Cook & Company

Commentary

Some years ago I was fortunate enough to land on

assumptions  and  to  candidly  report  problems  or

the aircraft carrier USS Nimitz and watch day and

failures, no matter how small. HROs conduct inci-

night carrier operations for two days. I was  given

dent reviews of unexpected events, no matter how

access to every part of the ship I wanted to visit, and

inconsequential.  They  conduct  them  frequently

marveled  at  the  precision,  consistency,  and  safety

and  soon  after  the  unexpected  occurs  –  before

with which some 5,000 individuals launched, recov-

people  have  a  chance  to  review  their  stories  to

ered, prepared and repaired dozens of aircraft, day

justify  their  actions   and  protect  their  images.

and night, in all weather.

HROs encourage viewing close calls as a kind of

early warning that reveals potential danger, rather

From that point on, I wondered if what I had experi-

than as evidence of success and the ability to avoid

enced had any relevance to organizational effective-

disaster. They are wary of the potential liabilities

ness. A recent article detailing a  conversation with

of success, including complacency, the temptation

an   organizational   psychologist   named   Dr.   Karl

to  reduce  margins  of  safety,  and  the  drift  into

Weick (reported in the April, 2003 issue of Harvard

“automatic processing.”

Business Review) rekindled my interest. Dr. Weick

has written several books on what he calls Highly

Reliable Organizations (HROs), like aircraft carri-

2.  Reluctance to Simplify Interpretations and

ers,  nuclear  power  plants,  and  emergency  rooms.

Recognition of Diversity in Thought

His premise is that HROs have  much to teach  us

about  how  to  make  our  own  organizations  more

HROs understand that the world they face is com-

effective.  I think there is considerable validity in his

plex,   unstable,   unknowable   and   unpredictable.

analysis, and have excerpted below a number of the

They   know  that   simplifications   produce   blind

important  concepts  from  Weick  and  Kathleen  M.

spots and they take deliberate steps to create more

Sutcliffe’s book, Managing the Unexpected.

complete and nuanced pictures. They simplify less

and see  more. They encourage  diversity because

HROs practice what  Weick calls “mindfulness,”

different  people  see  different  things  when  they

a state which encompasses five critical behaviors:

view the “same” event. If people work in a varied,

complex  environment,  those  people  need  varied

1.  Preoccupation with Failure

complex  sensors  to  fully  register  the  environ-

mental  complexities.  Simple  sensing  often  over-

HROs treat any lapse in performance as a symptom

looks  both  hints  of  the  unexpected  and  a  wider

that something is wrong with the system, something

range  of  options  to  deal  with  it.  Furthermore,

that  could  have  severe  consequences  if  separate

HROs encourage negotiating tactics that reconcile

small errors happen to coincide at one  awful mo-

differences of opinion without destroying the nu-

ment. They increase their knowledge base by creat-

ances that diverse people detect.

ing  a  climate  where  people  feel  safe  to  question

3.    Sensitivity  to  Operations  and  Operational

tween normal times, high-tempo times, and emer-

Relationships

gencies  and  clearly  signal  which  mode  they  are

operating  in.  Decisions  come  from  the  top  when

HROs   have   ongoing   concern   with   unexpected

the  mode  is  normal,  they  migrate  during  high-

events which usually result from “latent failures,”

tempo  operations,  and  a  pre-defined  emergency

or loopholes in the system’s defenses, such as im-

structure kicks in when there is imminent danger.

perfections  in  supervision,  reporting  of  defects,

safety training, and hazard identification. HROs are

Interestingly,  Weick  posits  that    there  are  three

attentive to the front line, where the real work gets

ways in which conventional strategic planning is

done. They train people to have situational aware-

at  odds  with  the  HRO  approach  to  managing

ness  and  to  make  continuous  adjustments  which

the unexpected:

prevent  errors  from  accumulating  and  enlarging.

They communicate constantly to deepen people’s

First, plans  are  built  from  assumptions  about

understanding  of  the  interdependent  workings  of

the  world  which  influence  what  people  see,

the complex system. Anomalies are noticed while

what they take for granted, what they choose to

they  are  still  tractable  and  can  still  be  isolated.

ignore and thus narrow perceptions by reducing

HROs are aware of the close tie between sensitivity

the range of things that people notice.   Any-

to operations and sensitiv-

thing    that    is    deemed

ity to relationships. People

“irrelevant”  to  the  plan

in  HROs  know  that  you

gets  only  cursory  atten-

can’t develop a big picture

tion. Yet it is these data

of operations if the symp-

that   exist   outside   the

toms     remain     cloaked,

limits   of   our   foresight

whether     through     fear,

that are often the seedbed

ignorance or indifference.

of the unexpected events.

So we need to put a pri-

4.    Commitment  to  Re-

ority  on  taking  note  of

silience

the  unexpected  and  the

abnormal.

HROs   develop   capabili-

ties to detect, contain, and bounce back from those

Second,   plans   can   undercut   organizational

inevitable errors and circumstances that are part of

functioning  because  they  specify  contingent

an indeterminate world. HROs learn from error and

actions designed to cope with the future.  But

implement that learning through fast negative feed-

they  restrict  attention  to what  we  expect  and

back.  Resilience  is a combination of keeping  er-

they limit our present view of our capabilities

rors  small  and  of  improvising  workarounds  that

to those we now have.   In other words, they

keep the system functioning. This means they work

tend to preclude improvisation. So we need to

to  develop  knowledge,  capability  for  swift  feed-

incorporate in our plans processes to deal with

back, faster learning, speed and accuracy of com-

the unexpected.

munication, experiential variety, skill at recombi-

nation of existing response repertoires, and comfort

Third,   plans   presume   that   consistent   high-

with improvisation. HROs mentally simulate worst

quality  outcomes  will  be  produced  time  after

case conditions and practice the equivalent of fire

time  if  people  repeat patterns  of  activity that

drills.  Managers  in  HROs  regard  successful  fire-

have  worked  in  the  past  –  but  routine  can’t

fighting as evidence that they are resilient and able

handle novel events. So we need to describe a

to contain the unexpected.

planning  world  in  which  the  unexpected  is

routine!

5.  Deference to Expertise

One of the best aspects of Weick’s perspective is

HROs cultivate diversity, not just because it helps

that it has nothing to do with adopting yet another

them  notice  more  in  complex  environments,  but

management “fad of the month.”  Instead, he ad-

also because it helps them do more with the com-

vances  several  key  concepts  which  have  proven

plexities  they  spot.  HROs push  decision  making

effective  in HROs in a way that draws our atten-

down and around. Decisions are made on the front

tion, and which we  can use to improve organiza-

line, and authority migrates to the people with the

tional effectiveness in our own enterprises.

most expertise and specific knowledge of the event,

regardless  of  their  rank.  HROs  differentiate  be-