San Jose State Resilience Engineering for High Risk Process Environments Paper i am having a hard time to write this essay, please help me. And I don’t und

San Jose State Resilience Engineering for High Risk Process Environments Paper i am having a hard time to write this essay, please help me. And I don’t understand how to write it. 11 T-Mobile
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AICHE
Learning From Organizational
Incidents: Resilience
Engineering for High-Risk
Process Environments
Stefanie Huber, Ivette van Wijgerden, Arjan de Witt,and Sidney W.A. Dekker
a Berlin Institute of Technology, Center of Human-Machine-Systems, Berlin, Germany, Stefanie.Huber@zmms.tu-berlin.de
(for correspondence)
b
Delft University of Technology, Faculty of Technology, Policy and Management, Delft, The Netherlands
Lund University, Center for Complexity and Systems Thinking, Ljungbyhed, Sweden
Published online 18 December 2008 in Wiley Inter Science (www.interscience.wiley.com). DOI 10.1002/prs.10286
as they are embodied in safety procedures and poli-
cies. © 2008 American Institute of Chemical Engineers
Process Saf Prog 28: 90–95, 2009
Keywords: chemical industry, incident reporting,
accidents, bazards, anticipation, resilience engineering
For years, safety improvements have been made by
evaluating incident reports and analyzing errors and
violations. Current developments in safety science,
however, challenge the idea that safety can meaning-
fully be seen as the absence of errors or other nega-
tives. Instead, the question becomes whether a com-
pany is aware of positive ways in which people, at all
level of the organization, contribute to the manage-
ment and containment of the risks it actually faces.
The question, too, is whether the organization has the
adaptive capacity necessary to respond to the chang-
ing nature of risk as operations shift and evolve. This
article presents the results of a resilience engineering
safety audit conducted on a chemical company site.
An interdisciplinary team of seven researchers carried
out 4 days of field studies and interviews in several
plants on this site. This company enjoyed an almost
incident-fre recent history but turned out to be ill-
equiped to handle future risks and many well-known
daily problems. Safety was often borrowed from to
meet acute production goals. Organizational learn-
ing from incidents was fragmented into small organi-
zational or production units without a company-
wide learning. We conclude that improving safety
performance hinges on an organization’s dynamic
capacity to reflect on and modify its models of risk as
operations and insight into them evolve, for example,
INTRODUCTION
In recent years, ideas on how to improve safety in
high-risk environments have followed a common
approach. Suggestions are often made to improve
safety by preventing human errors (1). In this para-
digm, safety is maintained by training, by disciplining
of people, adding new procedures, and adding new
safety automation. The system is considered to be ba-
sically safe because safety is something that is engi-
neered into a system.
Lately, new insights into how safety is improved
and maintained have revolutionized the whole dis-
cussion about safety in complex systems and have
established a new paradigm for analyzing human
error. In this new view, the emphasis is on the posi-
tive contribution of people at all levels of the organi-
zation, rather than solely on human errors (2,3). Deal-
ing with new procedures, new developments, and
new process problems is a daily responsibility. This
view acknowledges that the demands of high conse-
quence/low probability events cannot always be
handled by matching situational symptoms with
scripts of coordinated action used in training. These
scripts can help people (a) prioritize actions in the
© 2008 American Institute of Chemical Engineers
90 March 2009
Process Safety Progress (Vol.28, No.1)
face of time pressures and resource constraints, (b) to
assign tasks, (c) organize roles, and (d) continually
assess expectations. But the limits of and misplaced
confidence in such preparations have been commented
on before (4,5), and the literature has shed some light
on the difficulty of processes of sensemaking in
demand situations that lie beyond procedural reach (6).
Resilience engineering has been suggested as one
answer to eliminating these limits. It is a good
approach for handling systems that have to deal with
dynamic and complex environments where daily rou-
tine no longer works and systems have to be dynami-
an external safety audit to obtain a more objective
appraisal and (b) collecting ideas about further
improvements or changes. An interdisciplinary, inter-
cultural team of seven was formed to perform this
audit.
