High Reliability Organisation

Five principles about a HRO, that you need to know

This blog outlines what characterises a High Reliability Organisation, and why these five key principles relate equally to both projects of mind and of management.

I begin with a quote from two of the stalwarts of this topic and who nicely frame a reality I think most can relate to in any management or organisational setting.

is it really all that rare to have optimistic plans, insufficient staff, mis-estimates of complexity, broken promises, overlooked details, turf-battles, loss of control, unanticipated consequences? No!

Weick and Sutcliffe 2007 “managing the unexpected : resilient performance in an age of uncertainty” pp17.

This essay is focused upon the ability of a project to respond effectively to whatever circumstances become real. When the static plans, that were so good on paper, face the chaos of real world interactions. Those interfaces that were ignorant to the precision of the project script. How best to prepare for this change? How ready is the project to meet this friend or foe? How would the manner of your project preparedness, compare to the HRO?

Much of this sentiment perhaps applies equally well to people’s personal lives. The personal plans, lack of time or money, failures to anticipate, be ready, or adapt. There is opportunity to consider all scale with similar concepts of preparing for the unknown.

To plan or to train?

For me, this is fundamentally what the High Reliability Organisation is doing differently to most. Through the manner of organisational infrastructure, the attention to planning and training becomes quite differently orientated. As does the cultural implication too.

Much as we may associate emergency services, or armed forces, or special teams in some sports, there is a plan but it is the nature of the training that makes the adaptability count for more. Case studies in this area have focused upon processes upon US Navy Aircraft Carriers, emergency wards in hospitals, air traffic control, nuclear power plants. High profile failures have also been examined through this same lens. There are lessons and practice challenges that should be of interest to all.

High Reliability Organisations

Lekke (2011) writes a comprehensive review of the literature pertaining to HROs. Reflecting upon literary debate from 1990 onwards the more reliability-enhancing focused literature i.e., processes that an organisation uses to successfully manage its risk (as opposed early definitions that focused on accident statistics) present the most meaningful guidance for wider organisational application (Lekke 2011, pp5-6). This paper is available free from the HSE, and a link to the download page is offered toward the bottom of this blog.

The earlier work by Weick and Sutcliffe from 2007 is a more comprehensive examination of the five principles I address today. It is therefore their book that will draw the most comment and quotations in this blog.

Karl Weick and Kathleen Sutcliffe 2007 “Managing the unexpected : resilient performance in an age of uncertainty” 2nd ed. San Francisco, Jossey-Bass. Karl Weick is a professor of organisational behaviour and psychology, and author. Kathleen Sutcliffe an award winning researcher (2006), author and professor of management and organisations. I quote and summarise findings from chapters two, three and four. However, the fifth chapter, not elaborated upon in this blog, is well worth a read too – Assessing capability for resilient performance – a series of audit process steps that enable an assessment of corporate mindfulness across HRO principles.

Weick and Sutcliffe’s five HRO principles

These five principles are what are deemed the most pertinent to characterise an organisation truly focused upon safety in high risk environments. They are further elaborated upon further into this blog.

  1. Principle one – Preoccupation with failure and learning (per Weick et al 2007)
  2. Principle two – Reluctance to simplify. “less simplification allows you to see more. HROs take deliberate steps to create a more complete and nuanced pictures of what they face and who they are as they face it. Knowing that the world they face is complex, unstable, unknowable, and unpredictable, HROs position themselves to see as much as possible” (Weick et al 2007 pp10)
  3. Principle three – Sensitivity to Operations. “less strategic and more situational than is true of most other organisations. When people have well-developed situational awareness, they can make the continuous adjustments that prevent errors from accumulating and enlarging” (Weick 2007 pp13, citing Endsley (1995))
  4. Principle four – commitment to resilience. “a combination of keeping errors small and of improvising workarounds that allow the system to keep functioning. Both of these pathways to resilience demand deep knowledge of the technology, the system, one’s coworkers, and most of all, oneself” (Weick et al 2007, pp14)
  5. Principle five – Deference to expertise. “decisions are made on the front-line, and authority mitigates to the people with the most expertise, regardless of their rank” (Weick et al 2007 pp16).

