measuring the effects of strategic change on safety in a ... · measuring the effects of strategic...
TRANSCRIPT
Measuring the Effects of
Strategic Change on Safety in a
High Reliability Organization
Eric Arne Lofquist, PhD
Sikkerhetsforums årskonferanse
Stavanger
9 June 2009
Take-Off 05 project (2003-2005)
• New Public Management initiative in civil
aviation called “Corporatization”
• Deliberate large-scale organizational change in
a High Reliability Organization (HRO)
– Reorganization/downsizing
– New management systems/new technology
• “With no reduction in safety or service to
customers”
Agenda
• Personal background
• Review of the relevant safety literature
• High Reliability Organizations
• Avinor study
– Purpose
– Research design/methodology/data sources
– Organization of thesis
– Findings and implications for oil sector
Eric Arne Lofquist
Associate Professor at BI Bergen
Master of Management in HRM and HMS www.bi.no/hms
Commander, US Navy (28-years)– 15 years flying F-14 ”Tomcat” from US Navy Aircraft Carriers
– 13 years as a top leader and senior strategic planning officer • Norwegian Airforce Staff (Stavanger) 1989-1992
• CEO of US Navy industrial complex (New Orleans) 1992-1996
• NATO Headquarters (Brussels) 1996-2000
Relevant operational experience for study:– 15-years operative flight experience
•Operations/training/maintenance/safety
– Top leader experience responsible for organizational change•United States Navy/NATO
•Powersim/Nutec Crisis Management
Academic Background
• BS – Business Administration (Jacksonville University, 1976)
• MA – National Security Policy and Strategy (US Naval War College, 1985)
• MA – International Relations (Salve Reginia Universtiy, 1986)
• MBA – International Business (University of New Orleans, 1996)
• PhD – Strategy and Management (Norges Handelshøyskole, 2008)
Specialist education
• US Navy Flight School (1976-1978)
• Industrial Aviation Safety Specialist (US Naval Post
Graduate School, Monterey, California - 1988)
– F-14 Crash site investigator/team leader (1988)
Safety Literature
• Most safety literature written by sociologists, psychologists and engineers with specific paradigms ”with roots in two dissimilar scientific mechanisms for understanding socio-technical systems” (Roberts, 2001)
– Engineering, risk analysis and statistical modeling
– Social science (Sociology and Psychology)
• Most of the literature focuses on specific parts of safety, such as: accident prevention (barriers), risk management, human causes (human error)
Safety Literature (2)
• Theoretical standards for safety are based on grounded theory from real disasters (Three Mile Island, Bhopal, Challenger , Piper Alpha, Űberlingen, Columbia)
• Early safety literature focuses on reducing human error and risk mitigation (pre-1980s)
• From the 1980s onward, social science interests took on an organizational or “systems perspective”
Organizational accidents
• 1978 Barry Turner - Man-made disasters– Impossible without organizations
– Incubation periods (environmental changes)
• 1984 Charles Perrow - Normal Accidents– Tight coupling within interactively-complex systems
– “Accidents” are normal but undesired system outcomes
• 1987 Gene Rocklin, Todd LaPorte and Karlene Roberts (University of California Berekley)– High Reliability Organizations
• 1990 James Reason – Organizational Accidents
– Swiss Cheese Model – realignment of barriers
– Latent conditions
Organizational accidents (2)
• 1996 Diane Vaughan - Challenger Space Shuttle Accident
– Cultural deviance
• 2001 Karl Weick and Kathlene Sutcliffe – Managing the
Unexpected
– Mindfulness
• 2002 Hal Gehman – Columbia Space Shuttle Accident
– Resiliency of culture
Personal perspective on
safety/risk and HROs
• 1976 US Navy Flight School – first day
– ”Look at the person next to you ...”
• 1977 ”You boys know anything about a plane
crash?”
