The Electric Utility as a Complex Adaptive System

Transcription

1 Preparing for the Distribution System of the Future The Electric Utility as a Complex Adaptive System Source: IEEE Control Systems Magazine Dec 2001 Gary Wong, P.Eng., MBA DALCM Spring Meeting

2 How will the Distribution System of the Future impact Safety?

3 Why pay attention to Safety Culture Peter Drucker

4 In Healthcare, the natives are revolting

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6 Evolution Of Safety Thinking AGE OF TECHNOLOGY Scientific Management Reductionist thinking Humans are cogs in a machine Root Cause Analysis Boss-based safety culture Safety-I: what s going wrong AGE OF HUMAN FACTORS Leadership vs. Management Humans are hazards who need to be constrained Behaviour-based safety Compliance training & auditing Rules-based safety culture AGE OF SAFETY MANAGEMENT Engineering systems thinking Humans are heroes working in an inherently hostile environment Just Culture Safety & Productivity trade-off Values-based safety culture Safety-II: what s going right AGE OF APPLIED COMPLEXITY Biological evolutionary thinking Humans are storytellers Resilience vs. Robustness Emergence vs. Reductionism Networks and group wisdom Safety & Productivity: both/and Safety measurement: Impact vs. Outcome

7 Evolving from Safety-I to Safety-II THEORY OF ACTION Focus and appreciate the barely noticeable traits of everyday safe SYSTEMS and productive. THINKING Understand how the THEORY OF system adjusts and ERROR adapts under THEORY OF ERROR AnalyzeAnalyse accidents expected and accidents as as system failure. system failure. Avoid unexpected conditions SCIENTIFIC Avoid unacceptable unacceptable risk with MANAGEMENT and compliance risk withrules rules and Focus on what compliance goes wrong Focus on what goes wrong because we because we we assume assume things are things are ordered Safety-I Safety-I Safety-II ordered Copyright 2014 Cognitive Edge. All Rights Reserved.

8 SAFETY-I + SAFETY-II Different but not either/or... it s both/and Safety-I Safety-II Minimize number of failures. Build system to take a hit. See humans as potential hazards in a work-as-imagined process. Create many rules to induce behaviour compliance. React, Check, Control to stay within system parameters and avoid unacceptable risk. Accept failure to learn & adapt. Build capacity to self-heal, recovery quickly. See humans as heroes working in a naturally dangerous environment. Provide few simple principles to guide behaviour. Respond, Learn, Monitor, and Anticipate to understand and adjust system safety boundaries. Focus on robustness. Focus on resilience.

9 Survey and interview techniques are flawed Get invited into the room when the stories are being told Instead of interviewing, run storytelling sessions

10 Data Visualization: Safety Culture displayed as a 3D Landscape Valleys represent stability Peaks represent instabilities which are both threats or opportunities Yellow dots are Outliers Copyright 2014 Cognitive Edge. All Rights Reserved.

11 Ask your Safety professionals one question: Do you believe by focusing on the small stuff a Major injury will be prevented?

12 Preparing for the Distribution System of the Future The Electric Utility as a Complex Adaptive System Gary Wong, P.Eng., MBA 1960 Cypress St., Vancouver, BC, Canada V6J 3L8 GaryWong@gswong.com (604)