A structured questionnaire was developed for
interviews with operators and managers based on
topics that are critical for organizational success and
have turned out to be good indicators for resilient
organizations (7,9). Six dimensions were taken into
account:
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© 2008 American Institute of Chemical Engineers
scripts can help people (a) prioritize actions in the
90
March 2009
Process Safety Progress (Vol.28, No.1)
2/6
an external safety audit to obtain a more objective
appraisal and (b) collecting ideas about further
improvements or changes. An interdisciplinary, inter-
cultural team of seven was formed to perform this
audit
A structured questionnaire was developed for
interviews with operators and managers based on
topics that are critical for organizational success and
have turned out to be good indicators for resilient
organizations (7,9). Six dimensions were taken into
account:
face of time pressures and resource constraints, (b) to
assign tasks, ©) organize roles, and (d) continually
assess expectations. But the limits of and misplaced
confidence in such preparations have been commented
on before (4,5), and the literature has shed some light
on the difficulty of processes of sensemaking in
demand situations that lie beyond procedural reach [6].
Resilience engineering has been suggested as one
answer to eliminating these limits. It is a good
approach for handling systems that have to deal with
dynamic and complex environments where daily rou-
tine no longer works and systems have to be dynami-
cally stable and flexible rather than rigid (7-9). Fol-
lowing this resilience engineering paradigm, safety
cannot be engineered into a system as a property,
but must emerge as a quality of the joint human-
machine system (10).
Hence, it is not possible to find out if a system is
safe or not by deconstructing it: “resilience engineering
abandons the search for safety as a property, whether
defined through adherence to standard rules, in error
taxonomies, or in human error counts” (10). Further-
more, resilience engineering is a broader concept than
existing error counting taxonomies or other models
that include the “old view of human error” (11]. It is
not only about determining the probability that a
given function or component would fail under specific
circumstances” (10), but rather postulates that systems
“must also be resilient and have the ability to recover
from irregular variations, disruptions, and degradation
of expected working conditions” (10). Where old-view
models focus on counting errors that happened in the
past, resilience engineering concepts target present
working conditions as well as the anticipation of future
developments—or as Diamond (12) put it: “to antici-
pate a problem before it has arrived” (10,12).
The resilience engineering approach is a new and
fascinating one, because it de-emphasizes the old-
view models of human error investigation, and it con-
siders the system as a whole. It focuses on present
and future safety, i.e. on proactive safety instead of
reactive safety and hence does not concentrate solely
on past errors (10). It considers humans as an integral
part of resilience and does not focus only on techni-
cal components or redundancy as the main elements
for enhancing safety in systems.
All these ideas sound reasonable—but do they really
work in practice? The aim of the research reported
here is to test these ideas by conducting a resilience-
engineering safety audit in a chemical company.
1. Top-level commitment (e.g. Do you think your
boss appreciates your work?
2. Just culture (e.g. Do you feel comfortable reporting
safety issues/problems to your boss?)
3. Learning culture (e.g. Do you feel the discussion
about risk is kept alive in your company?)
4. Awareness and opacity (e.g. Do you know the major
safety concerns the company has to deal with?)
5. Preparedness (e.g. Do you feel ahead of upcoming
problems?)
6. Flexibility (e.g. Do you have any slack resources
available to cope with sudden trouble?)
Each dimension was covered by at least four ques-
tions. General questions were included about the
employees’ positions, their daily work, their work-
load, and personal experience with accidents, as well
as opener questions about the employees’ feelings
about the safety culture.
28 operators and 21 managers were interviewed
during the audit period. Additionally, 2 days of field
observation in various plants and with different oper-
ators were performed and background information
was reviewed about the company, concerning organi-
zational and industrial issues.
When analyzing the data a two-step approach was
chosen. First, responses from both operators and
managers were described and summarized in a
report. As “data never speaks for itself” (13) the sec-
ond step analyzed the interview and observation
data. Patterns and regularities (14) were presented in
the report, as well as higher-order categories for the
findings. This second-step analysis was supported by
literature and included proposals and interpretations
about the investigated company. It aimed to answer
questions such as: How could these phenomena have
been generated? What underlying principles can be
derived from the findings? What common principles
do these results identify? This approach was chosen
as research has shown that understanding the causes
of failure (the so-called second stories are crucial for
learning in organizations (15,16).