• 1979 First operational cruise on USS Nimitz – 14
crashes/14 pilots killed
• 25 May 1980 USS Nimitz crash
• This was the birthplace of HRO
High Reliability Organizations
• In 1984, a research group came together at the University of California - Berkeley to study organizations in which errors can have catastrophic consequences based on the question: – “If Accidents are “Normal” (Perrow, 1984), then why do some
industries operate with relatively few major disasters?”
– 3-year longitudinal case study – Electrical Grid, Air Traffic Control, and US Navy Aircraft Carrier Operations at sea
• In 1987, Gene Rocklin, Todd La Porte, and Karlene Roberts published “The Self-Designing High Reliability Organization: Aircraft Carrier Flight Operations at Sea” -Naval War College Review
High Reliability Organizations
• Industries that operate in inherently dangerous
environments with notably safe track records
• Conduct relatively error-free operations over long
periods of time
– Consistently make good decisions
– Learning environments/unlearning
– Sensemaking/mindfulness
USS Nimitz Facts
(30-knot off-shore oil well)
• Length - 1092 ft (333 meters) – 3 Football fields
• Width – 252 ft (76.8 meters)
• Height – 244 ft (24 Story building)
• Speed - 30+ knots (56+ km/hr)
• 6000 personnel
• 90 aircraft/24-hour operations in all-weather
• 2 Nuclear reactors
• Fully functional airfield and Air Traffic Control facility
Key features of
Aircraft Carrier Operations
• Challenging and high risk environment
– Tight quarters (3 football fields/80+ aircraft)
– 8 types of Aircraft (jets, props, helos)
– Fuel (heat, gases, noise, etc.)
– Weapons (Bombs, missiles, bullets, etc.)
– Changing political/environmental factors
• Small operating margins
• Average age – 20-years old
• 33% of crew replaced each year (100% turnover every 3-years)
• Two operating structures
Study findings
• ”Reliable performance is as much a product of
history and continuity of operations as design”
• ”Complexity so broad that know one knows all of
the parts”
• Everything is broken down into homogeneous,
”task-oriented” units
• ”Integrated vertically and horizontally”
• Culture is the ”glue” that holds it together
Paradox of turnover
• Assumed that the continual introduction of new personnel erodes proficiency … but
• Efforts in training and responsibility transfer compensate for this deficiency – creates a ”learning environment”
• Leaders are pushed to establish authority and take responsibility early in process
• Institutionalization of continual, cyclic training as part of organizational and individual expectations
Paradox of turnover (2)
• Organization uses training and retraining as a means
of socialization and acculturalization
• One of the great enemies of high reliability is the
combination of stability, routinization and lack of
challenge and variety which leads to complacency,
carelessness and error
Other key findings
• Operational redundancy and slack – compensatefor social-technical interface deficiencies
– Take-offs and landings
• Local authority – task ownership
– Local action and reporting without fear (Just Culure)
• Regular turnover enhances cultural contributionsthrough the use of ”war stories”
• Questions are always being asked and leadersalways listening
Follow-on work
• Collective Mind (Weick and Roberts, 1993)
– Actors in the system construct their actions (contributions), understanding that the system consists of connected actions by themselves and others (representation), and interrelate their actions within the system (subordination). p. 357
• Mindfulness (Weick and Sutcliffe, 2001, 2006)
– Cognative processes within cultural settings
Double-loop learning
(Argyris & Schön, 1974)
Real world
Information
feedback
Mental models of
real world
Strategy, structure,
decision rules
Decisions
Single-
loop
Double-
loop
HRO today
• NASA – Columbia Space Shuttle Accident (Safety culture/climate surveys – proactive indicators)
• Nuclear power generation
• Transportation
– Civil Aviation
– Maritime
– Trains
• Health care (Primary and acute care, and managed care)
• Offshore oil production?
