2024 Community of Human and Organizational Learning 30th Annual Conference

This session proposes a new approach to strengthening mission success and preventing failures by addressing human error at a cultural level. Traditional efforts have been focused on optimizing either safety or production, often at the cost of the other. The Framework of Risk Awareness for Mission Excellence (FRAME): High Consequence Events Prevention (HCEP) utilizes a taxonomy of behaviors to establish a Risk Aware Culture and ultimately support the ideal balance of safety and production. This session will illuminate the benefits of defining and implementing a Risk Aware Culture and provide practical guidance on how to do so.
FRAME began with the comprehensive investigation of numerous high consequence events across recent decades, during which the meltdown of the Fukushima nuclear powerplant highlighted a key concept. Tokyo Electric Power Company was staffed with skilled, technically competent people, yet the company did not effectively exercise that competence in the years before the disaster, resulting in major environmental damage and distrust toward a key energy source for Japan. The Chairman of the investigation identified “ingrained conventions of Japanese culture” to be the fundamental cause of the incident, specifically calling out several human element weaknesses central to their cultural failings. Similar manifestations of organizational cultures lacking risk awareness can be found repeatedly across scores of accidents analyzed from many domains (public and private).
Today, most analyses of accidents focus on learning from technical failures but fail to consider the role of the human element in the decision-making process. There are many examples illustrating the pitfalls of ignoring the human element, including the loss of the Space Shuttles Challenger and Columbia. A surface level understanding of these incidents would call out an O-ring failure and a foam strike on lift off, respectively. However, to really understand the root of these failures we need to understand why decisions were made. Why did Challenger launch after engineers warned of the O-ring risk in cold weather? Why were the foam strikes seen on every prior shuttle Columbia launch not fully investigated? FRAME focuses on getting to the final “why,” to the underlying Human Element Weaknesses that influence decision making. Once identified, Risk Aware Behaviors can assist with corrective actions that address the human root causes.
Developing the deliberate design for an organizational cultural can be daunting. FRAME provides both the structure to understand why decisions that led to failures were made and the tools to promote a Risk Aware Culture. Throughout the session, we plan to discuss key lessons learned during the design, development, implementation, and measurement of FRAME in a real-world setting. Furthermore, this session will arm attendees with a deeper understanding of the role of human error in decision making, citing real-world examples. Finally, attendees can expect to get exposure the specific behaviors that, if consistently and correctly demonstrated across an organization, can act to mitigate risk.