HRO five principles and five factors of mindfulness

Weick and Sutcliffe produced an earlier paper, entitled “Mindfulness and the quality of organisational attention” 2006, Organisation Science 2006 4:7-8 pp514-524 which per page 519 gives consideration to mindfulness as it pertains to HRO characteristics. Preoccupation with failure; reluctance to simplify; and sensitivity to operations; commitment to resilience; deference to expertise; all outlined across a stability (or instability) of attention. Concluding that where HRO failings arise these may be characterised as the weakened mindful attention which they term as “mindless” as actions become too routine and attention becomes more diffused.

Note the convergence with individual Mindfulness practice

This prompted me to revisit John Vervaeke’s five factors of mindfulness. These are examinations of ones self whilst in meditative practice. It is derived from eastern traditions upon which Mindfulness has been popularised in the west. I have blogged about John Vervaeke before. There is more than a little to compare across the five factors of both.

The five factors of mindfulness

Each of these five factors is as Vervaeke describes them. I offer the HRO principle that correlates in italics

Vigilance – as new awareness not accepting familiarity, being watchful, enquiring, exploratory. To this I equate HRO preoccupation with failure e.g., tracking all failures (Weick et al 2007 pp2)

Sensitivity – ensuring the unfolding process can be further understood, as would be comparing a movie developing over time, vs a still of a picture. This I equate to HRO deference to expertise. The expert at the scene is seeing an incident unfold, any command and control delay can only be acting upon summary or picture moments to the film.

Acuity – unpacking and observing each part. HRO Reluctance to simplify.

Flow – discern and discriminate, observing physical characteristic, emotional state, and the intentions of attention or distraction of the mind. HRO Sensitivity to operations

Reminding – in such analysis being reminded to retain the vigilance and not become distracted from why the attention has been brought to the present. HRO commitment to resilience, e.g., managerial interest in retaining capabilities to resilience (Weick 2007 pp2)

HRO Five Principles as applicable to behavioural control

Weick and Sutcliffe split these five principles into two groups. Principles of anticipation. Principles of containment. (Weick et al 2007 pp42). I now present these same principles in these two groups. And include the corresponding principle as it applies in Mindfulness. Have in mind how these relate to preparations necessarily being coordinated in respect to behavioural controls.

Anticipation

PRINCIPLE ONE – preoccupation with failure. [Vigilance]

Embrace failure by paying close attention to the weak signals of failure; and by amplifying the attention to what these weak signals are, so that all parties can be on the look out for them (pp46). Detection may be made easier with check-lists; vigilance to failed processes of operation, follow-up, or checking; awareness of resource stretch or communication failures; awareness of distraction by multiple task. Or by asking the better questions that are hands-on; addressing criticality; and at least as frequently as needed. As a leader, being candid about our own failures can become encouragement for others to do the same (pp48). Reporting failures; encouraging and even rewarding the reporting (pp49) which can promote greater trust.

PRINCIPLE TWO – reluctance to simplify [acuity]

HROs simplify slowly, reluctantly (pp54). By example of the need for caution, here are some listed hazards of when too quickly assigning labels:

  • minor works by value can be equated to less importance (pp55)
  • shared labels but diverse meaning (pp 56)
  • labelling too early denies further acquaintance (pp 57) and draws us away from more detail and hidden early warning signs (pp 58)

PRINCIPLE THREE – sensitivity to operations [flow]

This is about the work itself, what is actually happening (pp 60). Interdisciplinary and interdepartmental interactions both increase credibility and trust, but also deepens peoples understanding of the interdependency of the complex system itself. This includes leader and manager availability at key moments of transition, communication, or change (pp59). Quantitative and qualitative knowledge are equally valued, face-to-face dialogue equal to reports (pp60). Beware the mindless routine (pp61). Beware the complacency of all is okay (pp61)

Containment

PRINCIPLE FOUR – Commitment to resilience [reminding]

Resilience is a form of control (pp70). It reflects three abilities: absorb strain; stretch and recover not collapse; learn and grow (pp71)

“human fallibility is like gravity, weather, and terrain, just another foreseeable hazard”

Weick et al 2007 pp68

the mode of resilience is based on the assumption that unexpected trouble is ubiquitous and unpredictable; and thus accurate advanced information on how to get out of it is in short supply.

