1. OrganizationalDevelopmentJournalVolume25•Number4•WINTER2007

2. PUBLISHER
Dr. Donald Cole, RODC
Organizational Development Institute
11234 Walnut Ridge Road
Chesterland, OH 44026 USA
DonWCole@aol.com
EDITOR
Thiet K. Nguyen
tkn4@columbia.edu
MANAGING EDITOR
Elaine Steiner
ELAINE.STEINER@chanelusa.com
PEER REVIEW EDITOR
Dianne Clarke-Kudless, PsyD, MBA
dc-k@att.net
ASSOCIATE PEER REVIEW EDITOR
(REGULAR EDITION)
Virginia Bianco-Mathis, PhD
Virginia.mathis@marymount.edu
COPY EDITOR
Hania Qubein
hqubein@comcast.net
TECHNICAL EDITOR
Lucille Maddalena, EdD
Lucille@mtmanagement.net
STAFF EDITORS
Sandy Becker
Becker23s@yahoo.com
Andrew Cohn, JD
Andrew@lighthouseteams.com
Elena Feliz
felizelena@aol.com
Linda Myers, EdD, SPRH, GPHR
Linda_Myers@post.harvard.edu
GUEST EDITOR
Sharon Snyder
djs.snyder@patmedia.net
GRAPHIC DESIGN
Rita Witherly, MBB, MBA
Rita.witherly@moZenInc.com
Don Michalowski
don@rubywindow.com
ASSISTANT EDITOR
Gail Smith
Gatismi081@aol.com
Copyright © 2007 by the
Organization Development Institute
ISSN Number 0889-6402:
The Library of Congress
The Organization Development Journal is an international peer reviewed
journal published quarterly and is abstracted in Psychologizal Abstracts,
PsychINFO, PsychAlert, Psylit, Institute for Scientific Information and Anbar
Management Publication databases.The Organization Development Journal
enhances the capacity for practitioner-scholar dialogue and promotes
principles and practices of organizational development and change.
Submissions to the journal are encouraged on an ongoing basis.
Manuscript submission information can be found in this issue. Authors
who are not already receiving the OD Journal, will receive one compli-
mentary copy of the journal in which their article appears. Articles
should be submitted to Wei Huang, PhD, Managing Editor (Regular
Edition), at weihuang@nyu.edu.
Copies of the journal are provided as part of membership in the OD
Institute. Information on becoming a member can be found in this issue.
A subscription is US $100 per year for four copies. Single issues are
available at US$25; however, pre-publication orders are suggested since
quantities are often limited. Undeliverable copies due to address change
normally will not be replaced. People who receive the OD Journal
should notify the Post Office to guarantee forwarding to your new ad-
dress. Reprints can be requested at ProQuest, PO Box 1346, Ann Arbor
MI 48106-1346, tel: 800-521-0600; homepage: www.il.proquest.com.
Advertising information and rates for the journal can be obtained by
writing to Dr. Donald Cole, at DonWCole@aol.com.
Reprint Permission is granted to university or college faculty member
for reprinting single articles for in-classroom use if proper citation
accompanies each copy. All other reprint requests must be made in
writing to the Publisher.
ADVISORY BOARD MEMBERS
Dr.Terry Armstrong, RODC, (Former Editor)
Dr. Joseph Cangemi, RODP (Former Editor, Western Kentucky University
Dr. Allan H. Church, RODC (Former Editor), Pepsico, Inc.
Dr. Donald W. Cole, RODC (Publisher), Organization Development Institute
Dr. Robert T. Golembiewski, RODC, University of Georgia
Dr. Marilyn Laiken, RODC, University of Toronto
Dr. Jeanne Maes, RODP, University of South Alabama
Dr. Kenneth L. Murrell, University of West Florida
Dr. Peter F. Sorenson, Jr., RODC, Benedictine University
Thiet K. Nguyen (Editor), Johnson & Johnson

3. Table of Contents
From the Editor
Best Global Practices in Internal Organization Development ........................................................................... 3
Thiet (Ted) Nguyen, Johnson & Johnson
Articles
CHANGE MANAGEMENT AND CULTURAL INTERVENTION
Collaborate for Growth: Deepening Involvement through Hope ...................................................................... 13
Mike Markovits, IBM
Kristin von Donop, Cambridge Leadership Associates
Developing the Performance Culture .......................................................................................................... 19
Ellen Raynor, MMckesson Medical-Surgical
Employees CAN Make a Difference! Involving Employees in Change at Allstate Insurance ....................................... 27
Elizabeth Vales, Allstate Insurance Company
Instilling a Spirit of Winning at American Express........................................................................................... 33
Gabriella Giglio, American Express
Silvia Michalcova, American Express
Chris Yates, American Express
People and Error: “Human Factor” Principles in Safety Critical Industries ......................................................... 39
John Anfield, Rolls-Royce
Personal Transformation as a Leverage for Organizational Transformation:
The TEA Program as a facilitator of cultural change management .................................................................... 49
Melina Gretel Münner, Petrobas, Argentina
Results Matter: Unlocking Value through Avaya’s Business Transformation ....................................................... 55
Doug Reinstein, Avaya Inc.
Safety at the Center: A Model that Accelerates Learning ................................................................................ 63
Elizabeth Hostetler, Ph.D., University of Maryland Medical Center
When Opportunity Knocks: OD’s Response to Takeover in the Acquired Company ................................................ 67
James Shillaber, PsyD., Bayer HealthCare Pharmaceuticals
LEADERSHIP AND CAREER DEVELOPMENT
Ensuring Enterprise Success Through a Systemic Approach to Leadership Development ...................................... 77
Jeri Darling, BAE Systems
Enterprise Leadership ............................................................................................................................ 83
Brent deMoville, Allergan Inc.
Evaluating a Leadership Development Program ........................................................................................... 89
Judith Hayes, Manitoba Lotteries Corporation
Getting Results from a Systemic Front Line Leader Development Program at Raytheon ........................................ 95
Greg Till, Raytheon
KNOWLEDGE / TALENT MANAGEMENT
Action Learning Accelerates Innovation: Cisco’s Action Learning Forum ........................................................... 107
Annmarie Neal, Psy.D., Cisco Systems, Inc.
Lisa Cavallaro, Cisco Systems, Inc.