For this article, the results of the comprehensive
first step of the analysis will not be presented, but
the findings and patterns that were discovered
through the second step of our analysis will be
described and discussed.
METHOD
In May 2007, a resilience engineering based safety
audit was conducted in a chemical company (remains
anonymous) with more than 300 employees. The
company was founded more than 100 years ago and
today runs more than a dozen production plants at a
single site in Europe.
To maintain and enhance the plants’ high-safety
levels, a safety department was established some
years ago and incident reporting has become a major
way of keeping track of the plant’s safety state. For
confirmation, the safety manager was interested in (a)
Process Safety Progress (Vol.28, No.1)
Published on behalf of the AICHE
DOI 10.1002/prs
March 2009 91
RESULTS AND DISCUSSION
Safety is important when you are not busy, but if
there is production pressure safety is not impor-
tant, production is put first.
Safety Versus Production
Operators and managers were convinced that
safety and production are the two most important
Tail
baturan
duction
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Process Safety Progress (Vol.28, No.1)
Published on behalf of the AICHE
DOI 10.1002/prs
March 2009 91
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RESULTS AND DISCUSSION
Safety is important when you are not busy, but if
there is production pressure safety is not impor-
tant, production is put first.
Daily trade-offs between safety and production
occur in most companies that depend on producing
and selling their goods. It is a common problem in
the process industry, where the production consti-
tutes the right to exist (2). But as one can imagine, it
is not possible to be safe and efficient to the same
great extent in a given time (10) or as Hollnagel put
it: “If anything is unreasonable, it is the requirement
to be efficient and thorough at the same time (17].
To avoid such situations, sacrificing decisions have to
be made to deal with these problems—situations
where safety is put first and the pressure on through-
put and efficiency goals is relaxed (19). Management
plays a major role in making sacrificing decisions.
Whom else, if not the middle and higher manage-
ment, could mandate that safety is worth more than
production? But why is it so difficult to stand up and
stop the production in favor of safety?
Safety Versus Production
Operators and managers were convinced that
safety and production are the two most important
goals in the company and had to be met simultane-
ously. Company goals, often driven by external pres-
sure to produce and to meet customer goals were
internalized by almost all employees, and the conse-
quence resulted in situations where an employee had
to decide between safety or production, but could
not achieve both at the same time. Usually, such in-
compatible goals arose at the organizational level and
its interaction with the environment, but the actual
managing of goal conflicts under uncertainty was
pushed down into local operating units. There, the
conflicts had to be negotiated and resolved in the
form of thousands of daily decisions and trade-offs.
Efforts were made by the operators and managers to
deal with these conflicting goals simultaneously, but
trade-offs were always the final resolution. Small inci-
dents were neglected and often were considered as
normal side-effects of daily work.
These daily trade-offs often resulted operators
not putting on their safety gear because this would
“waste” some minutes in the production process.
Hollnagel (17) uses the expression “efficiency-thor-
oughness trade-offs” (ETTO) for these types of situa-
tions. There people have to decide to go for safety
and thoroughness or production and efficiency. “On
the one hand people genuinely try to meet their
(internalized) goals, i.e., they try to do what they are
supposed to do-or at least what they believe is rea-
sonable to do—and to be as thorough as they find it
necessary. On the other hand they try to do this as
efficiently as possible which means without spending
any unnecessary effort or time to do it” (17]. Underly-
ing organizational pressures and preferences were
reproduced in what individual people did and valued
(or undervalued), in a way that was invisible for the
organization as a whole.
Yet people also took their ability to reconcile the
irreconcilable as a source of considerable professional
pride. It was seen as a strong sign of their expertise.
The general faith in, and commitment to the com-
pany, and its advertised high concern for safety ini-
tially seemed overwhelming. “Safety is always first”
people often said at all levels, but often contradict it
decisively with their own actions not much later.
However, further questions about the main goal or
goals in the organizations produced responses to
keep the production running, not only from opera-
tors but also from middle-managers. They doubted
that safety was unconditionally put first by their supe-
riors. Most of them felt that other goals such as pro-
duction, costs, or delivery were at least equal. But
how can an organization claim that safety always
comes first and then insist on keeping production
running? Organizations often resort to “conceptual
integration, or plainly put, doublespeak” [18].
