Why a Preoccupation with Failure is a Necessity for HROs

By Lowers & Associates,

The very first sentence in Weick and Sutcliffe’s important book about High Reliability Organizations (HROs) is “Nonobvious breakdowns happen all the time.”[1] A “breakdown” is a failure. The first of five principles of HROs they discuss is the “Preoccupation with Failure.

Why is failure so important in the concept of the HRO? More importantly, in the day-to-day functioning of HROs?

The first answer is that in the HRO, every failure or anomaly is treated like the canary in the coal mine. Even the smallest failure is an indicator of a potentially significant problem, and every failure calls attention to an aspect of the HRO’s operations that can be improved. Failure is treated as an opportunity.

Putting this in the context of what an HRO is helps to understand why failure is such a core component. Writers continually refer to HROs as adaptive or resilient organizations. HROs are learning organizations that observe on-going operations closely and objectively, making changes as needed to maintain and improve performance over time. This ability to learn is increasingly embedded in the culture of every operating unit so that eventually, every part of the organization is contributing to the overall on-going success of the whole. This capability gives the HRO the ability to adapt to unexpected, “nonobvious breakdowns.”

The information needed to make adaptive course corrections is found in the failures.

Weick and Sutcliffe say that HROs are preoccupied with failure in three ways:

  1. They strive to detect small, emerging failures because they may point to more dangerous or systematic failures elsewhere in the organization.
  2. HROs try to anticipate failures, and ensure that those risks are mitigated.
  3. HROs accept that knowledge is incomplete, even about their own operations, and do not make complacent assumptions about “obvious” events.[2]

The preoccupation with failure points at the fact that much of the strength of the HRO is through the widespread adoption of attitudes and behaviors in the cultural domain. Members of the culture learn to recognize anomalies in performance, and to do that they must first know the expected operation deeply. Then, when anomalies/failures occur they must report them into an accepting chain of communications.

In the HRO culture, members learn to recognize “emerging mistakes”—they refuse to deflect attention from small anomalies that might evolve into major failures. They refuse to normalize small deviations from the expected and they avoid complacency. The organization institutionalizes the experience of failure to build on it and support the effort to recognize pattern failures. Members of HRO organizations are skeptical, they allow themselves to experience and express doubt.

A popular view on individual performance is that people should not be afraid to fail. Failure is a learning opportunity that can help the person perform better in the future. This metaphor captures the HRO’s preoccupation with failure accurately.

To learn more about the HRO, download our latest whitepaper titled, Building a High Reliability Organization.

[1] Weick, Karl and Kathleen Sutcliffe. Managing the Unexpected: Sustained Performance in a Complex World, 3rd Edition. Hoboken, NJ, John Wiley & Sons: 2015. p. 1.

[2] Weick and Sutcliffe, Ibid. p.46.

Can the Cash Processing and Transport System Become a High Reliability Organization?

By Lowers & Associates,

A High Reliability Organization (HRO) is one that achieves desired outcomes consistently, despite operating in a highly complex environment characterized by high risks. It learns from its failures, even those unanticipated, and uses them to improve over time.

Could the Cash Processing and Transport System (CPTS) operate like an HRO? Let’s begin by determining if CPTS shares the characteristics of an HRO. … Continue reading

5 Principles of High Reliability Organizations

By Lowers & Associates,

High Reliability Organizations (HROs) are anomalies. They exist in the kind of very complex, fast-evolving environments where you would expect chaos to prevail. But it doesn’t. HROs are able to cope successfully with unexpected conditions. That’s what makes these unusual organizations so attractive to researchers.

What can we learn from them?

Knowledge about HROs is rooted in what we call “heroic” organizations like aircraft carriers and air traffic control systems where a thousand things must go right every moment or someone dies. People like Karl Weick and Kathleen Sutcliffe, two of the most prominent scholars in the field, are beginning to stretch the concepts developed by evaluating HROs to apply to less heroic settings like banking, healthcare and manufacturing.

Weick and Sutcliffe use the phrase “mindful organizing,” which entails “sense-making, continuous organizing, and adaptive managing” to summarize the approach taken by HROs.[1] They identify 5 principles that make up the body of mindful organizing found in successful HROs, and in organizations that aspire to that continuously high reliability.

1. Preoccupation with Failure

Systems in modern organizations are complicated, and they experience failures. HROs focus like a laser on failure; they give “continuous attention to anomalies that could be symptoms of larger problems.” The basic insight here is that big problems don’t emerge fully formed in an instant. They are almost always preceded by smaller problems or anomalies, or evidence that would point to the big problem if it were given proper attention.

What HROs do NOT do is assume that if a control in place succeeds in containing a failure, everything is right. They look deeper into an incident to find underlying causes. They also do not lump a failure with common elements to another into a class that all are alike. Evidence is gathered and evaluated.