O R G A N I Z A T I O N D E V E L O P M E N T J O U R N A L
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4. Analyzing Critical Positions for Talent Needs ............................................................................................. 115
Mike Barron, Whirlpool
ORGANIZATIONAL CAPABILITY / EFFECTIVENESS
Creating a Strategy to Help Others Better Understand the Value of Organization Development ..............................121
Rose Katz, Aramark Healthcare
Developing the Capability to Be Agile ........................................................................................................ 127
V P Kochikar, Infosys Technologies
M P Ravindra, Infosys Technologies
Electric Utility Achieves Business Results through Organizational Development ................................................... 135
Ross Schifo, Central Vermont Public Service
Elements of Partnership Between HR and Learning and Development: Create a Win/Win ...................................... 141
Sue Kirkland, American Cancer Society, Eastern Division
Globalizing the OD Function – Meeting Global and Regional Needs ................................................................... 145
Jackie Alcalde Marr, Oracle Corporation
Organizational Development - From Public Relations Nightmare to Competitive Edge ........................................... 151
Sandra Torres, Aramark Healthcare
ORGANIZATIONAL DESIGN / TRANSFORMATION
Speak-Up All You Whistle-blowers: An OD Perspective on the Impact of Employee Hotlines on Organizational Culture.. 161
Allan Church, Pepsi Co Inc.
Jessica A. Gallus, University of Connecticut
Erica I. Desrosiers, PepsiCo, Inc.
Janine Waclawski, Pepsi-Cola North America
Strategic Intent: A Key to Business Strategy Development and Culture Change .................................................. 169
Jim W. Ice, Respironics, Inc.
FUTURE OF OD
The Future of Organizational Development in the Nonprofit Sector ................................................................... 179
Jeana Wirtenburg,Ph.D., Jeana Wirtenberg & Associates, LLC
Thomas E. Backer, Ph.D.,Human Interacion Research Institute
Wendy Chang, Dwight Stuart Youth Foundation
Tim Lannan, MSOD, Tim Lannon Consulting
Beth Applegate, MSOD, Applegate Consulting Group
Malcolm Conway, IBM Global Business Services
Lilian Abrams, Ph.D.,Abrams & Associates
Joan Slepian, Ph.D., Silberman College of Business
ACADEMIC IMPLICATIONS
Curriculum Implications Based on Analysis of Internal Consulting Best Practices ................................................ 197
Miriam Y. Lacey, Ph.D., Graziadio School of Business and Management, Pepperdine University
Teri C. Tompkins, Ph.D., Graziadio School of Business and Management, Pepperdine University
Terri D. Egan, Ph.D., Graziadio School of Business and Management, Pepperdine University
OD Special Team Bios .............................................................................................................................. 211
COMMUNITY CONNECTIONS
Calendar of Events .................................................................................................................................. 232
In Appreciation ..................................................................................................................................... 233
Call for Presentations ............................................................................................................................ 234
Subscription Information ....................................................................................................................... 237
Advertising Guidelines for OD Journal ....................................................................................................... 237
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5. VOLUME 25 NUMBER 4 WINTER 2007
Le er from the Editor:
Best Global Practices in Internal Organization
Development
By Thiet (Ted) K. Nguyen, Johnson & Johnson
I write this le er to conclude the third and final volume of the special global edition of the OD Journal from the
city of Dubai, United Arab Emirates, one of the fastest growing business centers in the Middle East.
Yesterday, as I was waiting to board my plane from JFK airport, I had a chance to relax in the Emirates lounge.
There, I saw an entourage of Middle Eastern dignitaries (with an even larger number of American bodyguards) –
presumably heading home on the same flight. With an hour to spare before departure to Dubai, I picked up the
Financial Times and read a headline that revealed Warner Bros, the largest Hollywood Studio, has made Abu
Dhabi, the capital city of this country, its entertainment hub. With an unprecedented investment in the breadth
and scope of activities, Warner Brothers expects to create a 6,000-acre theme park, movie studio, hotel, multiplex
cinemas, videogames, and infrastructure for Abu Dhabi’s digital transformation. Abu Dhabi will contribute $500
million to co-finance Warner films, a 50-50 joint venture on broad-appeal films. Together, Warner Bros and Abu
Dhabi are exploring opportunities in additional areas such as production facilities, digital content distribution,
and retail opportunities in the Gulf region. I boarded the plane smiling to myself as I considered the phenomenal
growth opportunities in the Middle East.
When I finally arrived here in Dubai 14 hours later, I took a short tour of the city. Knowing that I had arrived dur-
ing the observance of the Holy month of Ramadan, a Moslem religious tradition where people fast from sunrise
to sunset, I was fascinated to see that the Mall of Emirates was full of people enjoying fun activities, like snow ski-
ing inside – in an environment controlled at 2 degrees C while the outside temperature was 40 degrees C. The
hotel I am staying is directly across from the large American Hospital (actual name of the hospital), and a five-
minute drive to Healthcare City, where I am scheduled to meet with senior Johnson & Johnson business leaders
from the Pharmaceuticals, Medical Devices and Diagnostics, and Consumer sectors. Our meetings are scheduled
for Sunday, which is the first workday of the week here.
This morning, as I enjoyed breakfast and read the Gulf News, a local newspaper, I saw a headline in the Business
section that read “India Now Outsources Outsourcing.” The article described how India is now outsourcing out-
sourcing in this global economy, now that its own wages are rising and demands for its services are increasing.
India is facing competition from newly developing countries seeking to emulate its success in back office support
to wealthier nations. This is driving leading Indian companies to establish their operations in those competing
countries in order to outsource work to them. Infosys Technologies described its outsourcing strategy this way:
“to take the work from any part of the world and do it in any part of the world.” (Gulf News, p. 30, September 29,
2007)
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6. VOLUME 25 NUMBER 4 WINTER 2007
To me, the interesting part of this outsourcing article was not about how Infosys Technologies is becoming a
global matchmaker by outsourcing its work to low wage countries, such as China, Czech Republic, Philippines,
Poland, Mexico, and Thailand. It is about how it and other Indian companies are outsourcing its work to low-cost
regions of the United States. Americans from US universities accepted a novel assignment from Infosys to come
to India to learn computer programming so they can return to the US to work on back-office assignments. A ris-
ing number of Indian companies are opening back offices in Boise, Phoenix and Atlanta, where wages are rela-
tively lower than other parts of the US. Wipro is opening a so ware development center in Atlanta and will hire
500 programmers during the next three years. Wipro’s Chairman informed Wall Street analysts that “he was con-
sidering hubs in Idaho and Virginia, in addition to Georgia, to take advantage of ‘states which are less devel-
oped.’” (Gulf News, p. 30, September 29, 2007)
The world has changed and will continue to change at exponential rates. The marketplace is already global.
Many US corporations are experiencing faster international growth rates than domestic, and they continue to in-
vest heavily in emerging markets including Russia, India, China, and Brazil. Companies in emerging markets are
facing rising competition from lower wage markets and are beginning to invest in those markets and in client
countries. Yesterday there was serious concern that the US had lost a lot of jobs due to outsourcing. Today, it ap-
pears that the US is beginning to gain new jobs from a number of countries to which it has outsourced, like India
and China. What will the world look like tomorrow?