Five core values of HROs
• Sensitivity to operations
– Constant awareness of leadership and support staff of the
state of the system affecting performance
• Reluctance to simplify
• Preoccupation with failure
• Deference to expertise
• Resilience
– Change and response to external/internal environment
– Plan and implement improvement
initiatives
Measuring the Effects of Strategic
Change on Safety in a High
Reliability Organization
http://bora.nhh.no/bitstream/2330/1916/1/lofquist%20avh2008.pdf
Purpose of the Avinor study
http://bora.nhh.no/bitstream/2330/1916/1/lofquist%20avh2008.pdf
To study the effects of a deliberate strategic organizational change process on safety in a High Reliability Organization
To gain new knowledge in strategy development, planning, implementation, and consequences of change with particular focus on how change effects safety in an HRO
Provide expanded understanding of safety monitoring during a change process in a “proactive” vice “reactive” manner
Take-Off 05 project (2003-2005)
• Deliberate corporatization initiative that included:
– Complete reorganization (structure/leaders/HQ)
– Significant downsizing (700+ man-years)
– Introduction of new management systems (SMS)
– Introduction of new technology (NATCON)
• “With no reduction in safety or service to
customers”
http://bora.nhh.no/bitstream/2330/1916/1/lofquist%20avh2008.pdf
3-year longitudinal case study focusing on
four latent constructs:
• The leadership’s role in the context of strategic
change in an HRO
• Organizational culture (how safety culture/climate
contribute to safety)
• Organizational change (matching change
implementation type with culture in place)
• Safety (classical measures vs. changes in individual
perceptions of safety over time)
http://bora.nhh.no/bitstream/2330/1916/1/lofquist%20avh2008.pdf
Research Design
Literature review
Archival data search
–Internal publications/PowerPoint presentations
–Strategy, SMS, Take-Off 05 project, etc.
Three month orientation (HQ/site visits)
Leader group observations
Key informants
Semi-structured interviews (57)
http://bora.nhh.no/bitstream/2330/1916/1/lofquist%20avh2008.pdf
Data collection
• Extensive primary and secondary data from numerous
sources both internal and external
– Observational data (field notes, meetings, presentations, telepone
conversations, etc.)
• Qualitative data
– Semi-structured interview data (57 one-hour interviews)
• Quantitative data
– 2x Internal Leadership Questionnaires
– SHT Safety Questionnaire data
• Secondary data – DNV report/Media articles/other studies
http://bora.nhh.no/bitstream/2330/1916/1/lofquist%20avh2008.pdf
Data set
http://bora.nhh.no/bitstream/2330/1916/1/lofquist%20avh2008.pdf
Integrated Safety Management System
(Lofquist, 2008)
Proactive
Phase
Interactive
Phase
Reactive
Phase
System Design System Operation System Outcomes
Time
Organizational Culture
Environment
3 internal cases - tower, approach and ATCC
services at three locations:
Oslo (Gardermoen/Røyken)
Stavanger
Bodø
4 embedded cases (Oslo, Stavanger, Bodø,
Trondheim ATCCs)
http://bora.nhh.no/bitstream/2330/1916/1/lofquist%20avh2008.pdf
Research Design (2)
http://bora.nhh.no/bitstream/2330/1916/1/lofquist%20avh2008.pdf
Conceptual causal model
Culture
+
+
+
+
+
Leadership
Change Safety
Hypothesized relationships
• 1) How does the interaction between leadership choices
and organizational culture type affect attitudes toward
deliberate strategic change in a high reliability
organization?
• 2) How do the relationships between leadership actions
during strategic change, safety climate in place, and
employee attitude toward change, affect safety as an
outcome variable?
