HRO 15b: HRO Principle 6: Rigorous Training
Introduction
Widespread held, detailed technical knowledge is essential for High Reliability Organizing (HRO). That knowledge doesn’t come from self study, particularly because HRO requires participants to unlearn so much. Organizations practicing HRO place supreme importance on training, qualifications, and performance to a defined standard. For training and qualifications, the standard is technical manuals, operating manuals, and theory and systems technical references. Training is multi-dimensional. It is conveyed through interactive classroom sessions, seminars, hands-on mentoring, and frequent rehearsals for casualties (“drills”). The training program is formal. It is documented and statistics like test performance, time spent in qualification, and hours per person per week of training are available for review by external authorities. I will review each of these ideas in turn.
Importance of Training
High Reliability Organizing depends on “highly competent and rigorously trained” people (Rickover, 1962). Designs focused on safety and reliability constructed with high-quality equipment and material supported by procedures to reduce error are necessary for high reliability, but not sufficient to cover every situation in complex operating environments (DiGeronimo, & Koonce, 2016). Personnel operating, managing, and maintaining physical systems must have sufficient theoretical and practical knowledge of design, operations, and materials to collect the right facts and integrate them to manage the unexpected (Duncan, 1990).
Cross training to build shared understandings of roles and actions is necessary for HRO (Salas & Rosen, 2013; Weick, Sutcliffe & Obstfeld, 1999). It improves the ability of team members to anticipate and assist their partners on the team. Whose watchstation does my action affect? How do I make sure they know? What can I expect them to do after I take this action? What if I don’t get the response I expect? These questions are addressed by cross training.
Cross training is an important contributor to resilience in HRO (Wilson, Burke, Priest, & Salas, 2005). Failure can result from team members having different situational understanding (NOT loss of situational awareness) of what they action they need to take in relation to the action of other team members, especially when they aren’t next to each other. This has nothing to do with the folk theory of human error, “loss of situational awareness,” which explains nothing about human error (Dekker, XXXX). People always have situational awareness except in rare cases when they get become cognitively flooded. Cross training helps crew members develop shared mental models of evolving and dynamic situations and better conceptions of the interrelations of their responsibilities (Weick, Sutcliffe, & Obstfeld, 1999).
Detailed theoretical and practical knowledge are the foundations for several of Weick and Sutcliffe’s principles:
Preoccupation with Failure-you can’t pay attention to what might go wrong and how to respond to it without a technical understanding of systems, components, and the theories underlying their design and performance.
Sensitivity to Operations-this principle doesn’t “work” without shared understandings and integration of sensors, remote observations, reports by watchstanders, and in-the-moment integration of real-time status and performance of equipment and systems (Duncan, 1990; Weick, Sutcliffe, and Obstfeld, 1999). Operators must have the knowledge to “actively generate situational assessments”(Roth, 1997, p. 178) based on the data they collect.
Commitment to Resilience-training improves anticipation (prediction and prevention of failures) and resilience (recovering from errors and surprises as soon as they are detected) “by expanding general knowledge and technical facility, and generalized command over resources” (Wildavsky, 1991, p. 238). Commitment to resilience means little without an equal commitment to developing that resilience.
Deference to Expertise-expertise in HRO comes from both experience and technical knowledge acquired through training and self-study (Rickover, 1979). Experience is an important component of expertise, but you don’t get much deference if you can’t explain WHY you recommend a course of action or practice. When I was Reactor Officer, senior operators justified their actions so frequently with “because that’s the way it works for me” that my standard response was, “If you can’t justify what you do based on a technical requirement or theory and I can, you’re going to do it my way.”
Training must be rigorous and continuous. Training has to be continuously updated because knowledge is perishable and subject to update. It must be documented with auditable records of performance (Rickover, 1962; Rickover, 1979). This supports the transparency needed for another “missed principle” of HRO that I will address in a future post.
Content
Training for High Reliability Organizing needs to be rigorous, comprehensive and holistic.
One of the best descriptions of training program rigor was provided by Admiral Rickover in his testimony to Congress following the meltdown at Three Mile Island:
I consider the training of officers and men to be at least as important as any other element of the Navy Nuclear Power Program. …
The methods we use in training involve lectures, seminars, homework assignments and both oral and written examinations. We also require operators to be able to demonstrate their practical knowledge …
I am not satisfied with bringing an operator to a qualified level once, and then forgetting about him. Therefore, we continually reinforce theoretical and practical training with a continuing training program. This includes frequent practice in plant evolutions and casualty drills
(Rickover, 1979).