I passionately believe that we, as OD practitioners, can shape and influence tomorrow by leveraging our core
competencies in change management, organizational design, and leadership development. We can shape the ex-
ternal environment through our work in developing future leaders and guiding companies through change. I be-
lieve we must continually upgrade our skills and reinvent our knowledge to be effective in guiding our clients.
By publishing this global Special Edition, we expect to achieve our goal to help drive change and grow our pro-
fession.
This Special Edition will benefit the HR/OD community in several ways:
Academic community – The academic community will find the content of these contributions of value to
raise the awareness of current best internal practices with specific applications. Program directors can be
informed and encouraged to strengthen their curriculums and research directions. Graduate students
may use this edition to leverage their classroom experience, as they prepare to enter the OD profession
and compete for opportunities in the global marketplace.
Current practitioners – Both internal and external practitioners can use this knowledge to guide and grow
their practice areas, enhance their skills, and strengthen their core competencies, by learning from other
OD professionals.
Our clients and business partners – Potential and existing clients can be be er informed of the capabilities
OD professionals can bring to enhance employee engagement and organizational growth and vitality.
Content like this has never been captured or disseminated because internal practitioners do not have the luxury
of time to write. This is the first time many of these authors took the time to document their work, secure the sup-
port of their companies to release the information, and share their internal efforts with all who are interested. We
applaud all our authors for their trust in us, and their willingness to provide working papers without the benefit
of professional editors. In this global Special Edition, readers will experience truly authentic voices of internal
practitioners worldwide who share their stories from a place of caring and eagerness to advance the field of or-
ganization development.
While this series is titled a best internal OD practice edition, no one associated with its production has judged or
evaluated “a best global practice.” Rather, authors were encouraged to share what they perceived to be a best
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7. VOLUME 25 NUMBER 4 WINTER 2007
practice within their organization, whether that organization is a start-up company in India, a non-profit organi-
zation in the US, an energy company in Africa, or a hi-tech company in China. We also chose not to judge
whether an article fit the definition of organization development, since there are variations among the definitions
of OD. We recognized, too, that OD is practiced differently across geographies, countries, sectors, industries, or-
ganizations, groups and contexts.
To share additional insights into their workplaces, many authors have generously provided a reflection section
outlining their working environment, the benefits of the intervention as described in their paper, and finally, to
share their perspective of the overall outcome.
This final special edition is the collaborative labor of love of more than 30 authors and co-authors, and an all-vol-
unteer team of 105 practitioners, led by the highly dedicated leadership team from the New Jersey OD Commu-
nity. We became actively engaged because of our passion and burning commitment to enhance the capabilities
and reputation of our profession. Collectively, we share the common goal of advancing the field of organization
development. We have worked collaboratively with our colleagues from top corporations in China, UK, Brazil,
the Netherlands, Germany, Switzerland, Singapore, Finland, and Korea to bring this publication from concept to
reality.
The team has invested over 5,000 hours over the last 14 months that it has taken to prepare these three special vol-
umes. We have worked many long night and weekend hours to ensure the highest quality professional publica-
tion. If I were to estimate the dollar value of the time the team has invested, it would total well over $1 million.
However, it is impossible to put a price tag on our passion and dedication, not to mention the time each of us
could have spent with our families and loved ones instead of guiding authors and creating this 3 volume special
edition set of the OD Journal.
We are very proud to share this third and final special edition as we close out this project and our involvement
with the OD Institute, publisher of the OD Journal. As leader of this team of illustrious and generous profession-
als, I express our appreciation for the opportunity to contribute to the internal OD body of literature and to ad-
vance the field of organization development. We wish you the very best.
Ted Nguyen
Dubai, United Arab Emirates
September 2007
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The OD Journal Special Edition Team Members
EDITORS
• Ted Nguyen, Editor
• Elaine Steiner - Managing Editor
• Dianne Clarke-Kudless – Peer Review Editor
• Hania Qubein - Copy Editor
• Lucille Maddalena - Technical Editor
• Sharon Snyder - Guest Editor
• Patricia Polanco Licata – Proofreading Editor
• Rita Witherly – Graphics Editor
• Sandy Becker, Andrew Cohn, Elena Feliz,
Linda Myers, Lucille Maddalena - Staff Editors
PEER REVIEW COUNCIL
Internal Practitioners
• Lucille Adriaens – Philips (The Netherlands)
• Evelina Ascalon - Credit Suisse (Switzerland)
• Joe Bonito – Pfizer
• Leslie Berks - Hewle Packard
• Sharron Blunt – Wal-Mart
• Do ie Brienza - Johnson & Johnson
• Michael Broom - Verizon
• Susan Burne - Gap, Inc.
• K A Chang - Singapore Exchange (Singapore)
• Laura Christenson - Horizon Blue Cross Blue
Shield
• Allan Church – PepsiCo
• Jose Conejos – Nokia (Finland)
• Carolyn Davis – Abbo Laboratories
• Brent deMoville - Allergan
• Gerald Dietz - SAP AG (Germany)
• Sue Dodsworth - Kimberly Clark Corp.
• Tamar Elkeles – Qualcomm
• Marilyn Figlar – Lockheed Martin
• Anika Gakovic - HSBC Group
• Stefan Gartner – Amgen
• Lisa Geller - Honeywell
• Ann Giese – Motorola
• Jaime Gonzales – Warner Bros.
• Linda Go schalk –American Standard
• Dee Grosso – Solstice Neurosciences
• Hope Greenfield - Lehman Brothers
• Barbara Gutmann - Volkswagen (Germany)
• Ron Hadley - Wyeth Pharmaceuticals
• Bill Hector - Citigroup
• Art Heeney - DuPont
• Bob Hoffman – Novartis
• Bill Hunt – Raytheon
• Angela Hyde - AstraZeneca (UK)
• Julian Kaufmann - Tyco International
• Barbara Keen - Bristol Myers Squibb
• Louise Korver-Swanson - Bank of America
• Steve John - Sanofi-Aventis
• Leslie Joyce - Home Depot
• Fernando Lanzer - ABN AMRO (The Netherlands)
• Keith Lawrence - Procter & Gamble
• Sang Seub Lee – LG Electronics (Korea)
• Iris Lemmer - Microso
• David Lipsky - Sony
• Lori Malcolm - Wal-Mart
• Cindy Marlowe - Berlex Labs
• Kristin Meade - Quest Diagnostics
• Krystin Mitchell, 7-Eleven, Inc.
