SlideShare uma empresa Scribd logo
1 de 37
Baixar para ler offline
1
Falling objects: Engaging the ”man-
in-the-loop” to achieve real safety
improvement
Agenda
•  Introduction
•  Foreign Object Damage – An aviation
perspective
•  Health, Safety and Environment – a
holistic approach
•  Engaging the human element
•  Culture
•  Leadership’s role
Eric Arne Lofquist
eric.lofquist@bi.no
•  PhD from NHH studying “The effects of strategic
change on safety in High Reliability Organizations
(HROs)” - Avinor
•  Associate Professor Handelshøyskole BI Bergen
•  Health, Safety and Environment (HSE)
5 November 2010
USS Nimitz CVN-68
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
6
Foreign Object Damage
(FOD) in Aviation
*FOD costs the civil aviation industry 3-4 Billion dollars each year
7
Civil aviation describes the FOD program
as a two phase process:
• Avoidance of foreign objects
•  Removal of foreign objects
FOD program activities:
•  FOD walkdowns
•  ”Good housekeeping” activities
•  Reporting and investigation
•  Compiling data and trend analysis
8
The FOD program today is an integrated
part of the overall safety management
system
•  Safety culture/climate
But what about identification of foreign
objects?
•  Everyone’s responsibility
9
What are foreign objects?
Indian Ocean
3 May 1980
11
Concorde 2000
Columbia Space Shuttle 2003
From engineering to behavior
Technology, technical engineering
Safety Management Systems
Behavior
Number of
accidents
Trend in
practice over time
Pre-1960
1960s-1970s
1980’s +
A systems perspective
•  ”Since both failures and successes are the
outcome of normal performance variability,
safety cannot be achieved by constraining – or
eliminating it.”
•  Normal Accident Theory – (Perrow, 1984)
•  High Reliability Organizations (Rochlin et al.,
1987)
•  Resilience Engineering (Hollnagel et al., 2006)
•  Safety management cannot be based on a
reactive approach alone
Understanding the nature of systems
•  How systems are designed and developed to
operate in an ”expected” environment
•  How they evolve in response to the
environment
•  Based on our limited mental models – why a
particular risk assessment might be limited
•  Instead, expecting that challenges to system
performance will occur – because systems
evolve
The problem with models
•  ”All models are wrong” – Jay Forrester
•  All models are simplifications of reality
•  Includes our system of rules and regulations
•  Models are based on our limited cognative
capacity
•  Short-cuts
•  Rules-of-thumb
Safety Management Systems
•  Based on an ideal or rational view of an
organization
•  Where functions, roles and responsibilities are
clearly defined ”for people” according to
specified organizational goals, and as a result,
the organization is designed to ”behave” in a
rational way
•  A prescriptive approach ending up with a
normative organization against which practices
can be measured or assessed
Swiss Cheese Model – Reason (1990)
•  Focus and the Man-in-the-loop in MTO and on HSE-
culture.
•  Need to involve those who feel the problem in the
bodies – those on the shop floor.
•  Last line of defence
17
Latent conditions
Hazards
Losses
Man
Technology
Organization
HSE Management Systems
(Lofquist, 2008:2010)
Proactive
Phase
Interactive
Phase
Reactive
Phase
System Design System Operation System Outcomes
Time
Organizational Culture
Environment
Socio-technical system
HSE Management Systems
(Lofquist, 2010)
Proactive
Phase
Interactive
Phase
Reactive
Phase
System Design System Operation System Outcomes
Time
Organizational Culture
Environment
Socio-technical system
Proactive activities
  System design/redesign
  Processes, routines and procedures
  Creation of barriers
  Rules and regulations
  Risk analysis (based on incomplete and/or
changing assumptions)
  Personnel selection
  Personnel training/retraining
HSE Management Systems
(Lofquist, 2008:2010)
Proactive
Phase
Interactive
Phase
Reactive
Phase
System Design System Operation System Outcomes
Time
Organizational Culture
Environment
Socio-technical system
Reactive activities
  System outcomes
  Unplanned and undesired outcomes occur
  Incident and accident reporting
  Performance measurement
HSE Management Systems
(Lofquist, 2008:2010)
Proactive
Phase
Interactive
Phase
Reactive
Phase
System Design System Operation System Outcomes
Time
Organizational Culture
Environment
Socio-technical system
Engaging the ”man-in-the-loop”
  Socio-technical systems
  Understanding the nature of the human
element in a systems context
HSE Management Systems
(Lofquist, 2008:2010)
Proactive
Phase
Interactive
Phase
Reactive
Phase
System Design System Operation System Outcomes
Time
Organizational Culture
Environment
Socio-technical system
Organizational culture (Schein, 2004)
•  Culture – a dynamic phenomenon that
surrounds us at all times
•  Constantly enacted and created by our interaction
with others and shaped by leadership behavior
•  Creates a set of social structures, routines, rules and
norms that guide and constrain behavior
•  The dynamic processes of culture creation and
management are the essence of leadership
05-11
-10
Eric Arne Lofquist26
Culture and leadership
•  Two sides of the same coin
•  Culture decides what defines leadership but
leaders create and manage culture
•  Leadership creates and changes culture, while
management and administration act within
culture
•  Culture is the result of complex group learning
processes that are only partly influenced by
leader behavior
05-11
-10
Eric Arne Lofquist27
Culture drives our thinking and actions
•  Observed behavioral regularities when people
interact
•  Group norms
•  Espoused values
•  Informal ”rules of the game”
•  Habits of thinking, mental models and linguistic
paradigms – cognitive frameworks
05-11
-10
Eric Arne Lofquist28
Double-loop learning
(Argyris & Schön, 1974)
Real world
Information
feedback
Mental models of
real world
Strategy, structure,
decision rules
Decisions
Single-
loop
Double-
loop
Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement
Zohar, 2010
•  Conceptual attributes of the construct of
safety climate
•  Relative priorities
•  Alignment between espousals and
enactments
•  Internal consistency
•  Shared cognitions or social consensus
•  Motivation for climate perceptions: social
verification
05-11
-10
Eric Arne Lofquist31
How do leaders embed their beliefs, values
and assumptions
•  Primary embedding:
•  What leaders pay attention to, measure and control
•  How leaders react to critical incidents and
organizational crisis
•  How leaders allocate resources
•  Deliberate role modeling, teaching and coaching
•  How leaders allocate rewards and status
•  How leaders recruit, select, promote and
excommunicate
05-11
-10
32
High Reliability Organizations (HROs)
•  Creating a supporting organizational culture
•  Creating a ”learning environment”
•  Mindfulness
•  Knowing (Education and training)
•  Sensemaking
•  Seeing (Noticing)
•  Responding (Reporting)
•  Taking action
34
Key points
•  Targeting human error no longer target
•  Safety is the presence of something not the
absence of something
•  Attempting to fix unreliable human behavior
by:
•  Automation
•  More procedures and barriers
•  Increased monitoring
•  Only people have adaptive capacity
Using the operators
•  Operators, and their deep understanding of an
application area is an important source of
resilience – expertise in action
•  Two main sources of resilience
•  Picking up the faint signals when ”things are going
wrong”
•  Being able to develop resources that can adapt ”on
the fly”
•  Identify potential dangers
Takk for meg
37

