Managing the Unexpected

I’m just reading “Managing the Unexpected” by Weick and Sutcliffe.

It talks about how high-reliability operations (HROs) such as Accident and Emergency centres, Aircraft Carriers, Nuclear Power Stations ensure they have fewer than their share of “brutal audits” (aka disasters) despite having a very high potential for them.

The key attributes they identify of such high reliability organisations are:

  1. Track small failures
  2. Resist oversimplification
  3. Remain sensitive to operations
  4. Maintain capabilities for resilience
  5. Take advantage of shifting locations of expertise

Reading this, I have been struck by parallels with the Lean Principles (in particular as presented by Mary and Tom Poppendieck).

Track small failures = stop the line mentality.  Don’t let errors build up, but spot them early and fix them early.  If something unexpected happens, stop there until you understand it and know how to handle it.

Remain sensitive to operations = push responsibility down.  Make sure the people with the knowledge to understand the situation are empowered to deal with (and/or escalate) problems – but make sure they have backup they can call on when the situation moves beyond their area of expertise.  An example was cleaners at a nuclear power station were changing air filters every couple of days because of rust.  After about six months, it was discovered a section of the 6 1/2 inch-thick containment chamber had corroded to the width of a pencil eraser.  If someone had thought that changing the filters every couple of days wasn’t right, this might have been spotted before it got so perilously close to a disaster.

Maintain capabilities for resilience = decide as late as possible.  The example given here is Fedex.  Every evening 20 to 25 of their fleet of airplanes start their journey to the Memphis hub only 60% full.  This means there is spare capacity if they get a late addition, which can be diverted if necessary.  To control this, they say the plane MUST arrive at the hub by 1:30am.  If extra time for the diversion plus half an hour on the ground for loading still allows the 1:30 arrival, it is authorised.  Otherwise the extra load is delayed – don’t jeopardise the whole flight on the chance of making up ground.

You can find Managing the Unexpected on Amazon.

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One Response to Managing the Unexpected

  1. Pingback: Communicate for resiliency « Badger Taming

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