Managing the Unexpected

High Reliability develops an organization’s strengths through individual actions.
Shared attitudes fill the gap between organization and the individual to determine High Reliability.

HRO Implementation: Stories, Case Studies, Metaphors and Examples

Aspects of Implementation:  What We Do

General Tips

"What I teach today must explain yesterday or be used tomorrow.  It could be called the 72 hour rule.  People come back to me later, sometimes the same day, sometimes as long as 15 years later, and describe something I had taught them and how it helped.  The material they describe works its way permanently into what I teach.

Teaching methods of thinking and problem solving to those without public safety or military experience has some difficulty.  How to think and solve problems in uncertainty is difficult in civilian education.  This material grows slowly and the novice may not see its importance.  However, senior students or recently graduated students have advised me to continue teaching this material slowly and not leave anything out.  New material that does not seem to make sense will make sense later after new lessons.  New material also builds on previous material and the experience of the student.  It does take more time as they do not learn the material in their didactic education.  This is the challenge of teaching a new culture to those who do not see themselves as being in a new culture.

When physicians begin working with paramedics they have asked me how to teach paramedics.  I recommended that the physician learn from the paramedics.  Soon enough the paramedics would be learning from the physician."

Daved van Stralen, MD, writes on Aspects of HRO Implementation, including:

The Individual, The In-determinant Problem, The Fear response, Decision Making, Vulnerability, Collaboration, Information Flow, Credibility: The Theory of Knowledge, and Functional Leadership.

Behavior Matters in Building Trust

"What you do has greater impact than anything you say. If your behavior does not demonstrate what you said you believe, value, or will do, then credibility will suffer and people will see you as insincere. Words declare intent and can create enormous hope. When the words are followed by validating behavior, they increase trust. People can and do change their behavior. Behavior shifts, changes in doing, can actually change the way you think."

These documents written by David Christenson, MA, based upon the works of Covey, Weck & Sutcliffe.

Boyd's OOD Loop

OODA Loop, click to see larger image


Building a Healthy Culture

David Christenson, MA, A paper presented at the Wildfire 2007 international conference of wildland firefighters in Seville, Spain, May 2007 and the Bridging the Gap Between Theory and Practice, European HRO Conference, April/May 2007. Deauville, Normandy, France

Build a Healthy Safety Culture Using Organizational Learning and High Reliability Organizing

Case Studies Of HRO Implementation in Organizations

The following have been produced by the U.S. Wildland Fire Lessons Learned Center in 2008 and 2009:

Historical Application of HRO Principles

HRO Principles in History:

Standardization for Adaptability: Maurice of Nassau and the Dutch Army, 1590

Standardization of equipment, actions, and responses enable predictability in behavior of others in the same organization at sites distant in time or location from the event.  This standardization contributes to predictability and gives the organization the ability to plan for contingencies...This paper discusses how Maurice of Nassau used standardization in the Dutch Army to make it more mobile, flexible, and effective when fighting the larger Spanish Army.


When the event continues past our plans we must somehow figure out what to do. At this point we act without preparation, we improvise. While it seems we cannot study this we can look to the arts where improvisation is not only routine, it is an art form. Here we will study Comedy Improv and Jazz Improv to better understand what Karl Weick terms “Constrained Improvisation.”

Comedy Improv

In Comedy Improvisation the players spontaneously interact with each other, not fully knowing where the other players are going as each plays off the other. Comedians and actors learn this as an art form which has developed rules since the 1950s.

One of the first, and more basic rules, is to accept the information. This involves trust, avoiding judging what is happening, and not negating or denying the line presented.

Add new information.  Make statements, don’t always ask questions. When you do ask questions remember that questions can also give information.  Give information to your partner, be specific and add details.

Look beyond the words. Words carry a large amount of information. If this is true, what else is true? There is unspoken dialogue in what the other actors say and don’t say along with how they say it. There is unspoken dialogue within the dialogue.

The actor must maintain awareness of other actors and their actions. Observe the impact of your response. Actors will each listen, watch, and concentrate.  They are all part of the scene, meaning you save your fellow actor during the improvisation. This does not mean you enter the scene without reason. You must subdue your impulse to act solely for the reason to enter the scene.  When you do act, you act to advance the scene.





Jazz Improv

Under construction

Ballroom Dancing

"Ballroom Dancing has many elements found in High Reliability Organizations (HRO) but on the scale of two individuals in the immediacy of a performance.  Without trivializing live-or-die situations, ballroom dancing, as many activities such as rock climbing, team sports, and mountaineering, uses the same methods as HROs which underscores the part the human mind has in reliability.  Isolated from the danger and melodrama of high-stakes activities, ballroom dancing provides a heuristic and metaphor for descriptions and discussions of highly reliable behaviors." - By Daved van Stralen, MD Dance Lead & Follow


Why does story telling work? Stories give context and meaning. Stories teach, transmit values and beliefs, guide behavior, and give support. This document written by Daved van Stralen, MD, also includes, "Types of stories," "How to Learn a Story for Story Telling," and "Elements and Structure of a Story for Telling," written by Linda Aldridge, MS, Member Florida Storytellers Guild, and Story Telling Assistant Professor, St. Petersburg College, St. Petersburg, Florida, in March 2009. Story Telling

HRO Before We Knew It Was Called HRO, (7/24/2009) by David A. Christenson, MA, on HRO implementation in a jet fighter squadron's quick reaction alert force operations in 1980.

Four HRO Implementation Stories from the Wildland Fire Lessons Learned Center's Staff Writer Jonetta T. Holt:

Mindfulness: Are We Managing Our Expectations? (7/2/2009) Incident management teams bring order to chaos. We believe order is a good thing. But when does order create blind spots for us? Challenge your routine of thinking that LCES is "in place" and we are good to go. What other routines are we susceptible to? (A related article written by Brad Mayhew titled "The Intent of LCES" was published in the FireRescue magazine in April 2009.)

Creating Resilience on a Fire Assignment (5/12/2009) Managers that lead crews and teams into high risk environments want to believe the group they are leading is skilled, capable, strong...resilient even. Do we know what we mean when we are talking about having resilience or behaving resiliently?

Morning Briefings Reinforce Deference to Expertise (9/14/2008) Briefing crew leaders about the potential hazards they face and actions to take when they become realities.

Tracking and Responding to Small Errors in High Risk Environments (7/25/2008) Responding to small system failures before they become big problems, even deadly catastrophes, without being able to pinpoint the actual cause is confusing and often creates hesitation.

Powered by liveSite Get your free site!