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.
Ways to discuss HRO
Here I consider these constructs as models like houses. There are styles such as the Cape Cod, Mission Revival, Arts and Crafts which are found in various places in the US but are out of place in others. The market may describe houses by their financial purpose such as starter homes, move up homes, income property, etc. The buyer and insurer may look at resistance to local disasters such as heavy snowfall and the Alpine roof, earthquake reinforcement, and windows and roof treatment of high winds from hurricanes or tornadoes. Firefighters describe houses by the challenges of fire suppression and spread or rescue operations, contractors look at building materials, and architects incorporate aesthetics into function. It is not wrong to have different models. We would like them to be congruent between the various descriptions.
These models of HRO allow us to (1) describe the variables in the environment, (2) present concepts congruent with said variables, and (3) offer these concepts as unifying principles for the purpose of translating HRO to new environments and organizations. Each model will create high reliability and facilitate translate of HRO to other domains and organizations.
- Collective enactment
- Business construct
- Domains of knowledge
- Reasoning and decision making
- Network formation
- Neurophysiology construct
Knowing these models we can discuss HRO with people of different backgrounds. Each model has a unifying principle we use for translation. The models, though, do more than enable communication, they describe the intricacies and complexities developing during the enactment phase of a high reliability response. Combining unifying principles of different models in a nonlinear manner produces the complexity that is HRO which confounds our discussions.
We unknowingly operate with multiple models, simultaneously balancing the opposites of each model along their axes while we work combining, separating, and recombining as we balance our way through enactment. For example, induction and deduction are a unifying principle – evidence is strengthened until, at some point, it becomes a fact (commonly a p value > 0.05). With sufficient facts we move to deductive reasoning. At the same time the threat begins to resolve and we move from the amygdala toward the prefrontal cortex relying less and less on the modulating activities of the cingulate cortex on the amygdala. This describes the interactions of the principle of induction-deduction and emotion-logic (fear-thought). Each of us has develops a different enactment (relativity) from induction and fear to deduction and thought which we can map on the principles used and their interaction.
Collective enactment develops when sense making of individuals comes from shared cultural attitudes and beliefs. This leads to collective mindfulness and collective enactment.
People will make sense of their environment and will do it quickly because our brain is structured to see patterns and search for or develop meaning or reasons behind those patterns. In the first hours after a submersion event for their child the family begins sense making. (Drowning is death within 24 hours and near drowning is survival past 24 hours, even if the victim dies in the 25th hour.) The quickest sense is to identify the person caring for the child and the last parent to have custody. Immediately those individuals are blamed and the groundwork for divorce has begun. Seeing this, I tried some interventions to change their sense making and we saw the mother and father grow tighter, though at the expense of support from the extended family. Sense making is organic and responds to the social environment as well as the person’s perceptions. In these situations I brought the health care team into the operation and we developed a collective sense making to include and guide the parents.
We can influence attitudes and sense making. Influencing attitudes, for example by indoctrination, is lengthy and requires a degree of intimacy between people. Influencing sense making can occur through changing the individual’s interpretation of the environment, knowledge of available resources, or assisting in identifying or changing the individual’s attributes. Depending on our relationship with the person (physician-patient or family or commander-subordinate / novice) we can influence attitudes but influencing sense making is more effective with fewer complications. This is the same with the public, influencing sense making before the event is more effective than during the event or immediately afterward. The longer we wait the more fixed and ingrained the attitudes become and the greater effect they have on behavior and, hence, belief.
From there sense making people will create attitudes. Sense making may be naïve, biased, or adaptive. The individual notices what is salient to that individual. To the naïve individual this is usually the positive space, those objects that one looks at to take notice. With experience the individual learns that the negative space, the space not involved with the current affair, brings meaning and focus to the positive space. Experiences may bias sense making or be adaptive to sense making in which case the individual may be better prepared for new threats or the unexpected.
There is a difference in how the naïve and expert view circumstances and this relates to positive and negative space. Coning attention to the salient features of the threat, the positive space, reduces understanding necessary to know limitations on the threat and sources of security. “What do I look for first? Safety or threat?
Sense making easily develops into mindfulness which describes an active involvement with the circumstances. Detail is important here but not any and all details, only the salient details necessary for problem solving. In an interdisciplinary team there will be different salient details needed by each member. Through open and assertive communication the team can grow collective mindfulness.
