Carmen A. Medina-apparently recovering from pneumonia-but you can also find her on recoveringfed.com and follow her on

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Presentation transcript:

Carmen A. Medina-apparently recovering from pneumonia-but you can also find her on recoveringfed.com and follow her on

Are determined to avoid failure, so they think about failure a lot. They study it carefully when it happens. Do not simplify easily or prematurely. They're OK with messy. They worry more about jumping to conclusions. Are designed for resilience--multiple eyes, 360 degrees awareness. Are operations and process-oriented. They care about the means--the ends can never justify the means because you are always striving to identify predictable, reliable causal relationships. Defer to knowledge and expertise, i.e. not just to organizational relationships and hierarchy. High Reliability, High Risk Organizations....

from mikerbaker.com

1215: MISO operator forgets to turn the STATE ESTIMATOR back on. THINKING THE SYSTEM HAS BEEN SUCCESSFULLY RESTORED, THE ANALYST WENT TO LUNCH. 1331: EASTLAKE 5 OHIO GENERATION PLANT TRIPS AND SHUTS DOWN. 1402: The STUART/ATLANTA LINE FAILS 1420: REMOTE CONSOLES BEGIN TO FAIL. IT STAFF PAGED. 1414:FIRST ENERGY'S ALARM AND LOGGING SOFTWARE FAILS. 1427: STAR/SOUTH CANTON LINE TRIPS. 1441: PRIMARY SERVER FAILS AT FIRST ENERGY. IT STAFF PAGED. 1454: BACKUP SERVER FAILS AT FIRST ENERGY. IT STAFF PAGED. 1505: THE THIRD LINE, THE HARDING/CHAMBERLAIN LINE, FAILS due to tree contact. 1532: THE HANNA/JUNIPER LINE SAGS INTO A TREE AND FAILS. 1541: THE STAR/SOUTH CANTON LINE, OWNED BY FE AND AEP, FAILS AND BLOWS A CIRCUIT BREAKER CONNECTING THE TWO GRIDS. MANY OTHER LINES FAIL. 1546: THE TIDD/CANTON CENTRAL LINE TRIPS. 1605:57: THE SAMMIS/STAR LINE FAILS.

Cleveland must be sacrificed!!!!!

Dealing with the Normal Dealing with Complexity Reducing Redundancy Promoting Ownership Modeling Success and Failure Utilizing Spare Capacity Making Better Use of Talent Seeing the Whole

Dealing with the Unusual Sensitive to Weak Signals Accommodate Irrationality Exercise Emergencies

Dealing with Knowledge Reduce mental errors Create Exponential Wisdom Weakest Links?

There are Downsides... New styles for managers New types of employees New roles and expectations New performance metrics, system analytics Theoretical Deficiencies

Comprehensive Diverse Redundant Scaleable Quick and Agile Transparent Preferred Qualities of Terrorism Threat Analysis