Creating high reliability organisations

Dr David Rubens DSyRM, CSyP, FSyI

[email protected]

Creating High-Reliability Organisations in the 21st Century Threat Environment

BCI East of England Forum3rd November, 2017

External Problems

BCI East of England Forum 03/11/2017

Natural Disaster Terrorism

Social Disorder Cyber Failure

National Infrastructure

Pandemic


European Blackout – November 4th, 2006

• Once the second circuit was turned off, this caused alarms due to high power flow. Also the Landesbergen–Wehrendorf line was very close to its limit. Over the next half hour, the power first went down but then it crept back up. E.ON Netz thought that closing a contact would decrease this a bit; in fact, it had the opposite effect and once this was performed the line tripped out.

• Twenty eight seconds later, an electrical blackout had cascaded across Europe extending from Poland in the north-east, to the Benelux countries and France in the west, through to Portugal, Spain and Morocco in the south-west, and across to Greece and the Balkans in the south-east.


Someone get the cars…..



……and extract by air

Internal Challenges

BCI East of England Forum 03/11/2017IHSM, London - 02/06/2017

Levels of Events

Standard Incident

Local impact

Knownresponses

Clear solutions

Limited time-line

(SOP)

RoutineEmergency

SignificantImpact

Localised event

Controlled bythe

organisation

Well-definedresponses

(BCP)

Major Incident

Impacts theenvironment

Multi-agencyresponse

Innovativesolutions

Longer-termimpacts

Looselystructuredresponses

Crisis

Threatens theoranisation’s

existence

Destruction of environment / infrastructure

Multipleparallel crises

No endposition


Time Pressure

Potential Catastrophic Consequences

Necessity to Make Decisions

Goes Beyond Planned Scenarios

Lack of Information

Rapid Escalation


Shell

BP


Social Media & Crisis Management


United Airlines


Boston Police Department Social Media Account

• 1.38 pm 50,000 followers

• 1.52 pm ‘Explosion. Please keep area clear’ 566 retweets

• 2.02 ‘22 injured 2 dead’ 7557 Retweets

• 2 days later ‘No arrests made’ > 10,000 retweets

• Picture of suspect >19,000 retweets

• ‘Captured’ 143,000 retweets

330,000 followers, 50million people reached


BCI East of England Forum 03/11/2017IHSM, London - 02/06/2017

Developing Solutions

The Principle Cause of Failure in Crisis Management is….

Communication

Transfer of

Complex

Information

Under Pressure

Between Multiple Stakeholders


The most important function of crisis management is…..

... Manage ‘Information Exchange’


Organizational Network – FEMA Situation Reports (Kapucu, 2005)


Networks in FEMA Emergency Response Plan (Kapucu, 2005)


Bipartite Graph of Katrina EMON Source and Non-Source Organizations (Butts et al, 2012)


L5 Corporate Risk & Crisis Management - Manchester 9th-11th October, 2017

Resiliency and High Reliability Organisations

High Reliability Organisations

High Reliability Theory (HRT): The creation of operation management programmes that are fail-safe : ‘Systems that are not only foolproof, but damned foolproof’, (Schulman et al., 2004:23)


Problem Management

• There is no such thing as an insignificant problem

• Any problem is an indicator of a significant failing

• Any problem can be an indicator of a long-chained causal process

• All problems / solutions are time pressured

• All problems are treated as though they are an indicator of a potential crisis


Sensitivity to Failure

• Most organisations presume that things will go well

• HROs focus on proactively identifying things that can go wrong

Mindfulness and Culture

• HROs are identified by their mindfulness in terms of risk and their own responsibility for managing that

• It is a reflection of the overall culture of the organisation

• It is not controllable by introducing specific protocols


The Tenth Law of Wicked Problems

The Planner has no right to be wrong

*

* Rittel, H. W., & Webber, M. M. (1973). Dilemmas in a general theory of planning. Policy sciences, 4(2), 155-169.