In public safety we tell recruits to immediately engage the emergency and, if you do not know what to do, then do something, anything. In this way they probe the situation and learn what works through action. But what works changes the situation, making it better or worse, and they have more to do. As others join them there is a collective sense making and, when they work closely together, collective mindfulness. By paying attention to the evolving situation and working off each other’s actions they create collective enactment and bring the situation to a conclusion.
Culture is a social response to the environment represented by knowledge acquired through social influences (here I will use cultural knowledge to differentiate this from scientific or religious knowledge). Basic assumptions and attitudes (values are a specific type of attitude) lead to specific behaviors which, when repeated, produce specific beliefs. From this the culture produces unique artifacts and creations we can use to identify a particular culture. In HRO studies this is the structure or architecture of the organization. High Reliability (HRO) Culture describes the social knowledge and shared meanings necessary for performance in the face of environmental threat, that is, members interpret the environment in a similar manner and act in a coordinated style. Because attitudes are not fixed or static and will interact with the environment, for example through problem solving behaviors, they can change with change in the environment. Successful problem solving reinforces the attitude while failed problem solving changes the attitude or creates new attitudes. This makes HRO cultures adaptive and evolvable, a requirement of culture.
Within an organization there are also environments which differ between levels of the organization and have stronger similarities to the same level in other, quite different organizations. This is the differing environments between executive environments with regulatory, financial, and market threats and the working environment. As described above, these environments also receive differing contributions from concepts and variables. Managers translate between the two environments.
Culture is defined by the cultural knowledge passed from elder to novice. In organizations cultural knowledge can be informal and independent of the central authority (executives and supervisors) or it can be designed or sanctioned by them. When there is an informal culture independent of the central authority there is risk for development of an underground culture or counter-culture driven by self-protection, either of individual s or their small groups. The description of HRO as a culture requires a description of the:
- Environment, particularly the mental environment responsive to physical, social, or physiological threats;
- Individual and collective attitudes (Weick & Sutcliffe Five Principles) which form a coherent pattern and explains why members behave the way they do;
- Behaviors, individual responses and actions to the environment, interpreted through Tinbergen’s Four Questions;
- Beliefs which develop from behaviors through the reduction of cognitive dissonance;
- Artifacts and creations, mainly the HRO structure (Robert's Approach to HRO) or meta-structure described as architecture in high reliability network discussion below.
There are Just Attitudes and Safety Attitudes but not really a Just Culture or Safety Culture if we accept the above definition and description of culture. Behaviors will always be specific to the local environment but the evaluative process or attitude is not. Therefore, to discuss HRO out of the context of environment we would use something independent of environment – attitudes.
As a Business Construct, HRO is consistent with the idea that the purpose of a business is to make a product for or provide a service to society by taking an input and processing it to produce an output. The core processes of business are those necessary for the specific product and financial operations and must be conserved in the face of environmental change or threat. Core processes can be specific to the organization or industry and or can be in common. Those processes in common are points of symmetry we can use to translate HRO to other organizations or industries.
Organizations are robust if they continue to function and survive when faced with environmental change or internal noise or friction. HRO describes these robust, successful organizations. In living systems it is not survival of the strongest but survival of the fittest (most responsive to change) and fit derives from the ability to survive. Robust systems are hardy and vigorous, resistant to environmental perturbations to a degree they survive long enough to change. They can be sufficiently hardy and make changes slowly or they can be sufficiently complex and make changes rapidly. Rapid changes require greater variation within the organization for adaptive or evolutionary innovations but excessive variation makes inefficient use of resources. The ability to create innovations on the spot can meet the need for variability for change and strength for robustness.
Organizations are like all living organisms, unimaginably complex yet resilient. It is counter-intuitive that complexity produces resilience rather than fragility. To survive unexpected changes in the environment or in new environments the organization needs variation in its traits, keeping some traits that, though not useful in the present, could adapt for future circumstances.