Mais conteúdo relacionado

Semelhante a Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement

Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...
Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...
Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...Nawanan Theera-Ampornpunt
 
management thoughts & organizational behaviour
management thoughts & organizational behaviourmanagement thoughts & organizational behaviour
management thoughts & organizational behaviourPreeti Bhaskar
 
Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...
Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...
Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...Nawanan Theera-Ampornpunt
 
Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...
Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...
Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...Nawanan Theera-Ampornpunt
 
SM302_Endsem_merged.pdf
SM302_Endsem_merged.pdfSM302_Endsem_merged.pdf
SM302_Endsem_merged.pdfSahanaSedamkar
 
cupdf.com_chapter-1-definitions-and-foundations-of-od.ppt
cupdf.com_chapter-1-definitions-and-foundations-of-od.pptcupdf.com_chapter-1-definitions-and-foundations-of-od.ppt
cupdf.com_chapter-1-definitions-and-foundations-of-od.pptMuskanMere
 
Different Perspective On Organizational Communication
Different Perspective On Organizational CommunicationDifferent Perspective On Organizational Communication
Different Perspective On Organizational CommunicationSol Erwin Diaz
 
Bcu msc cg week 5 rm framework
Bcu msc cg week 5 rm frameworkBcu msc cg week 5 rm framework
Bcu msc cg week 5 rm frameworkStephen Ong
 