Comprehensive training for HRO will include topics like these adapted for an organization’s context
theory
system design
operations (procedures and their bases),
casualty response
recent problems
non-technical skills
Theory and systems training support Weick and Sutcliffe’s (2007) principles of HRO as I noted in the previous section. Procedural compliance and operations discipline is rooted in understanding the theory and technical basis for system design. Casualty exercises expose the crew to the most common failure modes to reduce the disorientation that inevitably results from surprises (Bierly and Spender, 1995). This disorientation is unpleasant, especially when a team of drill observers critique every action you take. Embarrassment can be a powerful motivator for improvement (Argyris, 1994; Lickel, Kushlev, Savalei, Matta, & Schmader, 2014). Smart people doing HRO don’t like to feel silly.
Training includes review and discussion of recent problems at one’s own organization and others. The Navy uses Incident Reports, Fact Findings, Judge Advocate General Manual Investigations, RAND reports, and other formal and informal inquiries for this kind of training. The deep analysis of and reflection on problems can teach people in the organization about their own vulnerabilities to surprise and disaster with sufficient reflection. Without guided reflection, reviews of the mistakes of others usually leads to superficial “they failed because they didn’t have the right stuff” thinking (Wolf, 2018). Reading about problems at other organizations can improve resilience by exposing team members to new and astoundingly creative ways to fail (Bierly and Spender, 1995). “Effective HROs, faced with infrequent failures, learn from the failures of others” (Weick, Sutcliffe, and Obstfeld, 1999, p. 54).
Training for HRO includes non-technical skills. These skills of teamwork, mentoring, professional development, questioning attitude, watchteam backup, and communications support the coordinated action that is a hallmark of HRO (Flin, O'Connor, & Crichton, 2008; Riley, Lownik, Parrotta, Miller, & Davis, 2011; Salas & Rosen, 2013). Non-technical skills are conveyed in formal training and on-the-job mentoring by experienced operators to trainees and journeymen. Leaders doing HRO use non-technical skills to inculcate behaviors, attitudes, and a culture of reliability (Bierly and Spender; Salas & Rosen, 2013; Weick, Sutcliffe & Obstfeld, 1999). Practice-based training, particularly casualty control drills, increases the effectiveness of learning, applying and remembering non-technical skills (Salas & Rosen, 2013).
The continuous training for HRO is holistic. Operators are taught to integrate the technical foundations of preoccupation with failure and sensitivity to operations with the resilience-building skills of questioning attitude, watchteam backup, believing their indications, and deference to expertise. Operators have to understand to recognize reliable operations as well as deviations (situation awareness) and act on this recognition using a “coherent explanation” of what is transpiring (Roth, 1997, p. 178).
Multi-Dimensional
Training for HRO is multi-dimensional. Because people learn differently, it includes classroom lectures, practice-based, hands-on (observed evolutions, theory to practice, walk-throughs), “what if?” mentoring, decision games (seminars), and casualty recognition and response. These diverse modalities contribute to reliable operations by building anticipation and resilience through cognitive flexibility (Spiro, Coulson, Feltovich, & Anderson, 1988).
Cognitive flexibility is the ability to represent knowledge from different conceptual and case-based perspectives and construct that representation into an adaptive knowledge arrangement tailored to the demands of the situation or most likely problems an operator will face (Spiro, Coulson, Feltovich, & Anderson, 1988). The use of multiple modalities for training with differing degrees of interactivity allows learners in HRO to construct their knowledge rather than being passive receivers. This enables learners to develop knowledge representations to adapt knowledge for future use in different types of situations (Roth, 1997).
Training for HRO comprises a spectrum of approaches from interactive classroom training to hands-on small group sessions to walkthroughs of team activities to full simulations where skills can be performed and evaluated in realistic scenarios (Frankel, Leonard, & Denham, 2006). Seminars are conducted by a knowledgeable leader in small groups using tabletop simulations or process walkthroughs. These can be done on or off watch. This more personal and interactive training develops cognitive and attentional skills such as anticipating (Wildavsky, 1991), noticing, monitoring, decision making, and “story building” (Roth, 1997, p. 177). These skills play important roles in sensemaking and learning how to build situational awareness (Crichton, Flin, & Rattray, 2000; Weick, Sutcliffe, and Obstfeld, 1999).
Formality
Formality in the process of training is necessary to support assessment. To remind people about the importance of keeping formal records of training, the U.S. Navy has an aphorism, “Training that isn’t documented didn’t happen.” Characteristics of a formal training plan include:
Based on technical documents-the content of all training is sourced to technical documents or requirements of higher authority documented in writing. The content of training is reviewed by a competent authority before it is given (“Deference to Expertise”).