• Bernd Moehle - Nestle (Switzerland)
• Kenny Moore - Keyspan Energy
• Jay Morris - Trinity Health
• Vas Nair - Schering Plough
• Nina Dankfort-Nevel - General Electric (China)
• David Owens - Bausch & Lomb
• Greg Parker – Shell (The Netherlands)
• Patricia Pedigo – IBM
• Michael Pepe - Yale New Haven Health System
• Sheila Person-Sco - Wachovia Bank
• Carol Pledger – Goldman Sachs
• Mary Plunke - British Petroleum (UK)
• Michele Prenoveau – Morgan Stanley
• Paul Roithmayr – TV Guide
• Renee Romulus – AholdUSA
• Renee Russell – Avon
• Robert Ryncarz – Merck & Co
• Rick Sawyer - Fujifilm USA
• Mike Stafford – Starbucks Coffee Company
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9. VOLUME 25 NUMBER 4 WINTER 2007
• Joan Szymoni a - L'Oreal
• Vera Vitels - Time Warner
• Renee Wallace - Ahold
• Kevin Wilde – General Mills
• Kathy Zukof - New York University
External Practitioners
• Lilian Abrams - Abrams & Associates
• Seymour Adler - Aon Consulting
• Dianne Clarke-Kudless - Caliper Management
• Andrew Cohn - Lighthouse Consulting
• Edana Desatnick - Edana Desatnick Consulting, LLC
• Vicki Foley - Lee Hetch Harrison
• Mauricio Goldstein - Pulsus Consulting Group
• David Jamieson - Jamieson Consulting Group
• Jeanne Maes - University of South Alabama
• Cynthia Ma hew - Wesleyan University
• Linda Myers - WorldWise, Inc.
• Joy McGovern - Right Management
• Rosa Colon - Global Talent Excellence, LLC
• Valerie Norton
• Lori Peterson - Integral Consulting Group
• Marianne Tracy - Development Dimensions
International
• Jason Wingard - ePals Foundation
• Jeana Wirtenberg - Jeana Wirtenberg & Associates
• Andrea Zintz - Hudson Talent Management
LIAISON TEAM
Liaison with HRCI (SHRM)
• Linda Myers - WorldWise, Inc. - SHRM Global HR
Certification Team
Liaison with various academic institutions
• Seymour Adler - NYU School of Applied Psychology
• Sandy Becker - Rutgers Business School
• Dianne Clarke-Kudless - Rutgers Organizational
Psychology Program
• Rosa Colon - Benedictine University
• Edana Desatnick - Duke Corporate Education
• Wei Huang - New York University
• Miriam Lacey - Pepperdine Master OD Program
• David Jamieson - Pepperdine Doctoral OD Program
• Steve John - Columbia University
• Jeanne Maes - University of South Alabama
• Cynthia Ma hew - Wesleyan University
• Linda Myers - Harvard University
• Lori Peterson - Augsburg College MBA Program
• Renee Russell - Duke MBA Program
• Jeana Wirtenberg - Fairleigh Dickinson University
• Andrea Zintz - Fielding Graduate University
SPECIAL EDITION STAFF
Project Managers
• Wei Huang - Crossing Over - Volume I
• Nina Wortzel-Hoffman - Johnson & Johnson -
Volume II
• Elaine Steiner - Chanel - Volume III
Design/Layout Team
• Hania Qubein
• Rita Witherly - MoZen
• Don Michalowski – Ruby Window Creative Group
Final Editing Team
• Andrew Cohn – Staff Editor
• Linda Myers - Staff Editor
• Sandy Becker – Staff Editor
• Lucille Maddalena - Maddalena Transitions
Management
• Sharon Snyder – Reflection Page Editor
• Deborah Melnick – Chanel, Inc.
• Mary Borquist – Chanel, Inc.
• Julia West-Johnson - Raritan Valley Community
College
Proofreaders
• Patricia Polanco Licata - New Heights Consulting
(team lead)
• Be ina Neidhardt.
• Joan Poling
• Jean Hurd - Janus Consulting
• Donna Lue Quee - Hess Corporation
Guest Reviewers
• Sandy Becker - Rutgers Business School
• Sharon Blunt - Wal-Mart
• Lable Braun - Dialogic
• Roy Chen - Johnson & Johnson
• Helen T. Cooke - Cooke Consulting Group
• Jean Hurd - Janus Consulting
• Surjeet Rai-Lewis - Johnson & Johnson Canada
• Donna Lue Quee - Hess Corporation
• Patricia Santen - Novartis
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10. O R G A N I Z A T I O N D E V E L O P M E N T J O U R N A L
VOLUME 25 NUMBER 4 WINTER 2007
Abstract
This paper explores the subject of Human Factors (HF)
and argues that proven, error reduction methods used
in “safety critical” industries including Aerospace, Nu-
clear and Medicine can migrate into mainstream busi-
ness and offer considerable business performance
gains. The methods used fit well with the values and
ethics of the O.D. profession, and suggests how busi-
ness leaders, O.D. practitioners and academics, can
gain more knowledge about this important subject.
About the Author:
John Anfield is Head of Organisation Development
and Learning for a large Rolls-Royce business unit
who joined the company a er an early career in the
Royal Air Force, an organization which gave high pri-
ority to flight safety. At Rolls-Royce, John spear-
headed a three-year Human Factors campaign that
commensurately enhanced the safety culture in aero-
engine maintenance facilities and met new regulations
set by the European Aviation Safety Agency. John has
an MBA, and is a Fellow of the Chartered Institute of
Personnel and Development (UK), as well as a Senior
Professional in Human Resources (USA).
Introduction to Human Factors:
In safety critical industries, where simple human mis-
takes can cost hundreds of lives and billions of dollars,
considerable organisational effort is put into multi-lay-
ered, preventive measures aimed at reducing or elimi-
nating all known risks. Despite all these safeguards,
tragic errors still occur. For example, the July 1988
Piper Alpha Oil Rig disaster in the UK’s North Sea cost
165 lives and had direct costs of over £2billion. The
cause was traced to a single, missing pressure safety
valve.
O en the hardest lessons learned are those that are
gained from painful hindsight. In industries that carry
an inherent risk, such as aerospace, rail, nuclear and
medicine; post accident investigation typically reveals
a large human error component. When the human ele-
ment, typically 75%-100% of the contributing cause is
investigated in greater detail, o en the final failure is
discovered to be the result of a chain of smaller errors
which have combined in an unexpected or untimely
way. In nearly every case, there are clear, early warn-
ing signs in the system that leaders ignore.
Another tragic example of Human Factors at play was
the Helios Airline accident in Greece. A design feature
of a cabin air pressurisation valve allowed that part to
remain incorrectly positioned during flight. When the
positioning error combined with a maintenance error
(someone le the valve in its ground position), the re-
sult was cabin oxygen starvation. As the aircra
climbed past 10,000 feet on autopilot, the aircrew be-
came confused and argued about the meaning of vari-
ous cockpit-warning bells. The incapacitated crew lost
control of the still fully flyable aircra , which ran out
of fuel, crashed, and killed all 121 passengers and
crew.
