rank in situations of emergency and the decision structure of HRO’s is a combination of hierarchy and specialization. What Sets the High Reliability Organisation Apart From Other Organisations? What sets the high reliability organisation apart from other organisations is that these systems are associated with systems of great benefit that are also very hazardous. Managers and Commanders count on high levels of operating performance and safety. HRO’s are characterized by high operational performance technical systems along with very stringent quality assurance measures in maintenance (Laporte, 1996, p 61).HRO’s are committed to exhibiting a strong sense of mission and operational goals. In each HRO an agreement is stressed regarding the hazard of the technology, the definition and seriousness of an error, the value or benefit of whatever is being produced in the organisation and the serious cost of failing to provide this. Functional processes are designed in ways that parallel or overlap activities so that there is a backup and contingency in case of overload or unit breakdown. Operators and supervisors are trained in multiple jobs ensuring a variety of skills and abilities and jobs are designed to limit the interdependence of functions. Premiums are placed on recruiting individuals with extraordinary skill or the ability and capacity to develop skills through continuous training. HRO’s also demonstrate a more collegial pattern of authority based on skill while relationships based on skills are acted out in times of acute emergency. Decisions are often developed based on intense bargaining and collegial interaction in order to effectively solve problems. Decisions are executed quickly and with little chance for review, recovery or alteration; it is therefore essential that decisions are based on the best possible information available and that the technical and procedural processes will not be the source of failure. There is an unusual emphasis on reward for the discovery and reporting of errors. HRO organisations argue that organisations can become more reliable by engineering a positive safety culture that uses reinforcement to promote safety related behaviors and habits. Normal Accident Theory as proposed by Charles Perrow assumes accidents are an inevitable factor in complex organisations that make use of high risk technology (Lekki and Hill, 2011, p3). Tight coupling and interactive complexity are thought to make accidents in high hazard organisations a certainty. Tightly coupled systems are often automatic and leave little time for human intervention in the instance of an emergency. NAT provides a pessimistic view and is a theory that offers no suggestions for improvement. This is in direct conflict with high reliability organisation theory. HRO Perspective HRO perspective is very similar to the theory that is most used in aviation, petrochemical and nuclear industries. This resilience engineering theory means the system is able to survive and return to normal functioning quickly. Despite the similarities’ HROT falls short by ignoring broader social and environmental contexts in which they operate… (Lekki and Hill, 2011, p3). This limits the potential these organisations have to learn from errors. HRO researchers rely on accident statistics to prove high reliability and error free performance. Statistics can lack objectivity and confuse the concept of reliability with safety. Reliability is not a necessity to safety and often the two can pull in opposite directions. Accident analysis creates an organisational memory of the event; what happened and why. A science is developed around the kind and types of accidents possible in an organization and parts of the system that should have redundancies are identified (Roberts and Bea, 2001, p 71). In distinguishing high reliability organisations from other organisations certain expectations are distinguished and reinforced that are not found in other organisations. Organisational culture inventory is used to asses an organisations belief and behavioral expectations using a scale that consists of over 100 statements describing expected behaviors of a member organization (Brown, 2012). Berkeley developed a scale with forty different ratings items to better distinguish high reliability organisations. The Berkeley scale is more able to distinguish characteristics that are cultural. Aside from this safety scale, communication, environment, health, and other organisational dimensions are also assessed in the organisational culture inventory. What are the limits and criticisms of HRO Theory? Research has been highly criticized because it relies on studies of organisations that are highly regulated and have a high degree of command and control. HRO is a process rather than an implementable structure which limits its use in some organisations such as health care. It is also a decentralized system trying to operate in a centralized world. It is suggested that even perfectly organized technologies will sometimes fail (Downer, 2010, p 22). Catastrophic potential is embedded within the very being of complex and tightly coupled systems. Working with real life systems requires making judgements with imperfect knowledge. The debate over whether accidents can be prevented now includes the question of what the true cause is of accidents and disasters (Managing, 2009, p 50). An entirely new industry has been developed around the notion or idea that private organisations can be made more reliable through the