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High Reliability, High Risk Organizations....

Carmen A. Medina-apparently recovering from pneumonia-but you can also find her on recoveringfed.com and follow her on Twitter @milouness. High Reliability, High Risk Organizations. Are determined to avoid failure, so they think about failure a lot. They study it carefully when it happens.

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High Reliability, High Risk Organizations....

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

  2. High Reliability, High Risk Organizations.... 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 justto organizational relationships and hierarchy.

  3. from mikerbaker.com

  4. 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 1414:FIRST ENERGY'S ALARM AND LOGGING SOFTWARE FAILS. 1420:  REMOTE CONSOLES BEGIN TO FAIL.  IT STAFF PAGED. 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.

  5. Cleveland must be sacrificed!!!!!

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

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

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

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

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

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