Tuesday, July 24, 2012

Errors, Misjudgments and Dishonesty- Building Barriers and Safeguards against Error

Accepting the premise of Reasons' work...that there are both personal and systems categories of error... what is it exactly that great leaders do to build defensive barriers and safeguards...the layers of Swiss cheese in his model?
Well documented standard operating procedures and discipline around execution of those procedures is a great place to start.   ExxonMobil's Operations Integrity Management System(OIMS) is a great example of just such a set of standard operating procedures and they have a well known record of discipline around execution of this system. Another is simply good project management/stage gate methodology...conducting appropriate reviews, challenge sessions and taking incremental decisions in the life of project development..  A third barrier would include simulations.  There are many different kinds of simulations from individual to team to large scale computer driven "war-games".  Flight and driving simulators are well known and widely used at the individual level .  There are also drilling simulators in the oil and gas field where operators can simulate the drilling of a well and the various circumstances that a driller can encounter.  The essence of all simulations is to place individuals or teams in an environment where they can practice without the risk or expense of actual error.  Good simulations can also allow for the introduction of low probability, high risk events.   Last, good emergency response/crisis management plans that are practiced, critiqued and refined is yet a fourth barrier.

All of these barriers exist in the context of a company culture.  Great leaders create not only the systemic barriers but the culture that leads to high reliability.

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