High Reliability Fundamentals: A New Way of Thinking
The graphic below illustrates what we know about the role of human performance in causing events or occurrences. Traditional event analyses concludes that about 80% of all events are initiated by human error. In some industries this number is closer to 90%. Roughly 20% of occurrences involve equipment failures. When the 80% human error is broken down further it reveals that the majority of errors associated with events stem from latent organizational weaknesses, (perpetrated by humans in the past that lay dormant in the system) whereas about 30% are caused by the individual worker touching the equipment and systems in the facility i Perrow,. Normal Accidents, Living with High-Risk Technologies, 1984; p. 183; Reason. Human Error. 1999, p.187..
The traditional belief is that human performance is a worker-focused phenomenon. This belief promotes the notions the failures are introduced to the system only through the inherent unreliability of people. "Once we can rid ourselves of a few bad performers, everything will be fine. There is nothing wrong with the system." However, experience has shown that weaknesses in organizational processes and cultural values are involved in the majority of facility events. Accidents result from a combination of factors beyond the control of the worker. Therefore, the organizational context of human performance is an important consideration. Event-free performance requires an integrated view of human performance from those who attempt to achieve it — that is, how well management, staff, supervision, and workers function as a team, the degree of alignment of processes and values in achieving the facility's operational and safety missions, and a cohesive culture that promotes shared mental models and collaborative working relationships.
Anatomy of an Event
- Initiating Action
- Flawed Defenses
- Error Precursors
- Latent Organizational Weaknesses
- Strategic Approach for Human Performance
Principles of High Reliability
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