Attendance records-roll is taken at all training to prove that people have actually attended.
Monitored. Someone monitors all classroom training and as much of the hands-on or seminar training as possible. The monitor reviews their assessment of the training with the person leading the training. Both the monitor and the person being monitored sign the form as an official record.
Checking to ensure the knowledge is retained. This includes evaluations of level of knowledge, time spent in qualifications, and test performance. I will have more to communicate on assessment in a future post in the series.
Summary
Detailed technical knowledge held across the organization is fundamental to High Reliability Organizing (HRO). Comprehensive theoretical and practical knowledge are the foundation for four of Weick and Sutcliffe’s principles: Preoccupation with Failure, Sensitivity to Operations, Commitment to Resilience, and Deference to Expertise. That knowledge can only come from a robust effort and documented, auditable processes. Training must be continually reinforced, applied, evaluated, and updated. Cognitive flexibility, essential in complex knowledge domains, is built through multi-dimensional training: interactive lecture for efficiency and breadth, small group seminars and tactical exercises for non-technical skills like teamwork, questioning attitude, watchteam backup, and hands-on training to reinforce theoretical and practical understanding. An HRO training program is transparent. Records are retained for all aspects of the program to facilitate periodic reviews, both internal and external.
In my next post, I will describe my second additional principle that is essential for High Reliability Organizing, but missed Weick and Sutcliffe. Stay tuned.
References
Argyris, C. (1994). Good communication that blocks learning. Harvard Business Review, 72(4), 77-85.
Bierly III, P. E., & Spender, J. C. (1995). Culture and high reliability organizations: The case of the nuclear submarine. Journal of Management, 21(4), 639-656.
Crichton, M. T., Flin, R., & Rattray, W. A. (2000). Training decision makers–tactical decision games. Journal of Contingencies and Crisis Management, 8(4), 208-217. Retrieved from http://www.savie.ca/SAGE/Articles/1221_000_CRICHTON_2000.pdf
DiGeronimo, M. & Koonce, B. (2016). Extreme operational excellence: Applying the US nuclear submarine culture to your organization. Outskirts Press, Inc.. Kindle Edition.
Duncan, F. (1990). Rickover and the nuclear navy: The discipline of technology. Naval Inst Press.
Flin, R. H., O'Connor, P., & Crichton, M. (2008). Safety at the sharp end: A guide to non-technical skills. Ashgate Publishing, Ltd.
Frankel, A. S., Leonard, M. W., & Denham, C. R. (2006). Fair and just culture, team behavior, and leadership engagement: The tools to achieve high reliability. Health Services Research, 41(4p2), 1690-1709.
Lickel, B., Kushlev, K., Savalei, V., Matta, S., & Schmader, T. (2014). Shame and the motivation to change the self. Emotion, 14(6), 1049-1061.
Rickover, H.G. (1962, Oct 29). Keynote speech at the National Metal Congress, originally published in Metals Engineering Quarterly, February 1963, 3(1).
Rickover, H.G. (1979 May 24). Statement before the subcommittee on energy research and production of the committee of science and technology, U.S. House of Representatives.
Riley, W., Lownik, E., Parrotta, C., Miller, K., & Davis, S. (2011). Creating high reliability teams in healthcare through in situ simulation training. Administrative Sciences, 1(1), 14-31.
Roth, E.M. (1997). Analysis of decision making in nuclear power plant emergencies: An investigation of aided decision making. In C. Zsambok and G. Klein (Eds.), Naturalistic decision making (pp. 175–182). Erlbaum.
Salas, E., & Rosen, M. A. (2013). Building high reliability teams: progress and some reflections on teamwork training. BMJ Quality & Safety, 22(5), 369-373.
Spiro, R. J., Coulson, R. L., Feltovich, P. J., Anderson, D. (1988). Cognitive flexibility theory: Advanced knowledge acquisition in ill-structured domains. Technical Report 441. Retrieved from https://files.eric.ed.gov/fulltext/ED302821.pdf
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. 32-66). Jai Press.
Wildavsky, A. (1991). Searching for safety. Routledge, Kindle Edition.
Wilson, K. A., Burke, C. S., Priest, H. A., & Salas, E. (2005). Promoting health care safety through training high reliability teams. BMJ quality & safety, 14(4), 303-309.
Wolfe, T. (2018). The Right Stuff. Random House.