HRO conserves the core functions of the business to allow resilience from damage, to adapt to short-term changes in the environment, or to evolve with permanent environmental changes. Resilience is the capacity to resist damage and recover quickly. Adaptability is the ability to cope with unexpected disturbances through change in structure or behavior to increase survival when the environment changes. Evolvability is in the sense the organization can either acquire novel properties or has the ability use variation to adapt through permanent structural changes in response to changes of the environment.
Greater evolvability enables these organizations to exploit more effectively new environments. This ability also enables the organization to exploit current environments so there is not much difference here. In resilience, adaptability, and evolvability the environment can only act on existing traits exposed to the environment. Internal structures not affecting these visible traits or plans do not contribute toward resilience, adaptability, and evolvability. In this sense, the organization can only act with existing structures and behaviors for an emergency.
This is possible because of the flow of information is maintained by relationships to ensure communication. Also, authority migrates to local areas where action must be taken in a timely manner. HROs accomplish this by ensuring information from the environment goes to the executive environment where strategic decisions are made centrally to guide actions in the external environment. Peripherally, tactical decisions lead to actions where immediate response is needed. The manager can enhance or impede information flow and authority migration by his or her attitude during routine operations.
During low tempo times long feedback loops support strong strategic decisions. In high tempo times short feedback loops allow rapid response to local threats based on local actions. This contains adverse events and produces resilience.
As Domains of Knowledge, HRO can be described by its Cognitive, Behavioral, and Affective Domains. The Cognitive Domain is our factual knowledge organized in concepts, principles, and laws. For this discussion, I define laws as those specific principles where the circumstances dictate a response like the law of gravity. This is the easiest to catalogue and teach as it is amenable to pedagogical and andragogical techniques (adult education for self-directed autonomous learners), particularly PowerPoint. The Behavioral Domain is how we use the knowledge in action. Though commonly thought of as skill-based knowledge such as working with tools it can also be thought of as action, such as team formation and communication. This is taught through simulation labs and in real-time, real-life situations. HRO has been taught from these two domains because the experience of educators lies in these domains and which are amenable to teaching programs. This underscores the difference between educators with professional training and experience in the Affective Domain of knowledge and those without. Affective knowledge and attitudes have a central role in recruit training for the military and public safety services.
Those who operate in dangerous environments look more closely to a person’s attitude which is in the Affective Domain of knowledge. There is a clear belief that the organization can teach the novice the cognitive and behavioral knowledge necessary for the job but the novice must bring a certain attitude. Attitudes are not so much taught as they are created or learned though there is initial indoctrination into the organization’s values and attitudes (initiating attitudes). Values are a specific type of attitude. Because some attitudes are intensely personal, such as values, there is a resistance in the public to teach or create initial attitudes through the indoctrination process. To some it encroaches on the concept of free will and freedom of thought. Because attitudes are more closely held they are less visible to researchers where cognitive knowledge can be tested and behavioral knowledge can be observed by its effects. Working side-by-side, attitudes are more visible.
This creates a gap between practitioners who believe HRO is learned from the Affective Domain and educators or researchers who believe HRO can be taught from the Cognitive and Behavioral Domains. Because attitudes are portable and independent of the environment they are effective means to translate HRO between organizations. They are also effective means to bring hazardous behaviors from home to the working environment. However, they can only be internalized and not imposed so they are learned through experience with guided interpretation of that experience or learned from modeling and mentoring.
Teaching HRO we would have the goal of making the novice feel comfortable in these situations and find patterns that have meaning. Learning HRO we would model and mentor for specific attitudes.
As a Reasoning and Decision Construct, HRO describes how a person identifies and is responsive to potential or possible threats. HRO goes beyond immediate personal safety in this model to ensure the organization’s productivity despite threats. I will divide this into three sections: safety and understanding, hypothesis testing, and decision making. This sequence describes why a person may start enactment toward self-preservation rather than problem solving.
A person must feel safe to function effectively. The brain processes information twice as fast through the fear center (amygdala) than the thought center (prefrontal cortex). Quite rapidly the person will evaluate the circumstances for threats that can be general and observable or specific to the individual. The latter could be someone they had a negative encounter with or someone in the room may elicit emotional memory where the trigger is in the present but the reaction is from the past. For example, an innocent person in the room may have the facial expressions or mannerisms of a school yard bully the person had fights with decades earlier. Here, the person first identifies threats then identifies if the situation is safe. After security is ascertained the person will make sense out of the circumstances to achieve understanding, that is, to find patterns in the circumstances, then give meaning to those patterns to “know” what is happening. This can be guided by an authority figure but the sense making will happen regardless.
