© Erik Hollnagel, 2014
Chief ConsultantCenter for Quality, RSD (DK)
Erik Hollnagel
ProfessorUniversity of Southern Denmark
The fundamentals of resilient organisational performance
© Erik Hollnagel, 2014
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.
© Erik Hollnagel, 2014
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
© Erik Hollnagel, 2014
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.
© Erik Hollnagel, 2014
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”
© Erik Hollnagel, 2014
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?
© Erik Hollnagel, 2014
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.
© Erik Hollnagel, 2014
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.
© Erik Hollnagel, 2014
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.
© Erik Hollnagel, 2014
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
© Erik Hollnagel, 2014
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
© Erik Hollnagel, 2014
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
© Erik Hollnagel, 2014
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
Rating scale + evaluation criteria
Rating scale + evaluation criteria
Rating scale + evaluation criteria
© Erik Hollnagel, 2014
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
© Erik Hollnagel, 2014
Thank you for your attention