Aaron Wildavsky (cited via Weick et al 2007 pp 69)

PRINCIPLE FIVE – deference to expertise [sensitivity]

The Karlene Roberts term is “migrating decisions, both up and down” (pp74). There is no place for delegation to an expert and leaving them to it. Citing the NASA Columbia enquiry “mission management welcomed this opinion and sought no others” in respect to one manufacturer opinion of tile efficacy going unchallenged (pp76).

HROs make an effort to see what people with greasy hands knows

Weick and Sutcliffe 2007 pp77

Expertise not experts – meaning an assemblage of knowledge not a person or institution. The example offered reflects ad hoc and self-organising networks that collectively provide expertise to solve a problem – without formal status and that dissolve as crisis is averted. This is characterised by pooling of expertise, flexibility, empowerment, based on increased skills and insight (pp 78). It also requires credibility (pp79), i.e., trust.

The comparison of personal awareness through careful and open meditative or contemplative practice, and the necessary attention necessary of management if a HRO environment is to be nurtured present opportunity for further examination of behavioural control theory in both project and psychological settings. The comparison made here is to demonstrate how connected these examinations may be possible to draw insight.

people in HROs work hard to counteract the tendency to seek confirmation by designing practices that incorporate the five principles. They understand their expectations are incomplete and that they can come closer to getting it right if they doubt those expectations that seem to confirmed most often

Weick and Sutcliffle, 2007 pp27

Additional factor comparisons

Saleh et al (2010), offered these same principles but the differently nuanced explanations offer some additional context to organisational commitment if following a HRO type ideal:

Production and safety as concomitant organisational goals. What Saleh et al (2010) summarise as organisational consensus i.e., as shared by all levels from senior management to front line operators;

Decentralised vs centralised operations with deference to expertise. An ability to shift from central authority during routine operation to the deferring to expertise at the location of situation in moments of need. Particularly where safety critical and time constrained. (per Weick et al 2007) “authority migrates to the people with expertise, regardless of their ranks” but also noting HROs operate centrally in normal times to engender culture, ensure training and readiness for crisis situations.

Organisational slack and redundancy. Enabling available mobility of task aware resource “if primary units fail or falter” (LaPorte TR., Consolini, PM. 1991)

Projects | within projects

mindful people have the “big picture” but it is a big picture of the moment…

…mindfulness is different from situational awareness in the sense that it involves the combination of ongoing scrutiny of existing expectations, continuous refinement and differentiation of expectations based on newer experiences, willingness and capability to invent new expectations that make sense of unprecedented events, a more nuanced appreciation of context and ways to deal with it, and identification of new dimensions of context that improve foresight and current functioning.

Weick and Sutcliffe 2007 pp32

A key factor of my current theorising and research motivation is my ongoing belief that the modelling of psychology and the modelling of project management and organisation theory have common ground. In the HRO I believe this to be particularly the case. The greater level of self awareness we can achieve as individuals, the equivalent increased awareness within a project or a firm. It seems to me more than coincidence that Weick and Sutcliffe write in the language of mindfulness and that my own comparisons with John Vervaeke’s psychological work in this area connect so completely.

v | behaviour | t

people in HROs try to weaken the grip of this invisible hand of expectations so that they can see more, make better sense of what they see, and remain more attuned to their current situation. They do this by attending to at least the five principles…

Weick and Sutcliffe 2007 pp32

There will be more to say on visibility and trust as cross references to both HROs and engagement with practices of mental training as outlined in mindfulness in non-escapism forms. Much of the five principles of both reflected upon here connect principally to behaviours and will therefore be revisited as challenges of accounted for same are researched and blogged upon further here.

Applicable to projects of any kind?

All materials I have reviewed to date on HROs consider the organisational readiness for crisis. The first major challenge is to connect this better to projects, and all parties therein not just the organisations that oversee them.