After safety and understanding the person may have to solve a problem. This will be through abductive, inductive, or deductive reasoning processes. Abductive reasoning describes how the person rapidly creates and tests a hypothesis based on the observable circumstances and situation as understood by the person. In inductive reasoning the person has evidence of varying strength (reliability) and has the goal of increasing the strength of the evidence to support a conclusion. The goal is to increase the inductive strength of the hypothesis. This is different from deductive reasoning where the person has facts (proven data) that guarantee the hypothesis (correctness of the conclusion). For inductive reasoning the person improves the strength or reliability of the evidence to support the conclusion whereas in deductive reasoning the person identifies facts and deduces the correctness or truth of the hypothesis. Simply put, we strengthen inductive conclusions with better / stronger evidence and prove deductive hypotheses with facts (100% correct).
You can see that deductive reasoning is preferred by scientists, regulators, and supervisors while operators, who do not have the luxury of facts, must constantly evaluate the strength of their evidence. Operators, then, must focus on confirming or dis-confirming their conclusion as a continual process incorporating new information. This is why dis-confirming evidence is critical to HRO people.
There are also some neurological correlates to inductive and deductive reasoning. The brain has a system that is relatively fast but heavily influenced by context and associations. This is similar to induction. The brain also has a system that is more deliberative and analytic or rule-based and is slower. This is similar to deduction.
Convergent or Divergent Thinking - besides these methods of reasoning is the difference between thinking patterns for threat. Conventional thinkers and the lay public prefer to have ideas come together, to converge, toward a single best or correct answer from a clearly defined question. This focuses on gathering information, recognizing the familiar, and identification of a ready-made answer if one is available (protocol or policy). In the face of threat this does not always work. A different approach is to use Divergent Thinking using fluency (the rapid recognition of patterns or production of ideas), flexibility (simultaneous consideration of alternatives), originality (produce novel ideas different from what is expected), and elaboration (think through the details and carry out the operation). As you see, divergent thinking is congruent with enactment for threat and uncertainty.
Decision making derived from deductive models is deterministic (the situation determines the intervention which determines the outcome) and relies on algorithms. Decision trees were introduced in the early 1960s to aid in decisions when data will not become available until after the decision is needed. Faced with uncertainty identifying safety or using inductive reasoning, the person will probe with feedback loops. These must be short loops for safety as there is little time to generate information. The more common feedback loop with significant complexity in its structure is the OODA Loop developed by John Boyd.
Decision making in uncertainty or during the unexpected is problematic as algorithms and decision trees assume a starting point yet there may not be a clearly delineated starting point or multiple starting points could exist. In dynamic states the person may not have sufficient time to identify where to start the decision process. Circumstances such as these, not knowing the situation well enough to start or not knowing what intervention will work, require decision methods targeted at identifying an achievable objective or decomposing objectives that are not achievable then developing multiple interventions that could work and select and test them as circumstances allow or permit. Here, accuracy has priority over precision in the search for what works. The decision maker follows the coda of the artillery, “Ready, Fire, Aim.”
Faced with threat and uncertainty one is best served by rapid identification of threats, inductive reasoning with divergent thinking, and short loop decision making will improve the effectiveness of enactment to simultaneously develop safety and generate information while bringing control to the situation. This is HRO.
As Network Formation, HRO describes how individuals come together at a problem or disturbance and organize themselves for a solution. For larger problems or longer standing situations they interact with others to form a network. In this manner an organization creates a structure that will rapidly respond to threats while maintaining the core functions of the organization, a description of an HRO.
These environmental perturbations result from simple principles or rules with nonlinear interactions resulting in complex situations. That is, though we arbitrarily divide the environment into discrete variables for specific purposes, the environment is made of continuous, nonlinear variables. Complexity derives from these continuous, nonlinear interactions. We find patterns in the environment, this we cannot help, then give meanings to these patterns, all this from our brain’s neurological structures. From these putative structures we identify our unique principles and beliefs. These perceived patterns guide our behavior locally. Complexity produces new and unexpected properties in the system.
