# Presentation: 306498

## High Reliability Organizing

- An Overview

## Objectives

- Define our operating environment
- Define HRO
- Discuss Managing the unexpected
- Discuss Mindfulness vs Mindlessness
- Principles of Mindfulness
- Discuss Processes Used to Manage the Unexpected
- Discuss the Risk of Plans
- Reason’s Four Cultures

## 

Think Outside the Box?

- Think Outside the Box?

## Thinking outside the box?

- Creative
- Inventive
- Resourceful
- Ingenuous
- Innovative

## Slide 5

**Notes:**
What if we defined the box as, Law , Regulation, Policy and Fiscal requirements.  Then what terms come to mind if you think outside the box?

## Thinking outside the box?

- Illegal
- Unethical
- Dishonest
- Unscrupulous
- Deceitful

**Notes:**
Does Ken Lay and ENRON, mortgage crisis come to mind. 

## Slide 7

**Notes:**
This is our box and defines the environment we must work within Our job is to think inside the box to make sure we have the full box to operate in an haven’t painted ourselves into a corner.

## Slide 8

**Notes:**
High Reliability Organizing enables us to be 
Creative
Inventive 
Resourceful 
Ingenuous
Innovative
Inside the box

## High Reliability Organizing

- Managing The Unexpected
- A continually “mindful” infrastructure

**Notes:**
Managing The Unexpected
High Performance Organizations all plan for what we expect to happen and even develop contingencies for ways we think things could go wrong.
Managing the unexpected is difficult to “plan” for by definition.
The ability to see things coming long before they arrive,
to recognize weak signals of trouble ahead,
to apply novel approaches to problem resolution,
to gain emotional maturity evidenced in respectful communication under duress,
and to have a deep knowledge of how our systems function
are all skills that are signs of a commitment to building resilient people, teams and organizations.
They can be learned and taught.

Highly Reliable Organizations continually create and sustain a mindful infrastructure.
The best HROs expect people to make mistakes and systems to fail in unimagined ways. 
Continuous updating in a mindful way minimizes the likelihood of large failure, speeds recovery, and facilitates real organizational learning.
“People who act mindfully notice and pursue that rich, neglected remainder of information that mindless actors leave unnoticed and untouched. Mindful people can hold complex projects together because they understand what is happening.” (Weick & Sutcliffe 2001)

## Managing the Unexpected

- Managing the unexpected consists of:
- extrapolating the possible effects of small discrepancies,
- imagining scenarios not yet experienced,
- hypothetically constructing alternative lines of action and
- envisioning what night have been overlooked given the narrow focus of expectations

## Mindfulness

- Mindfulness – a rich awareness of discriminatory detail and an enhanced ability to discover and correct errors that could escalate into a crisis.

## Mindfulness

- To act mindfully, HROs
- Organize in such a way that they are able to notice the unexpected in the making and halt is development or
- If unable to halt the development of the unexpected they focus on containing it.
- And if the unexpected breaks through containment they focus on resilience and swift restoration of system functioning

## Principles of Mindfulness

- Preoccupation with failure.
- Reluctance to simplify.
- Sensitivity to operations.
- Commitment to resilience.
- Deference to expertise.

**Notes:**
Often referred to as the principles of HROs or the HRO principles

## Mindlessness

- Mindlessness is characterized by a style of mental functioning in which people
- follow recipes,
- impose old categories to classify what they see,
- act with some rigidity
- operate on automatic pilot,
- mislabel unfamiliar new contexts as familiar old ones

**Notes:**
Gonzales last year and his story of the snake ashtray

## “The ability to deal with a crisis situation is largely dependent on the structures that have been developed before chaos arrives”

						Pat Lagadec

- 						Pat Lagadec

**Notes:**
Lagadec – Crisis expert

We operate in a chaotic environment within a operating environment defined by Lay. Regulation, policy and Fiscal Requirements.  Our efforts to work mindfully within environment is dependent on what we do before chaos arrives.

## Processes HROs Use to Manage the Unexpected

- Anticipating and becoming aware of the unexpected
- Preoccupation with failures rather than successes
- Reluctance to simplify interpretations
- Sensitivity to operations
- Containing the unexpected when it occurs
- Commitment to resilience
- Deference to expertise

## Preoccupation with Failure

- Track Small Failures
- HROs are preoccupied with all failures, especially small ones.
- Small things that go wrong are often early warning signals of deepening trouble and give insight into the health of the whole system.

