Why are dangerous places safe? Lessons from HROs


"I felt exactly how you would feel if you were getting ready to launch and knew you were sitting on top of 2 million parts — all built by the lowest bidder on a government contract."

- John Glenn


A plane landing on a carrier slows from about 250 kph (150 mph) to zero in seconds. It stops by catching a hook on a steel wire connected to enormous hydraulic motors under the flight deck. Hooking the arresting wire is difficult, made tougher when the carrier is in motion, tougher again at night, and horrendously difficult in rain or bad weathera. Consider also, that the plane carries jet fuel, and sometimes high explosives while landing above a nuclear power plant and an explosives magazine. It doesn't get much more dangerous than this. So why is it that nuclear aircraft carriers have better track records than most businesses?

Some of the best research in the area of risk management comes from studies into an area known as high-reliability organizations (HRO’s). HRO’s include organizations such as nuclear power plants, aircraft carriers, and air traffic control. At any given time, there are between 5,000 and 10,000 planes in the air. And yet our track record with air safety has only been improving for the past few decades. The complexity of this sort of a system is staggering.

HROs are notable because "these organizations have not just failed to fail; they have actively managed to avoid failures in an environment rich with the potential for error." [1] That ability to actively and reliably manage to reduce the chances of mistakes occurring, rather than to avoid the hazards, has been the distinguishing hallmark of most HRO’s. Their experience offers many lessons for the application of risk management at the enterprise level.

Five Elements of Successful Risk Management

Research [2] into this area suggests that five key elements contribute to a state of ‘mindfulness’:

  1. Preoccupation with failure

  2. Reluctance to simplify interpretations

  3. Sensitivity to operations

  4. Commitment to resilience

  5. Deference to expertise

At first many of these processes appear to be self-defeating on multiple levels. But, as they further explain why these processes are necessary if a high-reliability organization is to be successful their validity becomes increasingly more apparent.

Preoccupation with failure

A healthy amount of paranoia or preoccupation with the potential for failure is part of a recipe for success. An antidote to complacency. HRO’s like most organizations celebrate their successes but “a chronic worry in HROs is that analytic error is embedded in ongoing activities and that unexpected failure modes and limitations of foresight may amplify those analytic errors.” [2]

“You're mind is working at its best when you're being paranoid. You explore every avenue and possibility of your situation at high speed with total clarity.”

― Banksy, Banging Your Head Against a Brick Wall

Reluctance to simplify interpretations

Most organizations are happy to handle complex issues by simplifying them and categorizing them, thus ignoring certain aspects. HROs, however, take nothing for granted. They build cultures which attempt to suppress simplification because it limits their ability to envision all possible undesirable effects as well as the precautions necessary to avoid these effects.

HROs pay attention to detail and actively seek to know what they don't know. They endeavor to uncover those things that might disconfirm their intuitions despite being unpleasant, uncertain or disputed. Skepticism is also deemed necessary to counteract the complacency that many typical organizational management systems foster.

Sensitivity to operations

Sensitivity to operations points to “an ongoing concern with the unexpected. Unexpected events usually originate in ‘latent failures’ are loopholes in the system’s defenses, barriers and safeguards who’s potential existed for some time prior to the onset of the accident sequence, though usually without any obvious bad effect.” [2]

Management focus at all levels to managing normal operations offers opportunities to learn about deficiencies that which could signal the development of undesirable or unexpected events before they become an incident. HRO’s recognize each potential near-miss or ‘out of course’ event as offering a ‘window on the health of the system’ – if the organization is sensitive to its own operations.

Commitment to resilience

HRO’s develop capabilities to detect, contain, and bounce back from those inevitable errors that are a part of an indeterminate world. The hallmark of an HRO is not that it does not experience incidents but that those incidents don’t disable it. Resilience involves a process of improvising workarounds that keep the system functioning and of keeping errors small in the first place. Another word for this commitment might be persistence.

"Nothing in the world can take the place of persistence. Talent will not; nothing is more common than unsuccessful men with talent. Genius will not; unrewarded genius is almost a proverb. Education will not; the world is full of educated derelicts. Persistence and determination alone are omnipotent. The slogan Press On! has solved and always will solve the problems of the human race."

- Calvin Coolidge

Deference to expertise

HRO’s put a premium on experts; personnel with deep experience, skills of recombination, and training. They cultivate diversity, not just because it helps them notice more in complex environments, but also because rigid hierarchies have their own special vulnerability to error. As highlighted by the work of James Reason and HFACs, errors at higher levels tend to pick up and combine with errors at lower levels, exposing an organization to further escalation.

HRO’s consciously evoke the fundamental principle of risk management – that ‘risk should be managed at the point at which it occurs.' This is where you will find the expertise and experience to make the required decisions quickly and correctly, regardless of rank or title. The most junior sailor on the deck of an aircraft carrier has the authority to abort a landing or takeoff if they see a safety issue. Something as simple as a piece of metal on a deck that might be invisible to the pilot or the Captain can lead to a catastrophic crash. This is one of the best examples of devolving responsibility to the point at which risk occurs.

Unfortunately most organizations do not work at this level, preferring to manage risk through the introduction of standard operating procedures, policy and work instructions. While these undoubtedly have their place and can help people to make quick and consistent decisions, a significant body of research also indicates that the blanket application of these controls can reduce individuals ‘mindfulness’ and personal responsibility, thereby contributing indirectly to increasing operating risk.

Other lessons from HRO’s

Other lessons from HROs include the strong support and reward for reporting of errors based on a recognition that the value of remaining fully informed and aware far outweighs whatever satisfaction that might be gained from identifying and punishing an individual. In other words, they want to hear the bad news. Before it becomes worse news.

There is no place for shooting the messenger in HROs. That is a recipe for catastrophic failure and the sort of behavior that most of us have seen too often. A culture of reporting and trust is a culture where people can also learn from their mistakes.

The Icarus Paradox

Many experiments have shown that people who succeed on tasks are less able to change their approaches even after circumstances change. (The hammer and the nail syndrome). Starbuck and Milliken in their analysis of the Challenger disaster said: “Success breeds confidence and fantasy.

When an organization succeeds, its managers usually attribute success to themselves or at least to their organization, rather than to luck. The organization’s members grow more confident in their abilities, of their manager’s skills, and of their organization’s existing programs and procedures. They trust the procedures to keep them appraised of developing problems, in the belief that these procedures focus on the most important events and ignore the least significant ones.” [3]

This level of complacency is a breeding ground for inadequate or ineffective organizational risk management and needs to be fully considered when reviewing the internal context and the risk management context.

DISCLAIMER

Following the five principles above won't make you capable of landing a jet aircraft on the deck of a moving carrier on a rainy night, unless you're already a Navy pilot.

REFERENCES

[1] Rochlin, Gene (1996) "Defining 'High Reliability' Organizations in Practice: A Taxonomic Prologue," p. 15 in Roberts, Karlene, ‘New Challenges to Understanding Organizations’, Macmillan Publishing Company, New York, USA [2] Weick, Karl & Sutcliffe, Kathleen (2001), Managing the Unexpected: Assuring High Performance in an Age of Complexity, Jossey-Bass, New York, USA [3] Starbuck, W. H. and Milliken, F. J. (1988) “Challenger: Fine-tuning the odds until something breaks”, Journal of Management Studies, Vol. 25, 319-340, New York, USA

#Risk

© 2020 Julian Talbot