Adapting Test Teams to Organizational Power Structures
Adapting Test Teams to Organizational Power StructuresAdapting Test Teams to Organizational Power Structures
Adapting Test Teams to Organizational Power StructuresTechWell
 
Strategic Systems Thinking Week 1 2016.pptx
Strategic Systems Thinking Week 1 2016.pptxStrategic Systems Thinking Week 1 2016.pptx
Strategic Systems Thinking Week 1 2016.pptxmatthewfadedeji
 
Principles and policies of hrm
Principles and policies of hrmPrinciples and policies of hrm
Principles and policies of hrmRani Padmini
 
ISO 45001 Key Implementation Steps
ISO 45001 Key Implementation StepsISO 45001 Key Implementation Steps
ISO 45001 Key Implementation StepsPECB
 

Semelhante a Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement (20)

Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...
Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...
Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...
 
management thoughts & organizational behaviour
management thoughts & organizational behaviourmanagement thoughts & organizational behaviour
management thoughts & organizational behaviour
 
Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...
Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...
Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...
 
Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...
Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...
Case Studies in Health IT Implementation & Sociotechnical Aspect of Health In...
 
SM302_Endsem_merged.pdf
SM302_Endsem_merged.pdfSM302_Endsem_merged.pdf
SM302_Endsem_merged.pdf
 
Sociotechnical Aspect of Health Informatics
Sociotechnical Aspect of Health InformaticsSociotechnical Aspect of Health Informatics
Sociotechnical Aspect of Health Informatics
 
UNIT 1.ppt
UNIT 1.pptUNIT 1.ppt
UNIT 1.ppt
 
cupdf.com_chapter-1-definitions-and-foundations-of-od.ppt
cupdf.com_chapter-1-definitions-and-foundations-of-od.pptcupdf.com_chapter-1-definitions-and-foundations-of-od.ppt
cupdf.com_chapter-1-definitions-and-foundations-of-od.ppt
 
Sociotechnical Aspect of Health Informatics
Sociotechnical Aspect of Health InformaticsSociotechnical Aspect of Health Informatics
Sociotechnical Aspect of Health Informatics
 
Organizational Behaviour
Organizational BehaviourOrganizational Behaviour
Organizational Behaviour
 
Dokas Issil2011
Dokas Issil2011Dokas Issil2011
Dokas Issil2011
 
Group 3 Report.pptx
Group 3 Report.pptxGroup 3 Report.pptx
Group 3 Report.pptx
 
Different Perspective On Organizational Communication
Different Perspective On Organizational CommunicationDifferent Perspective On Organizational Communication
Different Perspective On Organizational Communication
 
Bcu msc cg week 5 rm framework
Bcu msc cg week 5 rm frameworkBcu msc cg week 5 rm framework
Bcu msc cg week 5 rm framework
 
Adapting Test Teams to Organizational Power Structures
Adapting Test Teams to Organizational Power StructuresAdapting Test Teams to Organizational Power Structures
Adapting Test Teams to Organizational Power Structures
 
System thinking
System thinkingSystem thinking
System thinking
 
Strategic Systems Thinking Week 1 2016.pptx
Strategic Systems Thinking Week 1 2016.pptxStrategic Systems Thinking Week 1 2016.pptx
Strategic Systems Thinking Week 1 2016.pptx
 
Principles and policies of hrm
Principles and policies of hrmPrinciples and policies of hrm
Principles and policies of hrm
 
ISO 45001 Key Implementation Steps
ISO 45001 Key Implementation StepsISO 45001 Key Implementation Steps
ISO 45001 Key Implementation Steps
 
Safety culture as a healthcare construct
Safety culture as a healthcare constructSafety culture as a healthcare construct
Safety culture as a healthcare construct
 

Mais de E.ON Exploration & Production

Samarbeid, mangfold og utfordringer - .. med hilsen fra Japan og Tyskland
Samarbeid, mangfold og utfordringer - .. med hilsen fra Japan og TysklandSamarbeid, mangfold og utfordringer - .. med hilsen fra Japan og Tyskland
Samarbeid, mangfold og utfordringer - .. med hilsen fra Japan og TysklandE.ON Exploration & Production
 
Forebygging av storulykker - Wintershalls erfaringer
Forebygging av storulykker - Wintershalls erfaringerForebygging av storulykker - Wintershalls erfaringer
Forebygging av storulykker - Wintershalls erfaringerE.ON Exploration & Production
 
