The Weekly Reflektion Week 19 / 2020

In last week’s Reflektion we described two near misses in the aviation industry where the resilience of the air crew was a factor in the prevention of a disaster. This week we will present some of our ideas on how resilience can be developed in an organisation. In order to do this, we would like to extend our definition of resilience in order to provide a better context. The definition we will use is from Erik Hollnagel an internationally recognized specialist in the field of resilience engineering.

Resilience is the intrinsic ability of a system to adjust its functioning before, during or after changes and disturbances so that it can sustain required operations under both expected and unexpected conditions.

Predicting all the situations and circumstances that we and our organisation will be subject to in the future is an impossible task. We can hope that we are able to cover the vast majority of these in our procedures and practices and in the training and exercises for the people in our organisation. When the unexpected and unpredictable happens the ability of our organisation to respond is critical to the prevention of tragedy. Resilience is a key factor in this response.

Qantas Flight 32 was a flight from London to Sydney via Singapore. On November 4, 2010, the aircraft operating the route, an Airbus A380, suffered an uncontained failure in one of its four Trent 900 engines. The crew managed a situation where the aircrafts’ systems were severely compromised, and the scenario had not been anticipated hence was not part of simulator training. Air Canada Flight 143 was on a domestic passenger flight between Montreal and Edmonton that ran out of fuel on July 23, 1983, at an altitude of 41,000 feet (12,000 m). The crew was able to glide the Boeing 767 aircraft safely to an emergency landing at a former Royal Canadian Air Force base in Gimli, Manitoba. The aircrew had not trained for loss of both engines and non-powered landings.

The resilient organisation is prepared for surprises and has an ability to improvise when the unexpected occurs. Improvisation must be within limits to ensure that the improvised actions do not make the situation worse. These limits may not have distinct boundaries due to the nature of the situation and the associated uncertainties.

One of the most important factors in a resilient organisation is the competence and experience of the people and their understanding of the facility and how it works. Maintaining competence is important. Maintaining experience is not so easy. One of the paradoxes of operations is that the more efficient and reliable the operation becomes, the fewer opportunities the organisation has to react to and test themselves in both known and unknown disturbances. How do you keep your organisation sharp while at the same time maintaining stable operations with no incidents and accidents?

‘What if’ scenarios can be used to stimulate discussion within the organisation and to propose and debate ways to handle the scenarios. Developing ‘what if’ scenarios requires imagination and it may be necessary for a facilitator to get the ball rolling and help the organisation with the process. Once the process is established however, it is usually received as being positive and stimulating for the people involved. An important prerequisite is that the organisation is given time to carry out the process. New scenarios can be built into simulators and used for training purposes. ‘What if’ scenarios can also be developed based on incidents or near misses on the facility or incidents and even Major Accidents on other facilities. One example used on a facility we have worked on was:

Provide the organisation with the executive summary of the Cullen Report into the Piper Alpha disaster and ask two questions:

In previous Reflektions we have talked about a pre-mortem approach to Major Accidents. Ask the organisation to construct a Major Accident based on a realistic sequence of events that could be based on real and imaginary incidents. Then ask the organisation to:

Both approaches require discussion around the technical, operational and organisational factors and should also address behaviour in handling the situation. and how this can be affected in tackling the situation. For example, handling stress, the importance of leadership, risk assessment and mitigation. How the organisation will behave in the situation is an important area to discuss since it brings in aspects of the culture in the company and on the facility. For example, trust between the people involved and towards the people tasked with taking decisions and the confidence that people will behave in a predictable and rational manner.

Another important aspect of understanding resilience is the investigation of incidents and near misses where resilience was an important factor in preventing a disaster. We have mentioned Quantas flight 32 and Air Canada flight 143. Next week we will look at the resilience of the offshore organisation in the response to the Snorre ‘A’ blowout on the 28th November 2004. 

Reflekt AS