http://bora.nhh.no/bitstream/2330/1916/1/lofquist%20avh2008.pdf
Research questions
• Part 1 – Introduction
– Chapter 1 – Introduction and positioning
– Chapter 2 – Phenomenon
• Part 2 – Literature review
– Chapter 3 - Literature review
• Part 3 – Method
– Chapter 4 - Methodology
• Part 4 – Results
– Chapter 5 – Chronological events
– Chapter 6 – Mapping the effects of change
– Chapter 7 – Snapshot of safety
– Chapter 8 – Summary of empirical findings
http://bora.nhh.no/bitstream/2330/1916/1/lofquist%20avh2008.pdf
Thesis outline
Thesis outline (2)
• Part 5 - Discussion and conclusions
– Chapter 9 – Discussion, recommendations, and future research
– Chapter 10 – References
– Chapter 11 - Attachments
Chapter 5
(Leadership choices leading to collapse)
• Chronological account of Take-Off 05 project
– Timeline (Jan 2000 – Jan 2006) - Need for change
– Detailed description of Take-Off 05 planning and implementation
processes
– Focuses on 2 key events (decisions) in 4 embedded cases -
processes leading to these decisions
– Internal and external reactions by key stakeholders
Chapter 5 - findings
• Participative process turns distinctively top-downleading to loss of consensus and trust, and leads to resistance and eventual failure of Take-Off 05 project
• Organizational mismatch between culture type and implementation method
• Demonstrated how incremental changes cansignificantly effect change implementation success
• Effects of external stakeholders
– Owners/Regulators/Government
– Public/Media
Chapter 6
(Mapping the effects of change)
• Mixed-methods approach for triangulating leadership
questionnaire data and semi-structured coded data
– Before the change process (2002)
– Turbulent 12-month period in (2005)
Across-case and within-case analyses of 4 embedded
cases (Bodø, Trondheim, Oslo, and Stavanger
ATCCs) experiencing 3 different phases of a
common change process
Leadership group statistics – all units
Trondheim
2002
Bodø
2002
Oslo
2002
Stavanger
2002
Bodø
2004
Oslo
2004
Stavanger
2004
(V01) Leader
Motivates
5.00 5.00 3.67 3.97 3.30 6.02 5.57
(V07) Leader
Discussion
5.38 4.81 3.87 2.97 3.62 6.38 5.54
(V19) Leader
Distributes
information
5.21 4.64 3.98 3.53 3.71 6.28 5.69
(V25) Leader
unity/commitment
5.03 4.34 3.56 3.37 3.20 6.37 6.06
(V41) Trust in
Leader
6.20 5.84 4.26 4.37 4.17 6.64 6.46
(V73) Top Leader
performance
3.38 3.48 3.54 2.37 1.48 1.13 1.89
Local leadership quote
• “The leadership’s contribution to the local
working environment is not impressive … they say
things that demonstrate that we live in two
separate worlds in many respects. Many times I
have actually wondered if we work in the same
company. It might be that they have a special focus
on greater things but it is not good when it turns
into a war.” (Bodø 06)
Chapter 6 - findings
• Reactions are predictably different between cases in
all areas except questions pertaining to top leadership
• Effect of Leadership commitment to safety most
significant finding
Chapter 7
(A snapshot of safety)
• Snapshot of safety
• Test conceptual causal model using the 4 refined
latent constructs in a structural equation model using
a multivariate data analysis technique (Lisrel)
• Turbulent 12-month period (2005)
Refined conceptual causal model
Perception of
Safety
Culture
+
+
+
+
+
Perceptions of
Leadership
Commitment
Attitude toward
Change
Perception
of Safety
Hypothesized relationships
Safety Measurement Model Results
Perception of
Safety
Culture
0.64
0.54
0.25
-0.02
0.28
Perceptions of
Leadership
Commitment
Attitude toward
Change
Perception
of Safety
RMSEA = 0.030 (Root Mean Squared Error of Approximation)
Total causal effect of 0.72
Chapter 8
(Summary of empirical findings)
• Chapter 5 presents the events leading to collapse of
the Take-Off 05 project
• Chapter 6 shows how individuals experience
different phases of a common change process
(embedded cases)
• Chapter 7 gives a snapshot of the relationships
between the latent variables in the conceptual model
Academic contributions
• Insights into the effects of deliberate organizationalchange on safety in a High ReliabilityOrganization
• How a mismatch between organizational culturetype and change implementation type can effectchange outcomes
• How perceptions of leadership commitment effectsattitudes toward change and perceptions of safety
Academic contributions (2)
• The value of using safety audits and structural equation modelling as proactive indicators of changes in safety
• Based on the results of the SEM model and thewithin-case/across case analyses it is clear thatsafety was negatively affected during the Take-Off05 process