This spontaneous, self organization is an internal process as opposed to the architecture or structure imposed on the organization by design. The observed pattern of this self-organizing response is due to positive and negative feedback loops in the local area rather than following a previously developed plan.
Spontaneous organization around a problem gives it the appearance of planned structure when the structure actually comes from self-organization. Self-organization occurs from local effects with positive and negative feedback loops much like water drops on glass. Water tension, a positive feedback loop, holds the drop together, and gravity, a negative feedback loop, pulls the drop flat. Drops will coalesce between these forces to reach a stable state. People act in a similar manner responding to a threat. A hallmark of an HRO is the balance of opposing forces or principles in response to uncertainty such as creativity vs. conformity or initiative vs. obedience.
This requires information, judgment, and action. We can call such a unit where this occurs, either person or group, a node which can be an individual, team, or larger group. Thus nodes can group to become larger nodes with nodes inside nodes and networks inside networks and so on. The function of a node is to process stored information for execution of some action. (This acts as a fractal incorporated in each increase in node size.) These judgment or decision nodes are linked by information and authority pathways or links with stronger linkages marking more vibrant movement of information (information + relationship = communication) and authority to act (authority migration). Because the linkages between nodes have different strengths the linkages and patterns are not random. This creates what is called a scale-free network.
Networks with random placement of nodes and links will have an average number of links per node. As the network grows in size the number of nodes and links must also grow. Also, if there are more nodes the network needs more links, if more links, the network needs more nodes. In the scale-free network the structure does not change based on increase in size or complexity. The network can grow through preferential attachments of the links. These links, in human networks, may show intent and describe the social network. HROs can be part of the design of the network or will be a meta-construct overlying the organization’s architectural design. This is how social networks form.
These networks are best described as groups of links rather than their nodes. Scale-free networks do not lose the overall network connectivity when a random node is removed. This explains the robust nature of the HRO scale-free network. Any damage to a node or group of nodes does not block communication or authority migration.
Linkages, either information flow or authority migration, can be used to explain communication using information theory as well as the command structure.
Nonlinear interaction of simple principles, particularly continuous, non-linear variables, produces complex environments and complex responses to the environment. Imagine any two of the HRO principles interacting with each other to varying degrees. These feedback systems can occur between two limiting factors such as carrying capacity and predation in a prey species. If the equation for this interaction has too high of a constant (3 is the number) then in fairly short order the system changes so much that its trajectory is dependent on the initial state and small variations in the initial state result in tremendous changes in trajectories. This is the math behind Deterministic Chaos.
As a Neuropsychology Construct following neuroanatomic structures, HRO is the balance between the amygdala and prefrontal cortex that occurs in the cingulate cortex. It is simplistic to say we are victims of the amygdala, an almond-shaped organ in the brain that directs our fear response. (Here, fear is the physiological emotion rather than a psychological feeling.) Covert, compensated states of fear can be seen in Situational Cognitive Distortions and there are methods one can be trained in to overcome the threat response.
Fear in the physiological sense creates the responses of fight, flight, and freeze mediated through the amygdala. In the lay sense, fear is a feeling commonly associated with weakness. Emotions have an unrecognized physiological basis demonstrated by the response to powerful odors. Certain strong odors produce involuntary gagging or vomiting while certain odors, even mildly, can produce nostalgia. Both sensations, one accepted as physical and one as a feeling or emotion, are processed the same way, through the amygdala.
The fear response of fight, flight, and freeze come from the amygdala. Fight and flight are mediated by adrenaline and freeze, a trait of prey species, is mediated by cortisol. The amygdala takes perception immediately to action without mediating influences. They manifest in people as anger, avoidance, and confusion. The amygdala is responsible for the distress in Hans Selye’s stress model.
The Prefrontal Cortex is responsible for the Executive Functions of the brain: planning (future thought), binary decision making, cognitive flexibility, abstract thought, and discrimination of sensory information. This matures in late adolescence, completing (as much as it will) by 25 years of age. Engineers and planners function here. The Prefrontal Cortex is responsible for the “no stress” part of Hans Selye’s stress model.
The Cingulate Cortex modulates the amygdala, processes error identification, and uses adaptive decision making. (It is the HRO Cortex.) The Cingulate Cortex is responsible for the eustress part of Hans Selye’s stress model. Function in the Cingulate Cortex controls emotion, identifies error, and makes adaptive decisions which work rather than are the best. This is what is used in HRO.
There are neurohormones associated with these operations. The threat hormones of adrenaline, cortisol, and vasopressin are all uncomfortable. The hormones associated with collaboration (oxytocin), problem solving (dopamine in the nucleus accumbens), serotonin, and enkaphalins (long-acting endorphins) are all pleasurable. Successful HRO organizations keep their people in the good hormones.
|Prefrontal Cortex||Cingulate Cortex||Amygdala|
(courtesy of Patty Sokol)
Situational Cognitive Distortions
Because people have a hard time accepting these behaviors as fear responses I have coined the term Situational (or Tactical) Cognitive Distortions: Anger or frustration, plausible avoidance or withdrawal, and confusion or freeze. Choking is added for those skills one needs but have not entered the midbrain as well-rehearsed actions. They remain in the cortex and cerebellum which causes the choke. The difficulty of Situational Cognitive Distortions is that they unexpectedly affect one’s judgment creating an unrecognized fear response. We do not recognize them in ourselves as we use judgment to judge our judgment. We cannot judge this deterioration of our own judgment. Judgment deficits and these distortions occur with hypothermia, environmental hypoxia, fatigue, and threat or fear. This is the significance of self-awareness in HRO.
One result of extreme threat is the production of emotional memories in the amygdala. These are the only memories that never extinguish and can lead to reactions before the person can identify what is happening. In primates some are genetic such as the sinusoidal wave form representing snakes. People who work in dangerous environments will develop their own sets of emotional memories unique to them. This can be seen when an “old timer” reacts out of proportion to the circumstances. My experience is, when see this disproportionate reaction, to assume the trigger is in the present but the person is responding to the past. Emotional memory in the amygdala is the basis for Post-Traumatic Stress Syndrome. Emotional memory will influence sense making and situational awareness.
There is discussion that collaboration, mediated by oxytocin, is the fourth fear response. The military and public safety train recruits to collaborate.
Modulate the amygdala
The amygdala and the physiological threat response can be overcome in the individual using the following four techniques. Though many of us use these techniques, they are captured as four techniques adapted from four recommended by an officer for the US Navy SEAL training:
- Goal setting. Clear and concrete objectives that can be decomposed to smaller objectives as needed. This helps the frontal lobes to focus and bring structure to chaos and overcome the amygdala, we see patterns in confusion.
- Mental rehearsal. Anticipate what can go wrong and visualize how you would respond WITHOUT the use of movies (this is where the untrained person gets it wrong). Then, when you do it for real it is really the second time you did it. In 1974 the LAPD taught us to plan for any contingency, even a plane dropping out of the air into a neighborhood next to you. I thought that was just plain bizarre. In 1986 two planes dropped out of the air in the city of Cerritos nowhere near an airport. The US Navy and Marine Corps Aviation calls this “Chair Flying”, where the pilot flies an entire flight in his or her mind while sitting in a chair, mimicking what would be done in an aircraft.
- Self-talk. Focus your thoughts and make positive comments to over-ride the amygdala. This is attitude.
- Arousal control. Breathing deeply and slowly mimics our relaxation response and stimulates efferent branch of the Vagus Nerve that provides pleasurable sensation. This is similar to the positive affect from smiling (holding a pencil in the teeth works) or the negative affect from frowning (holding a pencil with the lips works).
From my experience, I would add:
- Speak softly and use straightforward terms. Melodrama and excitement, even transmitted by voice, increase the flux of adrenaline involved in the situation.
- Do something to reach a previously obtained objective. Several people have described how this pulled them out of the cortisol-induced freeze. In one US Army study (Berkun, et al 1962) soldiers were placed in situations where they believed they might die. Those who focused on a task remained at the scene while those who did not ran away. The more focused the soldier was on the task the more calm they were.
- Collaboration – reach out to a supportive member of your team.
“And he shows me carefully, the valley where the two mountains of reason and emotion meet and twine their efforts together in winding streams that quietly defy your logic.”
- Vivienne, a teenager writing in her diary about her grandfather shortly before she committed suicide