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.


High Risk Organizations

The study of crises and catastrophes became more successful when Charles Perrow, a sociologist, became involved in the study of Three Mile Island. Before then, accidents were studied from the engineer’s eye as a technical problem to solve and, when possible, place the cause on human failure. While Perrow was studying Three Mile Island two other researchers were studying human behaviors during crises, Karl Weick as a social psychologist and Karlene Roberts as an organizational psychologist. From these three scientists came what is now called Normal Accident Theory (NAT) and the codification of High Reliability Organizations (HRO).

But years before these events men were fighting fires, crime, and wars using the best tools they had at hand – their minds and buddies. Similarly, men and women were running businesses where failure could destroy livelihoods and they, too, used their minds in a manner that was captured by the US War Production Board during WWII as Training Within Industry (TWI). This had been described from RAdm Thomas A. Mercer, USN, (retired) and his command of the USS Carl Vinson and Daved van Stralen, MD, FAAP, and his use of EMS and fire service methods to develop a pediatric intensive care unit.

This section presents descriptions of the work by Perrow, Roberts, and Weick along with the methods used by Mercer and van Stralen. Also covered are descriptions of the differences between Roberts and Weick and between HRO and NAT. It concludes with descriptions of other models discussed for high risk organizations.

Accident and Reliability Models

At the risk of extreme reductionism, NAT describes the consequences of human-machine interactions, that is, a source of threat (physical or technological), while HRO describes a social response to uncertainty, complexity, and threat (behavioral and physical), that is, a social behavior. NAT Diagnosis, HRO Prescribes. HRO is not a solution but a response and does not guarantee success but does guarantee successful response.

Accidents are so expected they are normal writes Perrow. People can organize to a degree of reliability that accidents won’t happen or be severe writes Roberts and Weick. Except now, it seems they, too, differ as Roberts tells us we can model our organizations from successful HROs and Weick tells us we find the path through mindfulness. Hollnagel now comes over and we learn how to engineer our own resilience. These methods could be separate silos where we gain refuge, cylinders of excellence we take pride in, or we debate with each other from our territorial imperative and argue their exclusionary nature.

Let’s enter an art gallery or climb a nearby mountain summit and think about this. Using our chosen metaphor to observe the activities, a painting (you can think Breughel as I do or Bosch but use care if you choose Dali or Picasso) or a cityscape (we can approach the events as a bird flying from the summit downward toward the field). 

We now can close in toward the activities from expansive, including all that is around unfolding events, toward small groups of people toward individuals, using artistic license to enter each person’s mind. The certitude of distance tells us accidents are inevitable. The ambiguity of proximity shows us nuance, accidents are preventable. George Orwell describes this well in “Shooting an Elephant: A story always sounds clear enough at a distance, but the nearer you get to the scene of events the vaguer it becomes." And the vaguer it becomes the more slack for us to find preventability. Let’s suspend our disbelief for a few moments and look.

We look upon a factory from some great distance. Moving closer we see a gauge turn. A red line is passed. Stream comes from somewhere deep in the machinery. Some people seem to go on about their business, appearing oblivious to what is next, others begin to watch, expectantly, as if watching will bring some control or relief, or maybe watching will produce more information. We cannot see their reason. The gauge appears to cause other gauges to change and gears begin to fail, valves open or close, all too quickly and people cannot respond quickly enough. Valves, gears, gauges, people, linked too tightly together and move too fast. We cannot tell what causes what or how to stop it. We witness the birth of the next minute. We see things from afar and with a greater world view, one that makes us think this is to be expected, that accidents of this nature and magnitude are normal.

Moving closer, we see people working together. Orders are given and followed. People seem to recognize risks and are observant of what is around them and how others respond. They seem to read each other, not by listening, actually read body movements, posture, and position. By their actions they recognize acknowledgment of events and appear to capture events, attenuating, slowing, and changing, in some way influencing events as they happen. Time becomes captured. Though events seem to be captured, we cannot know if others were prevented as what is prevented does not exist, neither do imaginary things exist or what is conjured by imagination. Prevented danger and imaginary danger, one and the same. But we see people organizing and, through their efforts, we begin to see curtailment of the unfolding crisis. Will something new initiate another series of events before this resolution? We do not know nor do we know if it will be curtailed. But this is what we see, coming closer, looking at organized reliability.

Even closer we now recognize individuals who seem aware of events and what is going on around them. Their actions change with fluidity though unpredictable. Everyone acts and reacts and interacts with each other and unfolding events. We think of amalgamation, what is separate but cannot be separated. Each new situation gives birth to another; each movement bears another new and different world. Different because each person is involved and changing the facts as if facts could exist in this state, or if facts could matter now. Each person is part of an equation yet to be solved. Each person is part of the problem, choosing to be part of the problem not in the negative sense of causation but in the positive sense of solution by immersion. They are mindful and enacting to their next future as a group. We are coming closer to the event where we begin to feel heat though not close enough to burn, we are mindful. We enact our own future.

We come closer to what is happening. The heat causes discomfort, even distress. We could leave and not burn. We can stand motionless as if the heat will not see us. By not moving we momentarily cease to exist, somewhere else yet standing at the same place. We could yell in anger, lash out and, in our rage, force the heat back, propelling our desires through the air. When we become angry do we propel our desires or our fears? Who are we shouting at? Our anger only isolates us. We must act. Do the right thing but do no harm. What is the right thing and what will not harm us? We cannot know as any movement hurts and by hurting it frightens. Confused and isolated does anyone see us or hear us? Those around us seem to ignore us, pay us little heed, they do not respond to our entreaties or anger. Are they feeling the same as we feel or are they indifferent?  Someone is acting, engaging the valve. Someone is acting, directing people what to do. Someone is acting, removing the heat. Without words they act in unison with a common direction. They do what works. It is unpredictable but also what is expected. Though others have been there they have not, meaning this is as new to them as if it were new to the world. In real time someone else’s experience is less useful than a fairy tale. By engaging, by staying with each other, they come together. One can survive alone but by surviving he dies. We can die together but by dying together we live.

The accident, this normal accident, has created an environment as its potential and as an event, that people must respond to and work within. Either to prevent it if they can, contain it if they cannot, but diminish it as possible.

People organize naturally for it. They also organize naturally to create the normal accident. Are these accidents inevitable or have we been lucky? We have the choice to live in such an environment of explorations and danger or we can ignore it. To avoid it risks our future.

Strength. Make the team stronger starting with the lowliest. Those who seem most inconsequential, give them the freedom to act. Saying no must be difficult as it takes no strength of the mind to say no but saying yes requires thought. One says “Yes, how can we” while another says ”No and we should not.” “How can we” takes us into uncertainty. “We should not” returns us to shore and safe harbor. Everyone is important. Take care of that and the flight deck takes care of itself.

We have moved from the geography of life to how we organize ourselves to how we work together to how we protect ourselves to how, together, we can move through uncertainty. This is Perrow, Roberts, Weick, van Stralen, and Mercer.

How we respond as an individual to the birth of the next minute, and how we work together, is the detail that produces high reliability or tragic failure. It is this minutia we discuss in this website.

Shooting an Elephant. George Orwell (1903-1950)

Models of HRO

Just click one of the names below to view an HRO Model.

HRO Model Overview | Perrow/Complex OrganizationsMercer/Naval Aviation | High Reliability OrganizationsRoberts & Libuser/Organizational Psychology | Weick and Sutcliffe/Social Psychology | Slagmolen/Change | van Stralen/Neuropsychology | HRO & Normal Accident Theory

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