Håndbok beste praksis forebygging fallende gjenstander
Håndbok beste praksis forebygging fallende gjenstanderHåndbok beste praksis forebygging fallende gjenstander
Håndbok beste praksis forebygging fallende gjenstanderE.ON Exploration & Production
 
Fallende gjenstander: resultater fra spørreundersøkelsen og anbefalingsliste ...
Fallende gjenstander: resultater fra spørreundersøkelsen og anbefalingsliste ...Fallende gjenstander: resultater fra spørreundersøkelsen og anbefalingsliste ...
Fallende gjenstander: resultater fra spørreundersøkelsen og anbefalingsliste ...E.ON Exploration & Production
 
Fallende gjenstander, bakgrunn og formål med prosjektet
Fallende gjenstander, bakgrunn og formål med prosjektetFallende gjenstander, bakgrunn og formål med prosjektet
Fallende gjenstander, bakgrunn og formål med prosjektetE.ON Exploration & Production
 
Presentasjon, fallende gjenstander resultat fra spørreundersøkelse
Presentasjon, fallende gjenstander resultat fra spørreundersøkelsePresentasjon, fallende gjenstander resultat fra spørreundersøkelse
Presentasjon, fallende gjenstander resultat fra spørreundersøkelseE.ON Exploration & Production
 
Life extension of aging petroleum production facilities offshore
Life extension of aging petroleum production facilities offshoreLife extension of aging petroleum production facilities offshore
Life extension of aging petroleum production facilities offshoreE.ON Exploration & Production
 

Mais de E.ON Exploration & Production (20)

Erfaringer ved bruk av felles beredskapsressurser
Erfaringer ved bruk av felles beredskapsressurserErfaringer ved bruk av felles beredskapsressurser
Erfaringer ved bruk av felles beredskapsressurser
 
Områdeberedskap – status i arbeidet
Områdeberedskap – status i arbeidetOmrådeberedskap – status i arbeidet
Områdeberedskap – status i arbeidet
 
Forebygging av storulykker
Forebygging av storulykkerForebygging av storulykker
Forebygging av storulykker
 
Forebygging av storulykker
Forebygging av storulykkerForebygging av storulykker
Forebygging av storulykker
 
Hvordan kan vi forebygge storulykker?
Hvordan kan vi forebygge storulykker?  Hvordan kan vi forebygge storulykker?
Hvordan kan vi forebygge storulykker?
 
Ledelse og storulykkesrisiko
Ledelse og storulykkesrisikoLedelse og storulykkesrisiko
Ledelse og storulykkesrisiko
 
Samarbeid, mangfold og utfordringer - .. med hilsen fra Japan og Tyskland
Samarbeid, mangfold og utfordringer - .. med hilsen fra Japan og TysklandSamarbeid, mangfold og utfordringer - .. med hilsen fra Japan og Tyskland
Samarbeid, mangfold og utfordringer - .. med hilsen fra Japan og Tyskland
 
Nytt HMS-regelverk – struktur og utvikling
Nytt HMS-regelverk – struktur og utvikling Nytt HMS-regelverk – struktur og utvikling
Nytt HMS-regelverk – struktur og utvikling
 
Forebygging av storulykker - Wintershalls erfaringer
Forebygging av storulykker - Wintershalls erfaringerForebygging av storulykker - Wintershalls erfaringer
Forebygging av storulykker - Wintershalls erfaringer
 
Håndbok beste praksis forebygging fallende gjenstander
Håndbok beste praksis forebygging fallende gjenstanderHåndbok beste praksis forebygging fallende gjenstander
Håndbok beste praksis forebygging fallende gjenstander
 
Fallende gjenstander: Tiltaksplan
Fallende gjenstander: Tiltaksplan Fallende gjenstander: Tiltaksplan
Fallende gjenstander: Tiltaksplan
 
Fallende gjenstander: resultater fra spørreundersøkelsen og anbefalingsliste ...
Fallende gjenstander: resultater fra spørreundersøkelsen og anbefalingsliste ...Fallende gjenstander: resultater fra spørreundersøkelsen og anbefalingsliste ...
Fallende gjenstander: resultater fra spørreundersøkelsen og anbefalingsliste ...
 
