FEATURED BLOG

Author: David Wilbur, CEO - Vetergy Group

To begin we must draw the distinction between error and failure. Error describes something that is not correct or a mistake; operationally this would be a wrong decision or action. Failure is the lack of success; operationally this is a measureable output where objectives were not met. Failures audit our operational performance, unfortunately quite often with catastrophic consequences; irredeemable financial impact, loss of equipment, irreversible environmental impact or loss of life. Failure occurs when an unrecognized and uninterrupted error becomes an incident that disrupts operations.

Individual Centered Approach

The traditional approach to achieving reliable human performance centers on individuals and the elimination of error and waste. Human error is the basis of study with the belief that in order to prevent failures we must eliminate human error or the potential for it. Systems are designed to create predictability and reliability through skills training, equipment design, automation, supervision and process controls.

The fundamental assumptions are that people are erratic and unpredictable, that highly trained and experienced operators do not make mistakes and that tightly coupled complex systems with prescribed operations will keep performance within acceptable tolerances to eliminate error and create safety and viability.

This approach can only produce a limited return on investment. As a result, many organizations experience a plateau in performance and seek enhanced methods to improve and close gaps in performance.

An Alternative Philosophy

Error is embraced rather than evaded; sources of error are minimized and programs focus on recognition of error in order to disturb the pathway of error to becoming failure. 

Slight exception notwithstanding, we must understand people do not set out to cause failure, rather their desire is to succeed. People are a component of an integrated, multi-dimensional operating framework. In fact, human beings are the spring of resiliency in operations. Operators have an irreplaceable capacity to recognize and correct for error and adapt to changes in operating conditions, design variances and unanticipated circumstances.

In this approach, human error is accepted as ubiquitous and cannot be categorically eliminated through engineering, automation or process controls. Error is embraced as a system product rather than an obstacle; sources of error are minimized and programs focus on recognition of error in order to disturb its pathway to becoming failure. System complexity does not assure safety. While system safety components mitigate risk, as systems become more complex, error becomes obscure and difficult to recognize and manage.

Concentrating on individuals creates a culture of protectionism and blame, which worsens the obscurity of error. A better philosophy distributes accountability for variance and promotes a culture of transparency, problem solving and improvement. Leading this shift can only begin at the organizational level through leadership and example.

The Operational Juncture™

In contrast to the individual-centered view, a better approach to creating Operational Resilience is formed around the smallest unit of Human Factors Analysis called the Operational Juncture™. The Operational Juncture describes the concurrence of people given a task to operate tools and equipment guided by conflicting objectives within an operational setting including physical, technological, and regulatory pressures provided with information where choices are made that lead to outcomes, both desirable and undesirable.

It is within this multidimensional concurrence we can influence the reliability of human performance. Understanding this concurrence directs us away from blaming individuals and towards determining why the system responded the way it did in order to modify the structure. Starting at this juncture, we can preemptively design operational systems and reactively probe causes of failure. We view a holistic assignment of accountability fixing away from merely the actions of individuals towards all of the components that make up the Operational Juncture. This is not a wholesale change in the way safety systems function, but an enhanced viewpoint that captures deeper, more meaningful and more effective ways to generate profitable and safe operations.

A practical approach to analyzing human factors in designing and evaluating performance creates both reliability and resilience. Reliability is achieved by exposing system weaknesses and vulnerabilities that can be corrected to enhance reliability in future and adjacent operations. Resilience emerges when we expose and correct deep organizational philosophy and behaviors.

Resilience is born in the organizational culture where individuals feel supported and regarded. Teams operate with deep ownership of organizational values, recognize and respect the tension between productivity and protection, and seek to make right choices. Communication occurs with trust and transparency. Leadership respects and gives careful attention to insight and observation from all levels of the organization. In this culture, people will self-assess, teams will synergize and cooperate to develop new and creative solutions when unanticipated circumstances arise. Individuals will hold each other accountable.

Safety within Operational Resilience is something an organization does, not something that is created or attained. A successful program will deliver a top-down institutionalization of culture that produces a bottom-up emergence of resilience.

These days, many enterprise-level organizations are likely to have similar operations in multiple locations regionally or even worldwide. When a piece of equipment fails or a safety incident occurs at one site, the company investigates the problem and identifies solutions or corrective actions. Naturally, the team wants to capture the lessons learned and share them with other sites that have similar equipment, processes and potential incidents. 

Advanced tools like the RealityCharting® software enable teams to share results of an Apollo Root Cause Analysis (RCA) across multiple layers of stakeholders. However, a large multinational enterprise might have dozens of different investigations going on at any given time. At the highest levels, decision-makers don’t necessarily want to see granular information about specific causes at any given plant. They need a top-down perspective of problems and patterns that are affecting the entire organization.

At ARMS Reliability, many of our clients have expressed a similar need. Our solution? Using classification tags to create and apply a consistent taxonomy to all root cause analyses performed for a given organization. Rolled up into a composite report, these tags reveal enterprise-wide trends and issues, allowing management to create action plans for tackling these systemic issues. For example, classification tags might uncover a large number of problems related to a lack of preventative maintenance on a certain type of pump, or a systemic non-compliance with a required safety process.

A classification taxonomy can be scalable and configured to an organization's goals and processes. Think of these classifications like buckets that can be applied at any level of the RCA — e.g., to the root causes or solutions, to individual contributing causes, or simply to the RCA investigation in general.

 Keep in mind: The Apollo Root Cause Analysis method is centered around a free-thinking approach to solving problems. That’s what makes the methodology so powerful — it doesn’t lead you down any generic predetermined pathways by asking leading questions or categorizing various causes or effects in any way. At ARMS Reliability, we advocate applying classification tags only after the root cause analysis investigation is completed, so you keep the free-thinking causal analysis and organize it later, for the purpose of rolling the findings up into a deeper systemic view.

Taxonomies can range from 5–20 categories into the hundreds. For example, here we’ve used a human factors taxonomy to tag causes as organizational influences and other people-centric issues.

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Reports can provide a summary of how many causes were classified under the various tags:

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In another example, an organization bases its taxonomy of reliability issues on the ISO 14224 - Collection and exchange of reliability and maintenance data for equipment.

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The taxonomy options are endless. Most organizations we work with have their own unique systems of classifications. It’s really all about codifying the types of information your organization most needs to capture.

If adding classifications to your Root Cause Analyses would be useful for your organization, contact ARMS Reliability. We’d be glad to show you more about what we’re doing with other clients and help you develop a taxonomy that works best for your needs.