HRO 15a Beyond Weick and Sutcliffe
Introduction
In Managing the Unexpected (2007), Weick and Sutcliffe distilled five principles of High Reliability Organizing based on observations of organizations that operated at very high levels of reliability. The organizations observed included aircraft carrier flight decks, commercial nuclear reactors, and air traffic control. It did not include the propulsion plants of aircraft carriers or nuclear maintenance, which is where my experience lies.
I revisit the principles here and reveal my thought process for augmenting them. My approach to assessing the sufficiency of the five principles goes beyond observation to compare my experience and reflect more deeply on the practices within HRO where there is value in doing so. With the perspective of a practitioner and academic, I look inside the processes and conventions of well-trodden HRO literature. Knowing what we now know about reliability in carrier operations, I ask “Are five principles too many, too few or too general?”
What is HRO?
The essence of High Reliability Organizing (HRO) theory is that organizations that are more reliable have a common set of mindsets oriented toward operations, sensemaking, and problem management. From their observations of organizations with exemplary safety records engaged in high-risk work, Weick and Sutcliffe distilled five principles of HRO (Weick & Sutcliffe, 2007):
Skills of Anticipation (keeping bad stuff in the box)
Failure (Preoccupation with Failure)
Simplification (Reluctance to Simplify)
Operations (Sensitivity to Operations)
Skills of Containment (getting bad stuff quickly back into the box)
Resilience (Commitment to Resilience)
Expertise (Deference to) (FSORE)
Failure-directing organizational attention to what might go wrong and preparations to deal with it.
Simplification reluctance-resisting the urge to accept simple explanations for problems, investigating unexpected results for what they reveal about vulnerabilities.
Operations-devoting lots of attention to what is happening in the field, what operators are doing, the problems they are having, and what needs to be improved.
Resilience-working just as hard to identify and trap errors as they happen as trying to reduce them.
Expertise-giving weight to the views of people that have front-line experience and recognized expertise when working on problems.
In summary, organizations practicing HRO pay more attention to failures than success, avoid simplicity rather than cultivate it, are just as sensitive to operations as they are to strategy, organize for problem recovery as well as anticipation, and give those with the greatest expertise larger roles in problem-solving regardless of organizational hierarchy (Weick, Sutcliffe, & Obstfeld, 1999).
Necessary, but Not Sufficient
HRO scholarship began with a set of observations grounded in operations on USS CARL VINSON (CVN 70) in the mid-1980s. The general principles induced from those observations weren’t wrong, but they are too terse. They were layered upon processes, assumptions, and mindsets that are difficult to grasp through observation alone. The general concepts embodied by the principles are sound, but more specificity is needed.
While the FSORE principles offer a compact description of the hallmarks of High Reliability Organizing, I propose that their very compactness is a barrier to understanding how to implement them in practice. This is especially so because they are not a complete description of HRO. For example, Weick and Sutcliffe do not describe how personnel become more reliable and the role of leadership in the necessary transformation and sustainment of HRO.
My intent here is to extend and enhance the five principles, not bury or change them. The deeper reflection on the principles reflected here suggests the value of additional principles. Weick and Sutcliffe’s list depends on a foundation of beliefs and assumptions about work and system knowledge for the five principles to work. This foundation needs to be more explicit.
For example, questioning attitude, a fundamental aspect of HRO practice, can’t be proceduralized. It is inherent in the way procedures are executed. The additional HRO principles I will propose are fundamental to putting Weick and Sutcliffe’s five principles into practice.
The Role of Management
In my Intro to HRO post, I provided my own definition of HRO: “high reliability organizing is the practice of active management to reduce failure and enhance the reliability of human and technology systems.” Lost amid the generality of Weick and Sutcliffe’s five principles is the crucial role of management, both local and centralized, in organizing for high reliability. When a Navy organization has substantive reliability problems (there are always problems) and too many close calls, the first thing regulators and superiors do is critically assess the performance of management. This includes locally, headquarters, regulators, and levels between. Of course, each level tends to be more critical of the levels below it than they are of themselves. This is just an institutional reality. Occasionally, outsiders are brought in to critique the emperor’s clothes, but this is rare like when the NTSB conducts public investigations of Navy ship collisions.
To understand HRO, it is essential to understand the roles managers play in organizing for high reliability, which involves these elements:
senior leader engagement in details of operations, training, and maintenance that emphasizes behavior and attitudes of skepticism that prioritize reliability and safety over efficiency (Bierly and Spender, 1995; Roberts and Bea, 2001),
centralized control by headquarters of technical design and explicit articulation of management practices,
decentralized decision-making for design and operations (Bierly and Spender, 1995), and
administrative and personnel processes that emphasize organizational learning from experience as well as training and personal development (Sagan, 1993).