• The ability to maintain operational efficiency under the stress of external changes

• The ability to absorb

• The ability to adapt

• The ability to return

• The ability to learn

Resilience Multidisciplinary Centre for Earthquake Engineering Research (MCEER)

Resilience


New Understanding of Resilience

• Engineering Resilience

• Able to withstand the environment

• Ecological Resilience

• Living part of the environment


Community Capital3

1

Resilience

• The ability to maintain operational efficiency under the stress of external changes

• The ability to absorb

• The ability to adapt

• The ability to return

• The ability to learn

Resilience Multidisciplinary Centre for Earthquake Engineering Research (MCEER).


Robustness

• Robustness describes the general toughness of an organisation.

• It is the ‘ability to operate under less than optimal conditions’


Resourcefulness

• Resourcefulness describes the quality of being able to find solutions, to work things out, to make things happen.

• The ability to develop innovative solutions

• Resourcefulness is required at every level, from the logistical manager, to the operations manager, to the person providing the food and coffee

• Resourcefulness is a critical quality of anyone operating in dynamic environments, and without that quality, none of their other capabilities would be able to be delivered


Redundancy

• Redundancy is the ability to maintain operational status despite the loss of significant operational pathways

• Redundacy can be considered in terms of spare capacity

• The opposite of redundancy is ‘single path critical failure points, which indicates where the failures of single components could lead to critical operational failures

L4 Advanced Corporate Risk & Crisis Management - MMU, 6th-8th June, 2017BCI East of England Forum 03/11/2017

Rapidity

• Rapidity is the ability of the organization to adapt to changing circumstances

• It includes developing solutions, communicating information, and integrating solutions into on-going operations

• Rapidity includes a speedy acknowledgement of potential problems as early as possible in their development cycle, and developing effective solutions before a higher level of disruption can occur

• As such, rapidity can be preventative as well as reactive


Reliability

• Reliability is the quality of delivering the required service under any circumstances

• It is the desire to operate as close as possible to a ‘zero failure’ organisation.

• Reliability is often confused with efficiency, but efficiency is concerned with ‘operating as planned within managed parameters’, whilst reliability concerns the ability to maintain that efficiency when the operating environment changes


1. The crisis is the result of weaknesses within our own systems, not the result of an outside event

2. There are a series of low-level ‘Normal Accidents’ that highlight those weaknesses – but they are ignored

3. When the crisis is triggered, it is not recognised as a crisis because people think that it is the same as the previous low-level ‘accidents’

Pathway to Disaster


Pathway to Disaster

4. When you start to react to the disaster, there are three shortages:

i. Equipment

ii. Manpower

iii. Management skills

5. When you do react to the crisis, it does not respond as predicted: Law of Unintended Consequences


Pathway to Disaster (cont.)

6. Once the disaster is over,

Lessons are not learned

(7. Once the disaster is over, it can be clearly seen that it was an inevitable consequence of systemic weaknesses that were known, and ignored)

Perrow, S. (1984) ‘Normal Accidents: Living with High-Risk Technologies’

Toft, B and Reynolds, S (1994) ‘Learning from Disasters’

Turner, BA and Pedegeon, NF (1997) ‘Man-Made Disasters’


Your Next Crisis Report

• The ability to acknowledge risk and learn from exercises has not been sufficient.

• The ability to implement decisions that have been made, and to use the plans that have been developed, has been ineffectual.

• The ability to coordinate and interact has been deficient.

• The potential inherent in information and communications technology has not been exploited well enough.

• Leadership's willingness and ability to clarify responsibility, set goals and adopt measures to achieve results have been insufficient.

• In the opinion of the Commission, these lessons learned are to a greater extent applicable to leadership, interaction, culture and attitudes, than to a lack of resources, a need for new legislation, organisation or important value choices.

From 22nd July Commission,

Utoya Island Massacre


Most man-made disasters and violent conflicts arepreceded by incubation periods during which policymakers misinterpret, are ignorant of, or flat-outignore repeated indications of impending danger’

(Boin & t’Hart, 2003:547)

Final Thought


We cannot Prevent the EventWe can Influence the Impacts

We can Manage the ConsequencesBut.....

We Control the Response


3-Day Level 5 Management Award in Corporate Risk and Crisis Management (Ofqual-Regulated)

Dr David Rubens DSyRM, CSyP, FSyI

[email protected]

Creating High-Reliability Organisations in the 21st Century Threat Environment

BCI East of England Forum3rd November, 2017

Creating high reliability organisations

Business

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