adoption of HRO characteristics despite the fact that HRO theory does not explain organisational disasters or provide an appropriate tool for assessment (Boin, 2008, p 1051). A very limited amount of organisations have been studied and it is still unclear how HRO’s develop the capacity to avoid disastrous events. Nuclear powered carriers are considered to be complex systems, and multiple software intensive systems (Rooksby, 2010, p 3). Aircrafts take off and land in very close proximity and hazardous materials such as fuel and explosives are common. These carriers are 24 stories high and contain enough fuel to last for fifteen years. They are at high risk for nuclear reactor accidents, flooding, fires, ground collisions, and mistaken identity of friend and foe. Despite these high risks they are considered high reliability with low crunch rates and few major accidents, achieved by their organisational design. Conclusion High reliability organisations have been studied extensively and information presented in this paper represent the findings of this research. Though many factors of these organisations are still not fully understood it is clear that despite being very high risk organisations with many inherent risks these behavioral systems of checks and balances allow organisations to remain error free and functioning. Emphasis on organisational learning unifies high reliability organisations though it is difficult if not currently impossible to apply what he have learned from organisational accident research into theorized frameworks which will provide better information for safety management in the future (Pidgeon, 2010, p 214). Recognizing the obstacles that are presented to learning in high risk contexts will better allow us to move forward to safe organisational designs, more effectively presenting failures in the future. Bibliography . Downer, John. (2010). Anatomy of a Disaster: Why Some Accidents are Unavoidable. Available: http://eprints.lse.ac.uk/36542/1/Disspaper61.pdf. Last accessed 23 April 2012. Boin, A, & Schulman, P 2008, Assessing NASA’s Safety Culture: The Limits and Possibilities of High-Reliability Theory, Public Administration Review, 68, 6, pp. 1050-1062, Business Source Premier, EBSCOhost, viewed 23 April 2012. Available: http://ehis.ebscohost.com.proxy.cecybrary.com/eds/pdfviewer/pdfviewer?vid=4&hid=6&sid=60be3670-3934-4380-b55d-7904838d3a64%40sessionmgr11 Brown William. (2012). Organizational Culture, Safety Culture, and Safety Performance at research Facilities. Available: http://www.humsyn.be/OCI%20and%20Safety%20%28Brown%20BNL%29.pdf. Last accessed 18 April 2012 Jeffcott Shelley, Pidgeon Nick, Weyman Andrew, Walls John. (2006). Risk, Trust, and Safety Culture in the UK Train Operating Cultures. Available: http://193.146.160.29/gtb/sod/usu/$UBUG/repositorio/10271628_Jeffcott.pdf. Last accessed 18 April 2012. Karina Aase, Torstein Tjensvoll. (). Learning in High Reliability Organisations. Available: http://www2.warwick.ac.uk/fac/soc/wbs/conf/olkc/archive/oklc4/papers/oklc2003_aase.pdf. Last accessed 17 April 2012 Kirchsteiger, C 2005, Review of industrial safety management by international agreements and institutions, Journal Of Risk Research, 8, 1, pp. 31-51, Business Source Premier, EBSCOhost, viewed 21 April 2012. Laporte Todd. (1996). High Reliability Organisations: Unlikely, Demanding and at Risk . Available: http://polisci.berkeley.edu/people/faculty/LaPorteT/High%20Reliability%20Organisations%20-%20Unlikely,%20Demanding,%20and%20At%20Risk.pdf Last accessed 18 April 2012 Lekki Chrysanthi, Hill Harpur. (2011). High Reliability Organisations; A Review of the Literature. Available: http://www.hse.gov.uk/research/rrpdf/rr899.pdf. Last accessed 18 April 2012. Managing the Unexpected: Six Years of HRO-Literature Reviewed 2009, Journal Of Contingencies & Crisis Management, 17, 1, pp. 50-54, Academic Search Premier, EBSCOhost, viewed 23 April 2012. Available: http://ehis.ebscohost.com.proxy.cecybrary.com/eds/pdfviewer/pdfviewer?vid=3&hid=6&sid=60be3670-3934-4380-b55d-7904838d3a64%40sessionmgr11 Muhren Willem, Van Den Eede, Van De Walle. (2012). Organisational Learning for the Incident Management Process. Available: http://is2.lse.ac.uk/asp/aspecis/20070116.pdf. Last accessed 17 April 2012 Pidgeon, N 2010, Systems thinking, culture of reliability and safety, Civil Engineering & Environmental Systems, 27, 3, pp. 211-217, Academic Search Premier, EBSCOhost, viewed 21 April 2012. Roberts Karlene, Bea Robert. (2001). Must Accidents Happen?. Available: http://high-reliability.org/files/Accidents-_Roberts,_Bea.pdf. Last accessed 17 April 2012. Roberts, K, Madsen, P, Desai, V, & Van Stralen, D 2005, A case of the birth and death of a high reliability healthcare organisation, Quality & Safety In Health Care, 14, 3, pp. 216-220, CINAHL Plus with Full Text, EBSCOhost, viewed 21 April 2012. Rooksby John. (2010). High Reliability Organisations. Available: http://www.cs.st-andrews.ac.uk/~ifs/Teaching/MScCritSysEng2010/Lectures%28PDF%29/L14-HROs-handouts.pdf. Last accessed 17 April 2012 The Health Foundation Inspiring Improvement. (2011). Research Scan: High Reliability Organisations. Available: http://www.health.org.uk/public/cms/75/76/313/3070/high%20reliability%20organisations%20-%20research%20scan.pdf?realName=BSzQGV.pdf Vincent, C, Benn J, & Hanna, G 2010, High reliability in health care, BMJ: British Medical Journal (Overseas & Retired Doctors Edition), 30 January, Academic Search Premier, EBSCOhost, viewed 21 April 2012 Read More