Thursday, October 11, 2022 • 10:00 a.m. – 10:30 a.m. • Location: Reno Ballroom

Mark Alavosius Ph.D.
Founder and President
Praxis2LLC
University of Nevada, Reno

High-reliability organizations (HROs) emerged across highly technical, and increasingly automated industries (e.g., aviation, aerospace, medicine, nuclear power, and oilfield services) where precise and prolonged operations are essential. HROs rely on complex human-machine systems to control deviations from optimal practice. Usually these systems extend over a large number of employees working in dynamic, and potentially dangerous environments. Effectively managing behavioral contingencies in HROs, to simultaneously promote safe but also efficient behaviors is a daunting task and notable failures reveal behavioral sources of catastrophic loss.

Investigations of the loss of NASA’s Challenger space shuttle revealed systematic sources of procedural deviation in critical flight operations over time. More recently, BP's oilrig disaster in the Gulf of Mexico (Macondo) was another bellwether event signaling the importance of managing interlocking human factors in HROs to avert disaster. Other examples are common and human behavior is widely seen as a main contributor to loss events in HROs.

Thomas Gilbert’s book (1978, 2007) titled “Human Competence” looked beyond training toward a rigorous approach to identifying sources of behavioral variation, engineering controls, and improving performance in organizations.  His behavior-engineering model (BEM) has guided behavior analytic research and applications with an emphasis on coherence, elegance and usefulness of behavioral methodologies. Throughout the past four decades, Gilbert's BEM provides strong foundation for behavioral systems engineering to establish and maintain adherence to work routines in highly engineered, highly technical environments (e.g., aviation, nuclear power, oil & gas exploration, medicine).

Two behavioral challenges face managers of HROs:

1. First, crews need to follow well-established procedures with little deviation to achieve milestones.
2. Second, on occasion, crews encounter anomalies not addressed in standard work instructions. During these crises, crews must stop following standard procedures, assess changing conditions and adapt their behavior to the unexpected events to avert catastrophe.

Crew Resource Management (CRM) is emerging in HROs as an approach for training and sustaining essential behaviors within work teams engaging with increasingly automated processes. CRM provides a competency framework that enables team adherence to standard work instructions while, at the same time, encourages adaptive variance in responding to effectively manage crises that depart from normal routines. 

Behavioral systems engineering integrates critical work behaviors understood via BEM with team coordination behaviors (CRM). The goal is to lead and manage human competence within increasingly automated systems so that complex processes adapt to changing contexts. As work becomes more automated, the human factors will increasingly focus on crew coordination, communications, and decision-making in the context of data-rich control systems.