Given these high stakes, it is imperative that preven-
tive measures focus on understanding why well-inten-
tioned and correctly trained professionals make
serious mistakes, which can sometimes circumvent the
considerable defences of a safety system. This ques-
tion transitions into a broad field labelled Human Fac-
tors (or HF for short). Today, HF research includes
aspects of design (latent errors); ergonomics (human-
People and Error: “Human Factors” Principles in
Safety Critical Industries
John Anfield, Rolls-Royce
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11. VOLUME 25 NUMBER 4 WINTER 2007P40
machine interfaces); cognitive research (stimulus,
memory, information retrieval and processing); bio-
medical research (drugs, alcohol and the circadian ef-
fects of shi working) and systems engineering
(processes and process compliance in socio-technical
systems in particular).
Much of this HF territory will be familiar to an experi-
enced Organization Development consultant. There
are also many overlaps between HF and Total Quality
Management (TQM) systems; although, in the opinion
of this author, TQM has become much more remote
from people in the past decade (i.e. more IT based and
highly procedural). Furthermore, an HF approach of-
fers a be er and much more effective method than
conventional, compliance-based, audits, which I be-
lieve have become an ineffective error prevention tool.
The HF Approach:
What is special and unique to the HF approach is the
considerable investment and effort made to seek out
information about errors and hazards from the people
who work inside the system, and to design a process
for them to share their learning with others before any
unwanted events happen.
The HF approach can be described as a method of ac-
celerating the acquisition and application of opera-
tional lessons learned across an organisation to avoid
their reoccurrence. The following five key conceptual
features of any HF-based approach to error reduction
are generated from this author’s own research and ex-
perience:
1. HF accepts that error is normal and will occur
in all human systems.
2. HF uses a high level of employee engagement
to discover all unreported events and potential
hazards, i.e. reading the weak, warning
signals early.
3. HF methods demand a fast and effective feed
back and communication loop.
4. HF acknowledges that an individual’s
awareness of error potential is the single best
defence against their occurrence.
5. HF requires that leaders behave ethically,
build trust, and accept their personal and
o en legal duty to address all reported
hazards.
Formal Definitions of Human Factors:
While each high-risk industry may have its own defi-
nition of Human Factors, within the field of aviation
there has been a convergence on one specific defini-
tion, which was originally issued by the International
Civil Aviation Organisation in 1986. It reads as fol-
lows:
Human Factors is about people in their living and
working situations; about their relationship with ma-
chines, with procedures and with the environment
about them; and also their relationships with other
people.
Given this definition of HF, there is li le doubt of the
overlap with the O.D. practitioner domain; yet, to this
author, it seems that these two related worlds rarely
converge. Beyond the human error that is known to
exist in safety critical industries, imagine the number
of human errors that must occur in banks, insurance
companies, manufacturing, catering, retail, social, and
in not-for-profit organisations. If a conservative esti-
mate of 10-15% of an organisations’ output may be lost
through unrecognised human errors, it stands that any
CEO, CFO, or OD professional could project the effect
of ‘error reduction’ on the bo om line of their own or-
ganisation.
Supporting HF Cognitive Research:
Having defined HF, and before considering whether
HF principles can be transferred to the wider business
community, two important questions are in order:
First, ‘why does human error occur?’ and second,
‘what can we do to prevent errors in organisations?’
Former Manchester University Professor James Reason
spent many years researching the causes of error and
methods for their possible prevention. In his book,
Human Error Reason provides a good first step in un-
derstanding HF principles and se ing them into a use-
ful psychological framework.
Typical HF Error Reduction Methods:
From Professor Reason’s work, my own and others’ ex-
periences implementing HF error reduction methods
across safety-critical organisation, the following fac-
tors are usually found in effective systems:
• Customer and product safety are declared as
strategic goals.

12. VOLUME 25 NUMBER 4 WINTER 2007
• Probabilistic risk assessments are used to focus
efforts on key hazards
• Risk management and risk mitigation risks
techniques are applied
• Elimination of the opportunity for error, o en by
foolproof design.
• Application of decision support systems and/or
clear safety policies.
• Use of checklists, models and other visible
memory aids.
• Leaders model a culture of trust, reporting, and
openness.
• Multi-format, communication channels are used
for error reporting and feedback.
• Prompt action is taken by leaders to address all
reported hazards and errors.
• O.D. and Learning interventions are used at
different organisational levels:
- Education for all on the underpinning HF
theory, principles and concepts.
- Training for competence in the actual tasks
being performed.
- Training in hazard awareness and risks of
specific errors.
- Simulation of scenarios that could be faced in
high-risk industries.
- Behavioural training including surveys of group
cultural norms.
- Leadership training to reinforce personal
responsibility for safety.
- Executive education on safety ethics and
decision making models
Reason and Hobbs (2003) well-wri en and readable
book for managers in safety critical industries expands
on all the above techniques and methods.
Assessing HF-Based Interventions:
United States civil aviation statistics reveal that the
number of hours flown on scheduled carriers between
2004 and 2005 was close to 19 million hours during
which there were 32 total loss accidents resulting in 22
deaths. While not a direct correlation for road fatali-
ties in the United States, the 2002 road death statistic
was 42,815. These data reveal an enormous discrep-
ancy between the error rates of two mass transporta-
tion systems. Indeed, pilot training standards are
much higher than driver training standards, and the
aviation industry is highly regulated. That notwith-
standing, these two numbers are so disparate that they
beg to suggest some very different and fundamental
system behaviours.
Rolls-Royce and HF:
Within Rolls-Royce, our A ermarket business over-
hauls civil and military aircra gas turbine units. Our
7,000 employees work in 17 facilities on four of the five
continents and operate under the jurisdiction of the
European Aviation Safety Agency (EASA) with an
EASA Part 145 licence. Rolls-Royce has an excellent
safety record and a world-class reputation for deliver-
ing excellent products and service. Why, one might
ask, did we need a Human Factors campaign?
The Human Factors campaign was driven by several
factors. First, in 2003, the newly formed EASA organi-
sation gave notice that all Part 145 certified mainte-
nance facilities must train all their employees in
Human Factors and as well as to implement a Mainte-
nance Error Management System (MEMS) to allow
employees to report potential hazards or to highlight
errors or omissions. The primary business driver,
then, was a change in industry legal and regulatory re-
quirements.
Behind these new requirements was a secondary
driver, focused on the remaining cause of civil aviation
accidents: maintenance error. While statistics had
shown that over the past two decades the number of
civil aviation accidents declined as a result of improve-
ments in aircrew training, navigation systems, be er
Air Traffic Control and be er weather forecasting, the
most persistent cause of civil aviation accidents was
maintenance error. This was the reasoning behind the
EASA two-pronged approach.
However, as Rolls-Royce addressed EASA’s manda-
tory HF and MEMS requirements we discovered
through focus groups and management workshops
that there were many costly unreported errors in our
businesses affecting both quality and productivity.