## Preoccupation with Failure

- Preoccupation with failure involves four questions
- What needs to go right?
- What could go wrong?
- How could things go wrong?
- What things have gone wrong?

## A Reluctance to Simplify

- HROs take deliberate steps to create a more complete and nuanced pictures of what they face and restrain their temptation to simplify through
- diverse checks and balances,
- vigorous dialog,
- adversarial reviews, and
- the cultivation of multiple perspectives.

**Notes:**
If simplifications lead to misspecifications of any one of the complexity analysis elements , brutal audits are more likely.

Challenge assumptions.  Know of some burn bosses who start the Go No go process with that it’s a No Go Today until we prove that it is a GO

## “HRO’ s have a deep appreciation for the liabilities of overconfidence demonstrated by ongoing mindfulness embedded in practices that enact alertness, broaden attention, reduce distractions and forestall misleading simplifications”
					Weick and Sutcliff					

- 					Weick and Sutcliff

## Sensitivity to Operations

- HROs make strong responses to weak signals (indications that something might be amiss).
- Everyone values organizing to maintain situational awareness.
- Make continuous adjustments that prevent error from accumulating
- Anomalies are noticed while still tractable and can still be isolated

**Notes:**
Change in wind speed, ember’s lofting across the line,  bolt found on flight deck. Pump goes down on engine.  Etc etc 

Small things but notice, discuss and adjust

##  Commitment to Resilience

- Resilience is a combination of keeping errors small and of improvising workarounds that allow the system to keep functioning.
- HROs pay close attention to their capability to improvise and act—without knowing in advance what will happen.
- Surprises are inevitable. And with surprise comes the necessity to improvise, make do with the hand you are dealt, adapt, think on your feet, and contain and bounce back from unexpected events.

## Become Better at Anticipating the Surprises

*“**In our work we think about the idea that you can try to anticipate as much as you can. But as you implement prescribed fire, you certainly are not going to be able to anticipate everything. Whether there is a certain risk that you are willing to live with is one thing. ****But there is also really focusing on that part of trying to contain or to act on the surprises that do come up. That’s where I would be spending most of my time . . . ***
***Plans do have their risk. Making sure you focus on the other end—on containment and how you can recover from things that go wrong—is where I’d also concentrate.”***
**Kathleen Sutcliffe**

## “Resilient action that enables recovery from setbacks is built out of a broad repertoire of action and experience , the ability to recombine fragments of past experiences into novel reponses, skill at respectful interaction and knowledge of how the system functions.”
					Weick and Sutcliff					

- 					Weick and Sutcliff

## Deference to Expertise

- HROs cultivate diversity because it helps them
- Notice more in complex environments and
- Do more with the complexities they do notice
- HROs shift decisions away from formal authority toward expertise and experience.
- Decision making migrates to experts at all levels of the hierarchy during high tempo times.

**Notes:**
This is nota simple case of deferring to the person with the most “experience”.  The decision migrates around these organizations in search of a person who has specific knowledge of the event

## Planning=Trouble?

- Creates an expectation.
- Becomes a fact.
- Narrows our search for disconfirmation.

**Notes:**
In the Sutcliff quote she noted that plans do have their risks because when we out something on paper it becomes a fact and it becomes difficult to disconfirm that fact because we know it to be so since it’s on the paper.  That leads into here  second point that if you do need to plan than place your emphasis on asking  the four questions related to preoccupation with failure 
What needs to go right?
What could go wrong?
How could things go wrong?
What things have gone wrong?

Plans can lead one into mindfulness if the principles of mindfulness are not applied continually.

## Informed Culture

- An informed culture requires the free exchange of information, which requires a culture that is:
- Just,
- Reporting,
- Able to learn from itself, and
- Flexible.

## Informed Culture

**Just Culture. **
- Don’t shoot the messenger.
-  **Reporting Culture. **
- Don’t be afraid of being shot.
- Are things happening that I did not plan/expect?
- Have I let someone know?
- Did I learn something that others should know about?

## Informed Culture

**Learning Culture. **
- Learning is continuous; be a student.
- Have I challenged my assumptions and expectations today?
- Was I lucky or was I good?
-  **Flexible Culture. **
**Rules don’t and can’t cover every situation. **
**This is not the same **thing as a “good rule” misapplied or ignored because it is not convenient or you don’t agree.

## By failing to prepare, you are preparing to fail.- Benjamin Franklin

## Slide 31