Fallende gjenstander, bakgrunn og formål med prosjektet
Fallende gjenstander, bakgrunn og formål med prosjektetFallende gjenstander, bakgrunn og formål med prosjektet
Fallende gjenstander, bakgrunn og formål med prosjektet
 
Hva gjør OLF etter hendelsen i Mexicogulfen
Hva gjør OLF etter hendelsen i MexicogulfenHva gjør OLF etter hendelsen i Mexicogulfen
Hva gjør OLF etter hendelsen i Mexicogulfen
 
The public sector and integrated operations
The public sector and integrated operationsThe public sector and integrated operations
The public sector and integrated operations
 
Scenariepresentasjon, OLFs årskonferanse
Scenariepresentasjon, OLFs årskonferanseScenariepresentasjon, OLFs årskonferanse
Scenariepresentasjon, OLFs årskonferanse
 
Energinasjonen Norge 2040
Energinasjonen Norge 2040Energinasjonen Norge 2040
Energinasjonen Norge 2040
 
Presentasjon, fallende gjenstander resultat fra spørreundersøkelse
Presentasjon, fallende gjenstander resultat fra spørreundersøkelsePresentasjon, fallende gjenstander resultat fra spørreundersøkelse
Presentasjon, fallende gjenstander resultat fra spørreundersøkelse
 
Helicopter Safety Study 3 (HSS-3)
Helicopter Safety Study 3 (HSS-3)Helicopter Safety Study 3 (HSS-3)
Helicopter Safety Study 3 (HSS-3)
 
Life extension of aging petroleum production facilities offshore
Life extension of aging petroleum production facilities offshoreLife extension of aging petroleum production facilities offshore
Life extension of aging petroleum production facilities offshore
 

Falling objects: Engaging the ”man-in-the-loop” to achieve real safety improvement