HRO principles steer people toward mindful practices that encourage imagination…it takes mindful practice that encourage imagination, foster enriched expectations, raise doubts about all expectations, increase the ability to make novel sense of small interruptions in expectations, and facilitate learning that intensifies and deepens alertness

Weick and Sutcliffe 2007 pp29-30

Creativity – rather than industry obediently completing without questioning a task – is a factor of personal assessments in the Big Five psychological tests. It always intrigues me that such industry is deemed a preferable factor in business application – I score low on industry (i.e. preferring creativity) which never did my job prospects any harm. This is reflected upon via several, more qualitatively focused, literature references I have blogged upon of late. Such principles may overlap between mind and management – as mindfulness or similar – but a sound and academically credible connection beyond mere comparison is yet to be adequately made, at least by me.

This is very much a work in progress. But the HRO was overdue some attention on this site.

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Additional credits

It was Professor David Stupples, from the School of Mathematics, Computer Science, and Engineering at City University who first introduced me to High Reliability Organisations. It was about this time two years ago. Deep into the introductory module of my Project Management MSc. Project Lifecycle with focus upon Systems Engineering – Systems Theory, Systems Management, Engineering Economics – then onto theorising about safety management. There we were told to read around the concept of the HRO.

I am also grateful to Professor Stupples keeping the HRO concept as a regularly feature in past exams. Alas, for me, January 2020 was not one of those times – for I had prepared a lengthy essay response – but the notes from that preparation aided my writing of this blog.

Some useful resources and links

Not all academic papers are accessible to all. The attached links are therefore offered as useful and worthwhile reading.

HSE link – The Health and Safety Executive (HSE) reviewed the HRO literature in 2011. The research was conducted by Dr. Chrysanthi Lekka.

HighReliability.org – this link is useful to compare the focus of different leading authors. I particularly like the directional attention toward the disaster response as either proactive or reactive, and how some key academic writers have addressed HRO inputs.

McKinsey & Company – this article considered the HRO from a more operational perspective. The focus on communication, problem solving and leadership all reflective of wider HRO traits. I particularly like their 2×2 explanation of locational accountability and strength (cf. Principle 5).

Deloitte 2017 – 35 page document that captures much of the language and concepts reflected above.

LaPorte TR., Consolini, PM. 1991 “High Reliability Organisations” Journal of Public Administration Research and Theory 1991 1:1 pp19-48

Pate-Cornell ME 1996 “Uncertainities in risk analysis : six levels of treatment” Reliability Engineering and System Safety 1996 54:2-3 pp95-111

Weick KE, Sutcliffe KM 2006 “Mindfulness and the quality of organisational attention” 2006, Organisation Science 2006 4:7-8 pp514-524

Weick KE, Sutcliffe KM 2007 “Managing the unexpected : resilient performance in an age of uncertainty” 2nd ed. San Francisco, Jossey-Bass.

Saleh et al (2010) list the following as key works of wider reading:

  • Turner, BA., Pidgeon, NF. 1997 “Man Made Disasters” 2nd Edition, Oxford Butterworth Heinemann
  • Perrow, C. 1984 “Normal accidents : living with high-risk technologies” New York Basic Books.
  • Karlehn Roberts works from 1987-1990
    • Rochlin, GI., La Porte, TR., Roberts, KH 1987 “The self-designing high reliability organisation”. Reprinted in Naval War COllege Review 1998, 51:3 pp17
    • Roberts, KH 1990 “Some characteristics of one type of high reliability organisation” Organisational Science 1990 1:2 pp160-176;
    • Roberts, KH 1990 “Managing high-reliability organisations” California Management Review 1990, 32:4 pp101-113
  • WASH-1400 and Probabilistic Risk Assessment (per Kaplin and Garrick).
    • Kaplin, S., Garrick, BJ 1981 “On the quantitative definition of risk” Risk Analysis 1981, 1:1 pp11-27

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About Me

In psychology we are required to look beneath the mask. This blog series is attempting to unmask some hidden parts of projects to engender a more collaborative way.

Find my professional mask here: