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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.


Our Book: High Reliability for a Highly Unreliable World: Preparing for Code Blue through Daily Operations in Healthcare.   PRICE $24.99


OUR BOOK IS ON Amazon! Get it here. Read About



Safety Culture: Enhancing Transportation Safety.

September 10-11, 2013, the National Transportation Safety Board (NTSB) will convene a forum titled, "Safety Culture: Enhancing Transportation Safety." The forum is free and open to the public. No registration is required. For more info

Recommended Leadership Books

We asked the 2013 HRO Conference Attendees about books they liked.
Here is an in depth list of some of the best!

View List


Systems and processes are essential to keep the crusade going, but they should not replace the crusade.
- Simon Sinek


Tactical Improvisation: San Bernardino City Fire Department

Please feel free to download and read the following PDF submitted regarding the  "After-Action/ Comprehensive Analysis of the Active Shooter Incident Response by the San Bernardino City Fire Department." The full 117-page official report on the attack—good reading as a training document—can be accessed free of charge with a click of the download button below.


To the Responders on December 2, 2015,

Significant improvement and insight can be made, not only internally, but for other first responder agencies throughout our country when the voices of the responders are heard. Those who responded to the IRC building that day, did so with consummate courage and professionalism. The collective training, dedication, and immediate actions of these first responders undeniably saved lives. We are extremely grateful to the responders who volunteered to relive the emotional events of December 2, 2015, in an honest attempt to not only improve their response to future incidents, but to share these insights and lessons learned with other agencies across the nation, enhancing their response capabilities.

What is HRO?

High Reliability Organizing (HRO) developed as a means to make an organization or unit stronger. In its natural state we historically found it in environments of danger or uncertainty such as military combat, firefighting, or business activities. While proactive components (plans and anticipation) and reactive components (after action reviews) are necessary parts of HRO, High Reliability itself derives from the ability of the organization and individuals to interact in real time with uncertainty or threat from the external environment.

HRO describes on the organizational level the structure necessary for High Reliability, on the social level the collaboration found in response to threat, and on the individual level the satisfaction of problem solving while modulating threat responses. These three levels facilitate the free flow of information and the migration of action for a quick response to, and interaction with, surprise or accelerating events. The High Reliability Organization emerges from the interactions between people responsive to the environment in an organization that allows this.

The problem of HRO?

The High Reliability Organization is commonly described as an organization that performs high risk work but without rare, catastrophic events. Researchers, as outside observers, have identified principles and characteristics to describe or characterize HROs but these tend to be distinct, and sometimes complex. Some of these principles are directed toward the organization’s structure and while some describe group interactions. Even more complex descriptions cover the processes of a crisis. While researchers attempt to describe how to move toward High Reliability they have not described how HROs originally formed. The overall research is unsettled to produce confusion between structural and functional principles, how to change people and organizations (most work describes imposed change), and the variety of the principles are assumed to be continuously connected. This has created confusion and gaps in our knowledge of HRO.

As longtime practitioners of what is now called High Reliability we believe these knowledge gaps come from unrecognized concepts and principles. These gaps can be connected when we view HRO as derived from specific attitudes and the importance of engagement of the situation when surrounded by uncertainty. Also inadequately discussed are descriptions of decision making with imperfect information along with understanding the ability of the individual to modulate the brain’s threat, or fear, response.

Why consider HRO?

In the world today we deal with uncertainty and threat. This can be on the personal level of family or job, on the business level of the economy, or in geopolitics. High Reliability, evolved for optimal performance in an environment of uncertainty and threat, can strengthen a person’s performance, improve the function of a team, and move an organization forward through uncertainty.

HRO, derived from human reasoning and behavior, looks at the commonality of decrements in quality, resilience, and safety. After all, these differ only in what is harmed: the product, the system, or a person respectively. It appears intuitively obvious that resources used for Quality, Resilience, or Safety (the QRS Complex) will not be available for Productivity. However, when done correctly Quality, Resilience, and Safety will improve along with Productivity. This is the process of High Reliability.

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