While we did not have any product safety concerns,
we had accidentally discovered a large ‘Error Iceberg’
in our own organisation.
The ‘Iceberg’ analogy for HF refers to the fact that 10%
of an iceberg is visible above the waterline, while more
than 90% is underwater. The concept is that mistakes
are latent, hidden, re-worked or sometimes passed on
unreported through to the customer. A similarly high
ratio (10%-90%) between known errors and unre-
ported errors and hazards were seen in both the
NASA Challenger and Columbia Accident Reports. In
the Columbia report in particular, the Accident Board
referred to ‘unknown unknowns’.
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13. VOLUME 25 NUMBER 4 WINTER 2007P42
It is reasonable to assume, then, that most non-safety
critical industries will have their ‘Error Icebergs’ too,
and that these ‘ugly lumps of inefficiency and business
risk’ in organisations may be surprisingly large. Simi-
larly, it is likely that someone inside will always know
about them!
Finally, to underscore this point, it is worthwhile to ex-
plore who in an organisation knows what about the
real the error rates. One assessment by the Australian
Defence Force’s Aviation Maintenance Improvement
Project reveals the existence of an Ignorance Iceberg -
The farther one moves from the hangar floor, the less
knowledge of the organisation’s errors are known at
approximately these percentages:
o 4% of senior managers are aware of errors (above
the waterline)
o 6% of managers are aware of errors (above the
waterline)
o 75% of first line supervisors are aware of errors
(below the waterline)
o 100% of employees are aware of errors (below the
waterline)
This is a sobering finding, considering that it is senior
managers who make all the key decisions about cus-
tomer issues, quality, people, resources and processes.
The percentages above suggest that significant deci-
sions are made based on li le knowledge of the reali-
ties of the errors in the complex systems that leaders
run!
The Rolls-Royce Journey into the Error Iceberg:
Rolls-Royce was challenged to meet the two critical
EASA requirements within two-years. First we needed
to implement comprehensive HF training for all 2,500
people in the UK. Second, we needed to implement a
Maintenance Error Management System, which Rolls-
Royce calls MEMS that would rely on trust and open-
ness. This is how we achieved these objectives:
The Burke-Litwin (1992)8 models gave us insight into
how an organisation works and can change culture.
The model proved very useful in planning our ap-
proach. Burke-Litwin makes a distinction between
three transformational areas of strategy, leadership
and culture, and of the other parts of an organisation
that are more transactional in nature.
To effect a large-scale organisational and cultural
change such as the introduction of HF and MEMS into
our own businesses, we knew that we had to first ad-
dress these transformational areas, in particular the
areas of leadership and culture. Addressing Strategy
was less critical because our a ermarket strategy was
reasonably stable and successful.
Tackling leadership first, we executed several interven-
tions at various levels of our structure. At an Executive
Seminar held in 2004, we gained full commitment
from our senior leaders to support the HF programme
and introduce the MEMS system. A er this event we
distributed a personalised le er of commitment from
our managing director to all employees to announce
the launch of the main HF programme. We also issued
several general communication articles.
Over the following six months we implemented an in-
troductory programme for all 190 managers and gave
them an overview of HF, beginning with the EASA
mandate, the potential operational impact of running a
large-scale training programme for their 2,500 employ-
ees, and the potential value to Rolls-Royce. This pro-
gramme was effective in meeting its goals by enabling
us to review the past to be er prepare for the future.
Within the confidential format of this event, we were
able to see how past errors had resulted in consider-
able cost, and in many cases, became aware that re-
peated human errors could have easily been avoided
through feedback.
Errors identified in this leadership programme formed
the basis of a clear ROI (return on investment) busi-
ness case for the external delivery of an employee HF
programme which we showed would be repaid two-
fold within three years, by teaching employees how to
reduce error. This business case was fully accepted by
Finance.
Another important group of people we involved were
our trade union leaders, first in face-to-face briefings,
and later with their participation in Managers’ HF pro-
grammes. Trade union support for our HF campaign
has been 100% from the start and several trade union
officials are now full members of the HF Steering and
Policy Group that was formed early in 2004.
The HF Steering Group includes Heads of Operations,
the Heads of Quality, our HF Training Vendor and sev-
eral of our O.D. team who have been involved in the
design and delivery of the interventions. The Chair of
the HF Steering Group has revolved among our Direc-
tor of Quality, our Director of Engineering, and me.
Our Managing Director a ends for part of the Steering
Group meetings, and he has also included HF and
MEMS status reports as two standing agenda items on
his regular Quality Board meetings.

14. VOLUME 25 NUMBER 4 WINTER 2007
Full credit must be give to our vendors, Baines-Sim-
mons Ltd, a specialised aviation safety and training
consultancy based in Woking in the UK. Directors
Bob Simmons and Kevin Baines have extensive knowl-
edge of HF, and have been critical to our campaign
from the start by providing invaluable advice and
guidance on our long and ongoing journey. The
Baines-Simmons team have now run over 150 events
at four UK sites.
To this point we had formed a coalition of key stake-
holders, all passionate about enhancing safety, and
who were certain that we could use the HF campaign
to improve quality and reduce the costs of errors. The
creation of such an internal-external coalition with a
common goal is o en the key milestone for moving on
to the next phase of a culture change, which in our
case meant training all employees to help build
enough trust for them to start using the MEMS system,
which by this time had “gone live” on our Company’s
Intranet site.
The “acid test” for any adult learner’s training pro-
gramme is its relevance to the work and/or life roles of
each participant. Anticipating this need, we worked
with Baines-Simmons to create a series of customised
programmes designed to have very high-relevance to
the particular facilities and product lines that we man-
age. In fact, our four programmes were identical in
their core content but used specific, relevant product
examples and images from the local site to engage
those learners.
Building Trust at Rolls-Royce to Make HF Work:
There can be many inhibiting factors in business or-
ganisations to obstruct the development of trust, or re-
duce the open sharing of errors and the lessons to be
learned. They can include fear of punishment, strong
peer pressure, financial consequences, concern about
adverse impact on the performance management
processes, career limitations, and group social norms,
all of which regulate the boundaries of what informa-
tion is normally shared between employees and man-
agers. This was an area where we spent a great deal of
effort to get things right.
In asking our employees to report incidents and haz-
ards that would normally be secretly reworked or kept
under cover, we focused on the benefits of reporting
and avoiding of errors. The programme had three
main goals, the first two related to HF knowledge and
personal error avoidance, the third and most impor-
tant goal was to build trust and encourage open re-
porting.
For us it was a slow start. A er six months of training
we had only a handful of employees who had gener-
ated MEMS inputs. However, when a critical mass of
40% of employees had been trained, and people saw
that raising MEMS reports did result in some positive
actions, the rate of submission rapidly increased, and
today all businesses are now participating at similar
rates. To date we have now had 580 employee gener-
ated MEMS reports and about another 400 issues arise
from the training programme summaries. See figure 1.