The role of managers in HRO can’t be captured by a principle. Managers engaged in High Reliability Organizing uphold the standards for performance in accordance with the well-understood, if not always explicit, principles, implementing practices based on them and assessing their effectiveness. From the list above, only decentralized decision-making for operations has a clear connection to the principles articulated by Weick and Sutcliffe, Deference to Expertise.
Criteria for Additional Principles
All articulations of theory need a balance between the general and the specific. Parsimony in theory articulation is good. A good organizational theory is succinct, which can make it easier to state and adapt for specific cases. At the same time, a theory that omits important elements can be a barrier to understanding. Gaps in theories impact their explanatory power and leave us without a sense of direction in “edge” cases. Terse theory statements can be a hindrance to people who want to apply the theory to their context.
To give myself some guardrails in the process of reflecting on the essential extra HRO principles, I developed some guidelines that additional principle candidates should meet. I practiced HRO for decades. I know a lot of detail about practices within them. I’ve started from the foundations many times and conducted numerous audits of organizations that were having difficulty in their practice of HRO.
My HRO experience is important, but it puts me at risk of the curse of experience. This is the inability of someone with a lot of experience to separate their understanding of it into a hierarchy of constituent elements or teach it to others. Knowing a lot of details about HRO practice overcomplicates the theory and risks submerging the essential aspects in a laundry list of activities.
I think that additional HRO principles must meet four criteria:
They don’t easily fit into restatements of Weick and Sutcliffe’s five principles (Weick and Sutcliffe, 1995);
They provide the necessary technical foundation for all or some of the five principles;
They underpin an organization’s culture and “what gets noticed” while practicing HRO (Bierly & Spender, 1995; Vaughan, 1999; Weick, 1995);
Their absence is often noted as a significant organizational weakness in post-accident investigations and organizational audits.
There are practices of HRO that are crucial like training, qualification, and learning from problems that require exceptional mental contortions to fit into Deference to Expertise as I will explain in my next post. Expertise in HRO is based on a technical foundation that Weick and Sutcliffe do not adequately address.
One of the things that sets personnel practicing HRO apart is their culture of what they notice and how they follow up on it. Seeking evidence that disconfirms the tendency to view the world as “everything is okay” runs counter to the way humans operate. Cultivating positive deviance to counter cognitive biases is part of the way culture is built in organizations practicing HRO.
Some principles of HRO are easier to articulate in their absence than as affirmations of what organizations should do. Performance audits and post-event reviews in HRO tend to note the absence of some principles after problems more often than they are articulated by leaders beforehand. I think this is just something built into humans learning. It is the same reason that the principle of not consuming mind-altering substances before operating heavy machinery is so often stated as “Don’t drink and drive.” Don’t drink and drive carries more emotional weight, particularly after witnessing a horrifying car wreck, than “you should be free from intoxicating substances when operating a vehicle.”
Summary
I revisited the five principles of HRO articulated by Weick and Sutcliffe in their groundbreaking work, Managing the Unexpected (Weick and Sutcliffe, 2007). I concluded that they are not a sufficient description of HRO. They were layered upon processes, assumptions, and reactions that are difficult to grasp through observation alone. Weick and Sutcliffe’s list depends on a foundation of beliefs and assumptions about work and system knowledge for the five principles to work. I articulated four criteria that additional HRO principles must meet: don’t fit within the existing five, provide technical foundations for HRO, essential for HRO culture, and their absence is frequently noted in audits and investigations of problems.
In my next post, I will proffer suggestions for additional principles that are essential for High Reliability Organizing that Weick and Sutcliffe missed. Feel free to choose your own to compare them to mine.
References
Bierly, P. E., & Spender, J. C. (1995). Culture and high reliability organizations: The case of the nuclear submarine. Journal of Management, 21(4), 639-656.
Roberts, K. H., & Bea, R. (2001). Must accidents happen? Lessons from high-reliability organizations. Academy of Management Perspectives, 15(3), 70-78.
Sagan, S.D. (1993). The limits of safety: Organizations, accidents, and nuclear weapons. Princeton University Press.
Vaughan, D. (1999). The dark side of organizations: Mistake, misconduct, and disaster. Annual Review of Sociology, 25, 271–305.
Weick, K. E. (1995). Sensemaking in Organizations. Sage.
Weick, K.E., Sutcliffe, K.M. (2007). Managing the unexpected: Assuring high performance in an age of complexity. Jossey-Bass
Weick, K. E., Sutcliffe, K. M., & Obstfeld, D. (1999). Organizing for high reliability: Processes of collective mindfulness. In R.S. Sutton and B.M. Staw (eds.), Research in Organizational Behavior, Volume 1 (pp. 81–123). Jai Press.
