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Ambiguity, uncertainty, change, risk - are any of these factors impacting your organization's performance? How is your organization reacting to these challenges? If you are implementing changes, do they really represent change, or is it at heart just business as usual, performed with a heightened sense of urgency?
According to Karl E. Weick and Kathleen M. Sutcliffe of the University of Michigan Business School and authors of Managing the Unexpected, a powerful source of remedy for these challenges can be found through careful examination of the management practices of high reliability organizations, or HROs. HROs, such as the nuclear power industry, firefighting crews, aircraft carriers, and others, perpetually operate under trying conditions yet experience fewer than their fair share of problems. Why? According to research data gathered over ten years by the authors of Managing the Unexpected, HROs share five unique characteristics: - Preoccupation with failure
- Reluctance to simplify interpretations
- Sensitivity to operations
- Commitment to resilience
- Deference to expertise
In the HRO world, small incidents receive as much attention as large incidents. Why? As author Ken Bloch of Flint Hills Resources points out in his article, Don't Let a Bad Economy Spoil Useful Reliability Habits, major accidents are rarely caused by a single, discrete event, but rather from complex and unpredictable interactions between multiple "minor" failures. Unfortunately, unlike HROs, many organizations do not foster an atmosphere conducive to the reporting of minor incidents. In fact, Weick and Sutcliffe point out that unless people feel safe to report incidents, they will ignore, or cover them up. QUESTION 1: Does your organization foster an environment in which workers are encouraged to report errors without fear of negative retribution? Do you have systems in place which allow for the timely and accurate reporting of incidents? HROs consistently resist tendencies to simplify assumptions, expectations, and analyses. When faced with a failure, representatives from multiple groups meet and share hypotheses about what is going on, what can be done, and what the long-term, system-wide consequences of any actions might be. As discussed in Enhancing the Value of Root Cause Analysis, the building of a cross-functional root cause analysis team is a critical step in the root cause analysis process and has several strategic advantages, including providing a broader range of knowledge, viewpoints and program ownership. QUESTION 2: Does your organization support a decision-making climate that embraces and encourages interaction and interpretations from all departments? In the HRO, operations is the king. Even small operation interruptions get undivided, widespread attention, helping assure that the unexpected gets noticed early. As Paul Casto, author of Six Key Factors to Building and Sustaining a Reliability and Maintenance Program, points out - "Operations is an often overlooked group whose participation is required for a reliability and maintenance improvement program to be maximized and sustained. Operations personnel work with the equipment on a daily basis and understand the operating and failure characteristics of the equipment. Their operating knowledge provides key information to identify and prevent conditions that lead to equipment damage." QUESTION 3: Do you pay serious attention to operations? Do you support operations personnel with the necessary technology to report out of limit conditions? And, once reported, do you act on them? Even HROs suffer unexpected events. Then what? Here too, authors Weick and Sutcliffe find two distinguishing characteristics within the HRO - a commitment to building resilience and deference to expertise. Error and the unexpected are pervasive. This is one of the overriding messages put forth by Weick and Sutcliffe. What the authors say is often not pervasive, outside of HROs, are well-developed skills to detect and contain errors at their earliest stages. Their explanation for this, in part, is our sometimes-overdeveloped focus on anticipation and corresponding need to develop procedures to avoid anticipated problems. While procedures hold numerous virtues, conditions sometimes change faster than the procedures and procedures cannot anticipate all situations, i.e., the response will only be as good as the procedure. The HRO on the other hand, is committed to resilience. HROs assume they will be surprised, so they concentrate on developing general resources to cope and respond to change swiftly. Weick and Sutcliffe share "When events get outside normal operational boundaries in HROs, knowledgeable people self-organize into ad hoc networks to provide expert problem solving. These networks have no formal status and dissolve as soon as a crisis is over. Such networks allow for rapid pooling of expertise to handle events that are impossible to anticipate. The ability to come together informally as the situation demands increases the knowledge and actions that can be brought to bear on a problem." QUESTION 4: Does your organization pay just as much attention to building capabilities to cope with errors that have occurred, as it does to improving capabilities to plan and anticipate events before they occur? There is a distinctive hierarchical twist in HROs - they place a premium on expertise over rank and decisions migrate both downward and upward as conditions warrant. The designation of who is the important decision maker migrates to the person, or team, with expertise in solving the problem at hand. QUESTION 5: Are expertise and experience more important than rank when trying to solve critical problems in your organization? If you've answered yes to all five questions, you might think that this is a measure of your organization's success. We'll leave you with a description Weick and Sutcliffe share on how success is viewed within the HRO: "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 of their own abilities, of their manager's skills, and of their organization's existing programs and procedures. They trust the procedures to keep them apprised of developing problems, in the belief that those procedures focus on the most important events and ignore the least significant ones. In effect, success narrows perceptions, changes attitudes, feeds confidence into a single way of doing business, breeds over-confidence in the efficacy of current abilities and practices, and makes leaders and others intolerant of opposing points of view. The problem is that if people assume that success demonstrates competence, they are more likely to drift into complacency, inattention, and predictable routines. What they don't realize is that complacency increases the likelihood that unexpected events will go undetected and accumulate into bigger problems."
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