2. Reluctance to Simplify

Complexity means that organizations have numerous potential sources of failure, and HROs do not apply generalized terms to describe them. It is a common and convenient response to a problem to name a general kind of cause and consider it a solution, e.g., ‘the bank has a state of the art alarm system’ so the failure of the alarm can be fixed by replacing it. What if the alarm’s failure is caused by something deeper, what specifically was the cause? In HROs, the occurrence of a failure is taken as an opportunity to dig deeply into the details of the system involved to find a real cause-you differentiate the details within those broad, convenient generalizations.

3.  Sensitivity to Operations

Operations happen in real time, they include both discrete components and the system they compose. As such, operations generate outcomes that we can observe. The HRO continuously evaluates outcomes to determine if they are in fact serving the objectives of the organization. They do not assume that the continuous outcomes will be the same as planned, assumed, or hoped for.

Operations are what an organization does. In this sense, HROs treat them as hands-on experiences from which lessons about the organization can be taken to further improve function in real time.

4.  Commitment to Resiliency

“The signature of the high reliability organization is not that it is error-free, but that errors don’t disable it.” HROs are essentially adaptable, learning organizations. They can experience a failure but continue operating under degraded conditions while marshalling resources to restore capacity.

To operate like this, HROs can recognize emerging anomalies despite prior beliefs, experiences, or plans. In large part, this requires both open-minded observation and a willingness to react appropriately even under unanticipated conditions.

5.  Deference to Expertise

The fact that an HRO must be open-minded rather than judgmental leads to the idea that the culture of the HRO defers to expertise. The key point, however, is that the “expert” involved is the person with hands-on knowledge of the operation at the point of a failure, not the “expertise” conferred by hierarchical authority.

In the HRO, the expert has access to upward reporting, and there is no intimidation from authority to impede the communication. The openness required for the HRO to succeed depends on accurate information from every source.

Not every organization will adapt every HRO principle, at least in the short term. Many organizations can improve continuous operational reliability by adapting the pieces that fit. Over time, more and more of the organization can be improved this way, moving toward the “perfect reliability” objective of the HRO.

Learn more about making your organization an HRO in our new whitepaper, Building a High Reliability Organization.

[1] Weick, Karl and Kathleen Sutcliffe. Managing the Unexpected: Sustained Performance in a Complex World, 3rd Edition. Hoboken, NJ: John Wiley & Sons, 2015. p. 7, 21.

What is a High Reliability Organization?

By Lowers & Associates,

What might be the ultimate risk management machine, is called a ‘High Reliability Organization’ (HRO). HRO can be thought of as a very advanced version of continuous quality improvement that extends to the performance of an entire organization.

Two of the leading researchers on HROs define it like this:

High-reliability organizations operate under challenging conditions yet experience fewer problems than would be anticipated as they have developed ways of “managing the unexpected” better than most organizations. (from Managing the Unexpected: Sustained Performance in a Complex World, K.E. Weick and K.M. Sutcliffe)

Weick and Sutcliffe’s book title points to some important characteristics of HROs:

  • HROs manage unexpected risks successfully. They go beyond traditional risk management practices in which internal and external risks are identified and controls are built to mitigate them. Instead, they create a culture and workforce that respond to threats dynamically.
  • The high-quality performance of HROs is sustained across time, allowing the organization to adapt to changing conditions. The HRO is a learning organization.
  • HROs evolve in very complex environments—they develop techniques and human capacities in response to challenging circumstances that would degrade the performance of less capable organizations.
  • HROs focus tightly on the outcomes that define the mission of the organization. In this sense, they are mission driven.

The concept of HROs emerged from the study of organizations that had to deliver specific outcomes reliably despite being in very risky, complex environments. The aircraft carrier, the commercial air traffic system, and nuclear power plants have been among organizations studied for their ability to deliver high reliability and safety when failures could be catastrophic. A graphic description of the aircraft carrier is a good case in point:

So, you want to understand an aircraft carrier? Well, just imagine that it’s a busy day, and you shrink San Francisco Airport to only one short runway and one ramp and one gate. Make planes take off and land at the same time, at half the present time interval, rock the runway from side to side, and require that everyone who leaves in the morning returns that same day. Make sure the equipment is so close to the edge of the envelope that it’s fragile. Then turn off the radar to avoid detection, impose strict controls on radios, fuel the aircraft in place with their engines running, put an enemy in the air, and scatter live bombs and rockets around. Now wet the whole thing down with seawater and oil, and man it with 20-year-olds, half of whom have never seen an airplane up-close. Oh, and by the way, try not to kill anyone. — Senior officer, Air Division (Naval War College Review, 1987)

Today, managers and researchers are extending the concept to organizations that are not quite as “heroic” as aircraft carriers and nuclear plants. Many healthcare systems and hospitals are looking at HRO characteristics to improve patient outcomes, specifically unnecessary deaths and hospital-induced diseases. Other complex systems such as cash management or power grid operations might benefit from the application of these principles to the outcomes they desire.

For more information about HROs and how the concept might apply to your organization, download a copy of our newest whitepaper, Building a High Reliability Organization.

  Category: Risk Management
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