Ch 9 Maintaining High Reliability

Question 1

Behaviors and practices that are essential for team leaders to remain vigilant, ensure a safe workplace, and minimize errors are known as _____________

Answer 1

high reliability behaviors

Question 2

_______ operate in high-risk environments; yet strive to maintain a learning environment so as to minimize the chances of error.

Answer 2

High reliability organizations

Question 3

Critical components that make up on HRO are also those that fit tightly with a just culture and an _________, such as crew resource management which relies on collective situational awareness.

Answer 3

open communications model

Question 4

an inclination towards inquiry and doubt as a means of evaluating and updating standard procedure, attention to the complexities of an emergency incident, commitment to resilience, and a willingness to defer expertise.

Answer 4

Mindfulness

Question 5

one’s susceptibility to falling into a routine and not paying attention to the small cues that accumulate overtime into one major incident

Answer 5

Mindlessness

Question 6

When people are expected to perform their jobs in a particular manner without deviation, when they work under severe time pressure, or when they are tired, they have a tendency to become __________ and operate as if by remote control

Answer 6

mindless

Question 7

If any specific pieces of CRM can serve as keystones, they are the part of the ________ that provide team members the ability to inquire, expressed doubt or concern, and update the team on whether the current plan is working

Answer 7

communication loop

Question 8

Expressing concerns or doubts is a necessary component of healthy, effective team _______

Answer 8

communication

Question 9

Creating a culture that allows people to openly question the reason behind __________ is critically important to successful CRM

Answer 9

actions, decisions, and behaviors

Question 10

_________ are immediate details that need to be addressed.

Answer 10

Micro issues

Question 11

_______ are long term effects of the decision or larger concepts

Answer 11

Macro issues

Question 12

In the CRM loop, ________ typically takes place during the “observe and critique” phase.

Answer 12

updating

Question 13

Updating involves sharing critical information that is necessary for __________

Answer 13

collective situational awareness

Question 14

Updating, evaluating performance, and critiquing are necessary for all members of the HRO to have a ____________ of the entire situation

Answer 14

conscious understanding

Question 15

A _____________ is important for HROs because they instinctively know that success might be the result of luck, or of a well-developed process or procedure, or because the failure points of the outwardly successful incident have not yet been identified

Answer 15

focus on failure

Question 16

The slow uncoupling of policy and actual procedure. It may be caused by complex systems.

Answer 16

Practical Drift

Question 17

Practical drift is used to describe how policies and procedure become ___________ for most operators, particularly veterans.

Answer 17

background context

Question 18

One place where simplification can be helpful is in __________; this can reduce operational ambiguity, improve training, and reduce errors related to equipment unfamiliarity.

Answer 18

standardizing equipment

Question 19

The most expeditious and common response to an accident or unwanted outcome is to _________

Answer 19

blame the operator (Pilot error)

Question 20

HROs focus on ______ because that is where the true learning is

Answer 20

failure

Question 21

Operations that are taking place in high complex, dynamic, and dangerous environments is where reactions and protocols that operators on the street employ are more than likely ___________.

Answer 21

third order controls

Question 22

This means operators will more likely use procedures that align with organizational cultures, stories associated with previous outcomes, and repetitive high fidelity training

Answer 22

Third Order Controls

Question 23

One resilient behavior is instituting, supporting, and continuing _________, which is situation based, hands on, low-frequency, high risk event practice, where teams and individuals are regularly tested under ambiguous and demanding dynamic conditions

Answer 23

high fidelity training

Question 24

An important attribute for the high reliability team is a collective understanding related to the power of the team’s _________

Answer 24

diversity

Question 25

Resilient teams respond better to stress, they learn from their mistakes, and they tend to view bad outcomes through a lens that allows personnel and __________

Answer 25

organizational forgiveness.