Figure 1. Number of Employee Raised MEMS (Maintenance Error Management System) Reports
between 2004-2007
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15. VOLUME 25 NUMBER 4 WINTER 2007P44
From discussions with other organisations, this slow
start and rapid ramp-up of employee input is typical
of all HF programmes, and HF should not been
viewed as a quick fix. At minimum, expect two years
of consistent HF communication, training, and MEMS
activity to embed this approach into the culture of any
business or organisation.
At the end of the employee HF training programme
we used a poster campaign to advertise the successful
completion and to keep the message out there in the
work-areas, see examples:
The True Leadership Challenge:
We have addressed the HF leadership component on
many levels, and now that the original employee HF
programme has ended, we have reached a critical
phase. The impact of leadership and training efforts
are at their peak, and employee expectations are high
that leaders will address issues that have been identi-
fied. From here, there are two potential scenarios: Any
failure of the leadership to respond to hazard reports
will rapidly erode trust and risk a decline to a position
lower than where we began. Clearly we must avoid
this risk.
Our intended model is one where leaders will take the
initiative and positively address all reported hazards
and problems, and it is this management passion and
drive that will take our HF campaign to the next level.
A er three years of effort, we are in the middle of this
critical consolidation phase and have already closed
out about 70% of our MEMS reports. Some are very
complex and will be more difficult to resolve.
Our future plans include three important components:
• a new, biannual HF Continuity Training
Programme employee refresher
• a major communication campaign focused on
error-feedback
• a new Leader HF workshop that will include an
HF update, a MEMS clinic and a structured
decision making model based upon a recently
developed safety ethics model by Patankar, Brown
and Treadwell (2005).
Evaluation of Benefits:
Evaluating and measuring the Return on Investment
(RoI) of HF programmes will always involve some
judgements made by business leaders even where a
wide range of quality and operating metrics are avail-
able:
At Rolls-Royce, we measured the investment in our
HF programme. To date, 2,500 UK employees have
spent 6,000 days in off-job training time and about
£0.5m in external costs directly a ributable to the HF
programme. What have received for this investment?
Our recent evaluation shows heightened employee
positive a itude towards safety up to 24 months a er
training (88%) and a reasonable degree of belief that
we are serious about HF.

16. VOLUME 25 NUMBER 4 WINTER 2007
• Over 580 MEMS reports have been submi ed by
employees in the first two years, giving us rich
data from the base of the ‘error iceberg’, this
proves that our efforts to build up trust are now
paying off (77% of employees state that they
openly report errors).
• Over 70% of these MEMS have been closed out
with remedial actions, about 20% of the MEMS
reports are complex and we now use a formal
process to investigate them.
• Increased positive feedback on HF ma ers and a
common ‘HF and error’ language are evident in
the workplace at all levels, for example in planning
meetings.
• We cannot measure the costs of accidents and
incidents that have not occurred, however, in the
evaluations we have done we have identified many
incidents which if they had not been reported
would have caused us major operational problems.
• The experience of other organisations, such as air
lines, is that it usually takes about two-three years
to get an effective HF campaign and MEMS fully
working and that the reductions in the costs of
non-quality will really begin to flow through in
years three-five, we are at that stage now and we
are seeing definite downwards trends.
Nevertheless, at this time we do not claim any major
Return on Investment victories; however, we do main-
tain our belief that we are safer now with HF embed-
ded, than without it; and the next two years will
determine how this translates to the bo om line.
The Transferability Question:
Many large organisations cycle through huge invest-
ments in ‘Customer Care, Total Quality, Business
Process Improvement and Six-Sigma Programmes,
and inevitably, senior leaders are o en disappointed
with the results of these campaigns when each is con-
sidered in the context of promised benefits. Somehow,
that last 10-15% of improvement is rarely realised; re-
gardless of what is adjusted in the formal systems.
This author contends that some of these well-inten-
tioned improvement programmes are missing the es-
sential point: “Unless you build a culture in which
employees will tell the leaders what is, or might be
going wrong and hold leaders accountable for ad-
dressing these issues”, then your organisation is prob-
ably destined to relive many costly improvement in-
terventions in the vain a empt to remove human
error.
Encouraging new work on the integration of opera-
tional excellence and safety improvements and the
seemingly natural convergence of these two ap-
proaches has been revealed by Ward (2006) who, dur-
ing her assignment with the UK’s Lean Aerospace
Initiative, made a very good case for significantly in-
creasing the dialogue between the HF, Quality and
Process Improvement communities. This is the true
road ahead where OD can best help.
Motivational factors:
In a safety critical industry there are many intrinsic
motivators to avoid life-threatening accidents and
much of initial training is focused on multi-layered
safeguards and rules. Therefore, an interesting ques-
tion to ask is ‘What might be equivalent motivating
factors in a non-safety critical’ organisation? Possible
answers might include:
• Providing be er levels of customer service
• Reducing the cost of non-quality and rework
• Reducing stress and pressure caused by errors
• Making the organisation more profitable
• Increasing job satisfaction
• Increasing employee employment security
Some of the answers are similar to, but not as power-
ful as the factors present in aviation, nuclear or med-
ical organisations. In my opinion there are two options
to enhance such motivation. The first would be to in-
centivise error reporting financially; the second would
be to reward error reporting by non-monetary means,
such as employee recognition events and publicity
about individuals who demonstrate a high standard of
professionalism.
Two activities that have been used in organisations
which may provide an avenue for the type of error di-
alogue that we are seeking are; Quality Circles and
Suggestion Schemes, which are o en categorised
under the banners of ‘Participative Management’ or
Japanese style management. I will not describe these,
as I am sure most readers will have a general apprecia-
tion of their use. What is interesting though is the way
most western organisation have tried these methods,
o en as a fad, then dismissed them and moved on to
something else like Processes Improvement or Six
Sigma. There must be a way to re-energise these two
methodologies to achieve a similar response to an HF
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17. VOLUME 25 NUMBER 4 WINTER 2007P46
campaign and release the unknown error data from
the base of the iceberg to the leaders in an organisa-
tion.
In Summary:
In safety critical industries the Human Factors based
approach, which combines human error awareness
with a reporting and learning culture has been shown
as a most effective way to engage employees and elicit
detailed information on secret errors that the organisa-
tion can then use in preventive campaigns based on
education and feedback communication systems to
improve safety and quality. An ‘ethical and just cul-
ture’ is a key prerequisite for trust.
There is considerable evidence that formal systems,
e.g. TQM methods of controlling quality and processes
in organisations are not fully effective and that they
are too reactive to events; senior leaders are o en be-
mused as to why this is, and exactly what to do about
the situation.