Digging deeper, we experienced critical voices that
talked about daily trade-offs that were made between
safety and production.
The Internalization of External Pressure
One answer is the internalization of external pres-
sure. There are a lot of goals that operators and man-
agers have to face everyday. Safety is never the only
goal in systems; often there are economic pressures,
cost goals, production goals, and so forth [2]. Many
operators have internalized these multiple goals and
try to achieve all of them simultaneously with their
best efforts. This was illustrated by a story told by
one of the operators in the audited company:
Usually you have to […] monitor the process
every 15 min. If you do it only after 16 min, you
have to fill a report and the paper error’ goes
down to the office. To avoid that, you usually
write down that you checked it on time. Some-
times you have to work for two production lines
at the same time and then it’s not possible to
perform the checks in time. So you look after-
wards what the temperature was some minutes
before and you write it down (e.g., 5 min too
late). Because you have to do things simultane-
ously and you have to do things right – these are
two goals that sometimes conflict.
One of the managers said that “the higher in hier-
archy you are, the more goals you have. You have
fewer goals if you go down the hierarchy, because
you act more locally”!. But actually the opposite is
the case. Goals are usually cascaded down the hierar-
chy, which is known as the management by objec-
tives principle. If a superior has the goal to produce
more the next year, then his subordinates have to
execute this goal. One manager told us about the
pressure he has and stated that he has to “improve
every working process and be cost-efficient and at
Direct quotes from operators and managers’ interviews, resilience engi-
neering based safety audit, 2007
92 March 2009
Published on behalf of the AICHE
DOI 10.1002/prs
Process Safety Progress (Vol.28, No.1)
month because of steam leaks (e.g., out of some
pipelines) and then the smoke detector reacts.
the same time produce and work safely”!. Exactly the
same goals and pressures were faced by the opera-
tors, because “institutional pressures are reproduced,
or perhaps really manifested, in what individual peo-
ple do” (11). There is no difference on your hierarchy
level: “Safety is first with maximum production”.
Not only is daily risk normalized, but also the
deviance from procedures or manuals are normal-
ized; i.e. procedures and manuals functioned as
Keeping that in mind when asked for the most val.
muidelines instead of fived and mandato mule
Tal
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T11:34
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Process Safety Progress (Vol.28, No.1)
Published on behalf of the AICHE
DOI 10.1002/prs
March 2009 91
3/6
RESULTS AND DISCUSSION
Safety is important when you are not busy, but if
there is production pressure safety is not impor-
tant, production is put first.
Daily trade-offs between safety and production
occur in most companies that depend on producing
and selling their goods. It is a common problem in
the process industry, where the production consti-
tutes the right to exist (2). But as one can imagine, it
is not possible to be safe and efficient to the same
great extent in a given time (10) or as Hollnagel put
it: “If anything is unreasonable, it is the requirement
to be efficient and thorough at the same time (17].
To avoid such situations, sacrificing decisions have to
be made to deal with these problems—situations
where safety is put first and the pressure on through-
put and efficiency goals is relaxed (19). Management
plays a major role in making sacrificing decisions.
Whom else, if not the middle and higher manage-
ment, could mandate that safety is worth more than
production? But why is it so difficult to stand up and
stop the production in favor of safety?
Safety Versus Production
Operators and managers were convinced that
safety and production are the two most important
goals in the company and had to be met simultane-
ously. Company goals, often driven by external pres-
sure to produce and to meet customer goals were
internalized by almost all employees, and the conse-
quence resulted in situations where an employee had
to decide between safety or production, but could
not achieve both at the same time. Usually, such in-
compatible goals arose at the organizational level and
its interaction with the environment, but the actual
managing of goal conflicts under uncertainty was
pushed down into local operating units. There, the
conflicts had to be negotiated and resolved in the
form of thousands of daily decisions and trade-offs.
Efforts were made by the operators and managers to
deal with these conflicting goals simultaneously, but
trade-offs were always the final re…
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