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Update post on HROs

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Dimitri Lozeve 2022-06-03 19:16:16 +02:00
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--- ---
title: "High reliability organizations" title: "High reliability organizations"
date: 2022-06-01 date: 2022-06-03
tags: management, social science tags: management, social science
toc: false toc: false
--- ---
@ -21,11 +21,14 @@ shuttles. They share several characteristics: an unforgiving
environment, vast potential for error, and dramatic scales in the case environment, vast potential for error, and dramatic scales in the case
of a failure. of a failure.
[cite/t:@weick1999_organ] use the concept of "mindfulness", a kind of The paper identifies five processes common to HROs, that they group
"enriched awareness" (which I interpret as "awareness with explicit into the concept of /mindfulness/ (a kind of "enriched
processes"), consisting of the five elements listed below. This awareness"). Mindfulness is about allocating and conserving attention
mindfulness leads to the capacity to discover and manage unexpected of the group. It includes both being consciously aware of the
events, which in turn leads to reliability. situation and /acting/ on this understanding.
This mindfulness leads to the capacity to discover and manage
unexpected events, which in turn leads to reliability.
* Characteristics of a high reliability organization * Characteristics of a high reliability organization
@ -33,38 +36,53 @@ An HRO is an organization with the following five attributes.
** Preoccupation with failure ** Preoccupation with failure
There are many possible failures, most of them extremely Failures in HROs are extremely rare. To make it easier to learn from
rare. Consequently, HROs study all forms of failure and near misses them, the organization has to broaden the data set by expanding the
with extreme carefulness and attention to detail. They also study the definition of failure and studying all types of anomalies and near
/absence/ of failure: why it didn't fail, and the possibility that no misses. Additionally, the analysis is much richer, and always
flaws were identified because we weren't attentive enough to potential considers the reliability of the entire system, even for localized
flaws. HROs encourage reporting all mistakes and anomalies by anyone. failures.
HROS also study the /absence/ of failure: why it didn't fail, and the
possibility that no flaws were identified because there wasn't enough
attention to potential flaws.
To further increase the number of data point to study, HROs encourage
reporting all mistakes and anomalies by anyone. Contrary to most
organizations, members are rewarded for reporting potential failures,
even if their analysis is wrong or if they are responsible for
them. This creates an atmosphere of "psychological safety" essential
for transparency and honesty in anomaly reporting.
** Reluctance to simplify interpretations ** Reluctance to simplify interpretations
HROs avoid having a single interpretation for a given event. They HROs avoid having a single interpretation for a given event. They
encourage generating multiple, complex, contradicting interpretations encourage generating multiple, complex, contradicting interpretations
for every phenomenon. People are encouraged to have different views, for every phenomenon. These varied interpretations enlarge the number
different backgrounds (important for [[id:cdfc701f-7b6e-40ec-be94-db64a74aef0d][Hiring]]), and are re-trained of concurrent precautions. Redundancy is implemented not only via
often. To resolve the contradictions and the oppositions of views, duplication, but via skepticism of existing systems.
interpersonal and human skills are highly valued, possibly more than
technical skills. People are encouraged to have different views, different backgrounds,
and are re-trained often. To resolve the contradictions and the
oppositions of views, interpersonal and human skills are highly
valued, possibly more than technical skills.
** Sensitivity to operations ** Sensitivity to operations
HROs rely a lot on "situational awareness". Basically, we have to HROs rely a lot on "situational awareness". They are ensuring that no
check that there is no emergent phenomena (cf [[id:cabacd0d-2d40-450d-bbba-85c3539ff939][Complex systems]] and [[https://en.wikipedia.org/wiki/Emergence][emergent phenomena]] emerge in the system: all outputs should always be
[[id:65e2d955-ab29-432f-9f48-30605e3f688f][Compositionality]]): all outputs should always be explained by the known explained by the known inputs. Otherwise, there might be other forces
inputs. Otherwise, there might be other forces at work that need to be at work that need to be identified and dealt with. A small group of
identified and dealt with. A small group of people may be dedicated to people may be dedicated to this awareness at all times.
this awareness at all times.
** Commitments to resilience ** Commitments to resilience
HROs train people to be experts at combining all processes and events HROs train people to be experts at combining all processes and events
to improve their reactions and their improvisation skills. Everyone to improve their reactions and their improvisation skills. Everyone
should be an expert at managing surprise. This can include rapid should be an expert at anticipating potential adverse events, and
formation of ad hoc teams to improvise solutions to novel problems. managing surprise. When events get outside normal operational
boundaries, organizations members self-organize into small dedicated
teams to improvise solutions to novel problems.
** Underspecification of structures ** Underspecification of structures
@ -97,11 +115,12 @@ An interesting discussion is around the (alleged) trade-off between
reliability and performance. It is assumed that HROs put the focus on reliability and performance. It is assumed that HROs put the focus on
reliability at the cost of throughput. As a consequence, it may not reliability at the cost of throughput. As a consequence, it may not
make sense for ordinary organizations to put as much emphasis on make sense for ordinary organizations to put as much emphasis on
safety and reliability, as it may cost money. safety and reliability, as the cost to the business may be
prohibitive.
However, investments in safety can also be viewed as investments in However, investments in safety can also be viewed as investments in
learning. HROs view safety and reliability as a process of search and /learning/. HROs view safety and reliability as a process of search
learning (constant search for anomalies, learning the interactions and learning (constant search for anomalies, learning the interactions
between the parts of a complex system, ensuring we can link outputs to between the parts of a complex system, ensuring we can link outputs to
known inputs). As such, investments in safety encourage collective known inputs). As such, investments in safety encourage collective
knowledge production and dissemination. knowledge production and dissemination.
@ -116,8 +135,8 @@ of the catastrophic consequences of any failure, but non-HROs can
adopt the same practice to boost efficiency and learning to gain adopt the same practice to boost efficiency and learning to gain
competitive advantage. competitive advantage.
Additional lessons that can be learned from HROs (implicit in previous Additional lessons that can be learned from HROs (implicit in the
discussion): previous discussion):
1. The expectation of surprise is an organizational resource because 1. The expectation of surprise is an organizational resource because
it promotes real-time attentiveness and discovery. it promotes real-time attentiveness and discovery.
2. Anomalous events should be treated as outcomes rather than 2. Anomalous events should be treated as outcomes rather than