A Human Factors based approach may offer a be er
alternative, but is neither a panacea nor a (palliative)
short-term measure. Considerable effort over a long
period of time will have to be invested to bring around
cultural changes, educate the leaders and allow the
building up of trust. The key is to demonstrate that
leaders do care about, and will take action to resolve
those items at the base of the Error Iceberg that are
perennial and invisible.
Next Steps:
Actions that can be recommended to others as a result
of my experiences with an HF based, error-reduction
campaign within Rolls-Royce include:
• Educate academics in business schools and
universities to HF principles and error reduction
methods, and encourage their inclusion within
existing curricula, especially in Business schools,
e.g. in MBA or MSc programmes.
• Educate consultants and OD professionals in HF
and during OD assignments they should aim to
build mutual trust and dialogue around error
management, supported by an appropriate internal
reporting and feedback system.
• Educate employees in basic HF training during t
their induction into any organisation and teach
them how to report errors and participate in feed
back activities.
• Educate Quality and business improvement
professionals about how to review their approach
and consider if they can adapt HF principles to the
benefit of their line-customers, remembering that
audits only reveal what is above the waterline of
the error ice-berg.
• Conduct further research to fully explore the
potential of HF based, error-reduction methods in
non-safety critical businesses and run a pilot
programme within a very large commercial
organisation.
Epilogue: As I write this final paragraph, I hear a
broadcast news report of a train derailment which
seems to be due to a maintenance error on a set of
points, with missing bolts alongside the track and a
safety inspection that was overlooked…...
References:
Australian Defence Force – Aviation Maintenance
ImprovementProjectAMIP,h p://www.defence.
gov.au/dgta/AMIP.htm, 2005
Burke-Litwin, A Causal Model of Organisational
Performance and Change, Journal of Management,
Vol 18, No3, 523-545 (1992).
Insurance Information Institute quoting National Air
Transportation Board statistics at h p://
www.iii.org/media/facts/statsbyissue/aviation/
Patankar S., Brown J.P. and Treadwell M. Safety Ethics
Cases from Aviation, Healthcare and
Environmental Health, Ashgate, 2005.
Reason James, Human Error, Cambridge University
Press, 2003.
Reason James, Hobbs Alan, Managing maintenance
Error a Practical Guide, Ashgate publishing,
Burlington USA.
Report of Presidential Commission on the Space
Shu le Challenger Accident,
Executive Order: #12546, February, 3rd 1986.
Source Aviation Safety Network quoting Hellenic
Aviation Authority, h p://aviation-safety.net/data
base/dblist.php?Year=2006
The Columbia Space Shu le Accident Investigation
Board, Vols I-VI, nasa.gov, August 2003.

18. VOLUME 25 NUMBER 4 WINTER 2007
Ward, Y. (2006), "Integrating Operational and Safety
Improvement in Aviation Through a European
Innovation Network", European Operations
Management Association (EurOMA) Conference
Proceedings, Glasgow, 18-21 June 2006.
Author’s Reflection
Rolls-Royce plc is a provider of power systems for use
on land, at sea and in the air. The company operates in
four global markets – civil aerospace, defence aero-
space, marine and energy. Gas turbine products are at
the core of the Company’s activities and the provision
of repair and a ermarket services provides a long-
term revenue stream, managed under ‘Total Care’ con-
tracts. A ermarket Services now generate over 54% of
the company’s total profits.
John Anfield is Head of Organisation Development
and Learning for the Aero Repair and Overhaul Busi-
ness, which provides a ermarket services through a
network of seventeen facilities, based on four conti-
nents. The business employs over 6,000 people, includ-
ing many in Joint Ventures established with major
Airlines. From within the unit’s central HR function,
John leads an OD team, which focuses on strategic is-
sues related to organisations, people and teams.
The large-scale, Human Factors intervention described
here was a very challenging OD project that took place
over a four-year period from 2003-2007 and which is
still in progress today. The critical challenges included:
convincing an executive team of the opportunity to
take a regulatory driven requirement and turn it into
an opportunity for building employee trust and creat-
ing an open reporting culture, so that preventative
steps could be taken to avoid costly maintenance er-
rors.
The challenge was overcome through a number of di-
rect interventions involving a strong HF communica-
tion programme and training of the entire workforce,
coupled with the building of an HF infrastructure to
support the reporting of errors and their investigation.
To undertake this project the author personally led the
campaign and has used his role as an internal consult-
ant to gain significant momentum, which eventually
resulted in the engagement of an external vendor to
deliver the majority of the face-to-face training for
managers and employees.
Rolls-Royce’s HF campaign has been highly effective
and a recent evaluation shows that 88% of the employ-
ees report an enhanced safety awareness regarding po-
tential human errors and over 77% stated that they
will open report hazards and errors to their leaders; as
evidenced by the 580 reports received in the past two
years. Over 60 % of the reports have now been closed
by management, and the nature of the reports has re-
cently changed, with tougher issues being highlighted
by employees. For the more complex problems, we use
formal investigative methods.
The HF Campaign continues today with five new pro-
grammes being delivered in 2007-2008, the most sig-
nificant one is the HF Seminar for Leaders. These
events will use real data from the operational engine
fleets and the local business error reports from their
own employees to drive a local dialogue around the
business pressures, ethical issues and decision making
models that managers must employ to operate safely
while meeting some very tough commercial targets.
Finally, at the two-year point our executives are now
reporting a clear downward trend in errors and re-
work costs; and, in addition, we now fully meet the
European Aviation Safety Agency’s (EASA) regulatory
requirements for Human Factors Training and Mainte-
nance Error Reporting.
Author’s Bio
John is the Head of Organisation Development and
Learning for Rolls-Royce’s A ermarket Services busi-
ness, which has 4,700 employees, who overhaul civil
and military jet engines. Overhaul facilities are located
at 17 sites in the UK, USA, Canada, Brasil, Hong-Kong
and Singapore, several are Joint Ventures with major
Airlines. From 1998-2003 John was the Director of Ca-
reer Development for Rolls-Royce North America Inc;
and before that he was based in Derby as the Aero-
space Group’s Management Development and Re-
sourcing Manager. John joined Rolls-Royce in 1992
and was the Engineering Group’s Training Manager
during a period of major organisational change and
growth of the product range.
Before joining Rolls-Royce John enjoyed a successful
career as an officer in the Royal Air Force Education
Branch, where he worked in operational squadrons,
management colleges, maintenance bases and helicop-
ter flying training units.
John is a Fellow of the Chartered Institute of Personnel
& Development, and a member of the American Soci-
ety for Human Resource Management, and he is also
certified in the USA as a Senior Professional in Human
Resources (SPHR).
John Anfield, Roll-Royce plc,
john.anfield@rolls-royce.com, (4726)
P47