  • 1. 1 Falling objects: Engaging the ”man- in-the-loop” to achieve real safety improvement
  • 2. Agenda •  Introduction •  Foreign Object Damage – An aviation perspective •  Health, Safety and Environment – a holistic approach •  Engaging the human element •  Culture •  Leadership’s role
  • 3. Eric Arne Lofquist eric.lofquist@bi.no •  PhD from NHH studying “The effects of strategic change on safety in High Reliability Organizations (HROs)” - Avinor •  Associate Professor Handelshøyskole BI Bergen •  Health, Safety and Environment (HSE) 5 November 2010
  • 6. 6 Foreign Object Damage (FOD) in Aviation *FOD costs the civil aviation industry 3-4 Billion dollars each year
  • 7. 7 Civil aviation describes the FOD program as a two phase process: • Avoidance of foreign objects •  Removal of foreign objects FOD program activities: •  FOD walkdowns •  ”Good housekeeping” activities •  Reporting and investigation •  Compiling data and trend analysis
  • 8. 8 The FOD program today is an integrated part of the overall safety management system •  Safety culture/climate But what about identification of foreign objects? •  Everyone’s responsibility
  • 12. From engineering to behavior Technology, technical engineering Safety Management Systems Behavior Number of accidents Trend in practice over time Pre-1960 1960s-1970s 1980’s +
  • 13. A systems perspective •  ”Since both failures and successes are the outcome of normal performance variability, safety cannot be achieved by constraining – or eliminating it.” •  Normal Accident Theory – (Perrow, 1984) •  High Reliability Organizations (Rochlin et al., 1987) •  Resilience Engineering (Hollnagel et al., 2006) •  Safety management cannot be based on a reactive approach alone
  • 14. Understanding the nature of systems •  How systems are designed and developed to operate in an ”expected” environment •  How they evolve in response to the environment •  Based on our limited mental models – why a particular risk assessment might be limited •  Instead, expecting that challenges to system performance will occur – because systems evolve
  • 15. The problem with models •  ”All models are wrong” – Jay Forrester •  All models are simplifications of reality •  Includes our system of rules and regulations •  Models are based on our limited cognative capacity •  Short-cuts •  Rules-of-thumb
  • 16. Safety Management Systems •  Based on an ideal or rational view of an organization •  Where functions, roles and responsibilities are clearly defined ”for people” according to specified organizational goals, and as a result, the organization is designed to ”behave” in a rational way •  A prescriptive approach ending up with a normative organization against which practices can be measured or assessed
  • 17. Swiss Cheese Model – Reason (1990) •  Focus and the Man-in-the-loop in MTO and on HSE- culture. •  Need to involve those who feel the problem in the bodies – those on the shop floor. •  Last line of defence 17 Latent conditions Hazards Losses Man Technology Organization
  • 18. HSE Management Systems (Lofquist, 2008:2010) Proactive Phase Interactive Phase Reactive Phase System Design System Operation System Outcomes Time Organizational Culture Environment Socio-technical system
  • 19. HSE Management Systems (Lofquist, 2010) Proactive Phase Interactive Phase Reactive Phase System Design System Operation System Outcomes Time Organizational Culture Environment Socio-technical system
  • 20. Proactive activities   System design/redesign   Processes, routines and procedures   Creation of barriers   Rules and regulations   Risk analysis (based on incomplete and/or changing assumptions)   Personnel selection   Personnel training/retraining
  • 21. HSE Management Systems (Lofquist, 2008:2010) Proactive Phase Interactive Phase Reactive Phase System Design System Operation System Outcomes Time Organizational Culture Environment Socio-technical system
  • 22. Reactive activities   System outcomes   Unplanned and undesired outcomes occur   Incident and accident reporting   Performance measurement
  • 23. HSE Management Systems (Lofquist, 2008:2010) Proactive Phase Interactive Phase Reactive Phase System Design System Operation System Outcomes Time Organizational Culture Environment Socio-technical system
  • 24. Engaging the ”man-in-the-loop”   Socio-technical systems   Understanding the nature of the human element in a systems context
  • 25. HSE Management Systems (Lofquist, 2008:2010) Proactive Phase Interactive Phase Reactive Phase System Design System Operation System Outcomes Time Organizational Culture Environment Socio-technical system
  • 26. Organizational culture (Schein, 2004) •  Culture – a dynamic phenomenon that surrounds us at all times •  Constantly enacted and created by our interaction with others and shaped by leadership behavior •  Creates a set of social structures, routines, rules and norms that guide and constrain behavior •  The dynamic processes of culture creation and management are the essence of leadership 05-11 -10 Eric Arne Lofquist26
  • 27. Culture and leadership •  Two sides of the same coin •  Culture decides what defines leadership but leaders create and manage culture •  Leadership creates and changes culture, while management and administration act within culture •  Culture is the result of complex group learning processes that are only partly influenced by leader behavior 05-11 -10 Eric Arne Lofquist27
  • 28. Culture drives our thinking and actions •  Observed behavioral regularities when people interact •  Group norms •  Espoused values •  Informal ”rules of the game” •  Habits of thinking, mental models and linguistic paradigms – cognitive frameworks 05-11 -10 Eric Arne Lofquist28
  • 29. Double-loop learning (Argyris & Schön, 1974) Real world Information feedback Mental models of real world Strategy, structure, decision rules Decisions Single- loop Double- loop
  • 31. Zohar, 2010 •  Conceptual attributes of the construct of safety climate •  Relative priorities •  Alignment between espousals and enactments •  Internal consistency •  Shared cognitions or social consensus •  Motivation for climate perceptions: social verification 05-11 -10 Eric Arne Lofquist31
  • 32. How do leaders embed their beliefs, values and assumptions •  Primary embedding: •  What leaders pay attention to, measure and control •  How leaders react to critical incidents and organizational crisis •  How leaders allocate resources •  Deliberate role modeling, teaching and coaching •  How leaders allocate rewards and status •  How leaders recruit, select, promote and excommunicate 05-11 -10 32
  • 33. High Reliability Organizations (HROs) •  Creating a supporting organizational culture •  Creating a ”learning environment” •  Mindfulness •  Knowing (Education and training) •  Sensemaking •  Seeing (Noticing) •  Responding (Reporting) •  Taking action
  • 34. 34
  • 35. Key points •  Targeting human error no longer target •  Safety is the presence of something not the absence of something •  Attempting to fix unreliable human behavior by: •  Automation •  More procedures and barriers •  Increased monitoring •  Only people have adaptive capacity
  • 36. Using the operators •  Operators, and their deep understanding of an application area is an important source of resilience – expertise in action •  Two main sources of resilience •  Picking up the faint signals when ”things are going wrong” •  Being able to develop resources that can adapt ”on the fly” •  Identify potential dangers