POWER January 2016 - 50

WORKFORCE
want to make, and we are operationally
vigilant.
■ Reluctance to simplify. We deliberately
create a complete and nuanced understanding
of situations. For example, when
facing a high-risk situation that's similar
to something we've experienced before,
we probe the differences.
■ Sensitivity to operations. Leadership is
close to the front lines with eyes and ears
wide open. We want to know what is actually
happening where people could be
at risk. We interpret close calls as signs
of danger rather than as a success we can
move on from.
■ Commitment to resilience. We know that
no matter how well we do, there will be
surprises. We prepare to handle these
events in a way to return to normal operations
with minimal harm.
■ Deference to expertise. Decisions migrate
to experts. Expert knowledge is tapped at
point and time of need. Rigid hierarchies are
viewed as slow and vulnerable to errors.
The field of resilience engineering was invented
by a group of safety experts who noticed
that some things about traditional safety
didn't make sense considering what we know
about cognition, complex systems, and work.
For example, studies have shown that we
are emotional rather than rational in decision-making
and are blind to much of what
happens around us. " Being complacent " is a
natural state of mind as conscious awareness
is fleeting (our minds are prone to daydreaming,
mental replay, perceptual tunneling, and
so on). This is why admonishments to " be
careful " and " pay attention " don't always
work. It didn't make sense that expert operators
became temporarily incompetent. There
was a whole lot of work going on that went
exceptionally well because of-not despite-
the good efforts of people doing the work.
Safety expert Erik Hollnagel noted that resilient
organizations have four abilities:
■ Ability to respond to regular and irregular
variability, disturbances, and opportunities.
■ Ability to monitor what happens and recognize
if something changes so much that
it may affect the organization's ability to
carry out its current operations.
■ Ability to learn the right lessons from the
right experiences.
■ Ability to anticipate developments that lie
further into the future, beyond the range of
current operations.
To " engineer " resilient systems, we design
according to these principles:
■ Principle 1: Variability and uncertainty are
50
www.powermag.com
POWER | January 2016
inherent in complex work.
■ Principle 2: Expert operators are sources
of reliability.
■ Principle 3: A system view is necessary to
understand and manage complex work.
■ Principle 4: It is necessary to understand
" normal work. "
■ Principle 5: Focus on what we want: to
create safety.
This introduction to the approach continues
with details concerning the first two principles.
The other principles will be covered in
a future article.
Principle 1: Design for Variability
Don't worry. There is no need to ditch existing
systems and practices-they are our
starting point. Here are a few examples.
Planning Work. Is your Pretask Brief / Job
Safety Analysis / Job Hazard Analysis / Safe
Work Permit a " check the box " process filled
out by one person and then put away before
starting the " real " work? If so, stop. You are
missing the boat. It's not that checklists themselves
are somehow bad. They're not. Aviation,
for example, also uses checklists in a rigorous
way. But checklists alone don't go far enough
in preparing for the unexpected.
Let's apply the theories and principles outlined
above to preparing to work safely (Figure
2). We want to collaborate and include
people who bring different points of view
and probe risks with open-ended questions.
Think about how responses to the openended
question, " What are your concerns? "
differ from responses to the closed question,
" Do you have any concerns? "
We learn from success and failure and
avoid assuming everything is just like when
we did it before; we ask, " What's different? "
We talk about what we will do if we notice
the situation changing.
The concept of " sunk costs " heavily influences
our decisions, in sometimes negative
ways. If we are part of the way down
the road, most of us keep going, because it's
not our nature to stop or turn back if we have
invested time and effort toward reaching a
goal-unless we make the decision of where
we will stop before we start. Given this bias,
it is important to build " off ramps " where it
is okay to turn back. In aviation, this is a goaround
for a different approach on landing.
Ask, " How could we fail? "
Managing Risk. Resilience engineering
departs from traditional risk management in
three key ways:
■ Planning for risk. We prepare for the general
shape of risk and discuss in advance
how we will change our strategy if the risk
level changes.
■ Noticing risk. We approach work with
intelligent wariness, paying attention to
general signs that a situation is risky or
that the risk profile of a system, such as an
outage, is changing.
■ Responding to risk. We identify critical
steps (points of no return where something
really bad can happen) and we manage
those steps more rigorously, for example,
getting peer checks and being more deliberate
with our actions.
We can teach ourselves to notice risk
through language: " We'll be really careful " or
" I've never seen... " or " This will just take a
minute " or language that indicates uncertainty
(such as " maybe, " " not sure, " or " should
be OK " ). If we hear (or think) any of these
phrases, we should stop and regroup. Escalate,
2. Meaningful briefs. Consider using pretask briefs that require more engagement from
more people than the standard checklist. Courtesy: Calpine Corp.
http://www.powermag.com
POWER January 2016

Table of Contents for the Digital Edition of POWER January 2016
