‘High Reliability Organisations’ (HRO's) are organisations that have succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity. HRO’s and learning organisations push decision-making down as far as possible and rely on expertise in the field rather than on rules and punishment.
HRO's are committed to learning from failures and refuse to simplify what is inherently complicated’ (Weick & Sutcliffe, 2007). They can ill-afford large-scale failures because of the potential catastrophic outcomes - nuclear power plants, hospitals and air traffic control to name but a few.
Where does the Concept of the HRO Originate?
The concept of High Reliability Organisation was developed in the 1980’s by the ‘Berkley Group’ as a response to Perrow’s (1984) pessimistic conclusion that accidents are inevitable or ‘normal’ in systems that are interactively complex, tightly coupled and operate high-risk technologies – Normal Accident Theory or NAT. In contrast, High Reliability Theory (HRT) recognises that some organisations are able to effectively operate in such environments and achieve a record of consistent safety over long periods of time (La Porte and Consolini 1991; Roberts 1990). HRO researchers maintain that accidents in complex systems are not inevitable because there are processes in place that enable high hazard organisations to effectively prevent and contain catastrophic errors, thus helping them to achieve a consistent safety record over long periods of time.
In defining the HRO, the Berkley Group based its studies on three ‘error free’ organisations: the Federal Aviation Administration’s air traffic control, Pacific Gas and Electric Company’s operation of its nuclear power plant and the US Navy’s nuclear powered aircraft carriers, using a multi-method approach which included facilitated workshops with high level operators and managers, interviews, observations and surveys.
The Devil's in the Detail
For the HRO operating in a potentially hazardous environment, it is essential that small failures be understood, resolved and learned from before they can become or lead to larger-scale, even catastrophic failures. This means paying close attention to small failures or weak signals in the system. The organisation must be resilient, or able to recover quickly from failures, but it is also expected to learn from them at the same time.
HRO researchers maintain a positive view regarding the nature of accidents in complex systems by arguing that organisations can become more reliable by creating or ‘engineering’ a positive safety culture and reinforcing safety-related behaviours and attitudes (e.g. Weick and Roberts, 1993). This line of research has examined the characteristics of such organisations and the practices and processes that they adopt which enable them to both achieve and maintain their excellent safety performance record. HRO researchers do not maintain that such organisations are error-free; rather that they are constantly preoccupied with failure such that they can anticipate areas of potential failure and can cope with and bounce back from errors when they do occur.
Characteristics of HRO’s that contribute to impeccable safety records:
- a strong learning orientation
- prioritisation of safety over other goals
- continuous training
- an emphasis on checks and procedures
Health and Safety and Process Safety practitioners have long been seeking to understand the concepts of the HRO and explore how they can be translated to general industry and it’s fair to say that the jury is still out on this front. However, a simple google search will reveal its application in fields as far apart as healthcare, firefighting and construction and its inherent concepts are widely, if not specifically translatable.
Key Features of a High Reliability Organisation
Weick and Sutcliffe (2007) argue that HROs and non-HROs are more similar than they appear to be and further research by Waller and Roberts (2003) argues that there is much to be learnt from the core principles that are incorporated in HRO processes.
The key elements of an HRO have been broken down into five features by two categories; anticipation and containment:
- Successful containment of unexpected events
- Redundancy: by this, it is meant the provision of backup systems and continuous checking of safety critical activities, or backup systems in place in the event of failures, cross-checking of important decisions and drawing on experts within the organisation to make important safety-critical decisions irrespective of their rank
- Deference to expertise: those with expertise (irrespective of standing within the organisation) are allowed to make important safety-related decisions in emergencies, a clear hierarchical structure during routine operations and an understanding of who is responsible for what, oscillation between hierarchical and flat organisational structures - deference to expertise in emergencies, a clear commitment to investing in training and technical competence
- Carefully defined procedures for all possible unexpected events
- Effective anticipation of potential failures
- Sensitivity to operations: regular two-way communication with staff on the ‘front line’ to paint the ‘bigger picture’ of operations
- Preoccupation with failure: minor or trivial indications of potential problems paid due regard – incidents and near-misses used as indicators
- Reluctance to simplify: avoidance of making assumptions surrounding nature of failures, collections and analysis of all warning signs. Explanations of incident cause systematic and not focussed on assigning individual blame
- Just culture
- Systems of reporting incidents that are open and free from the fear of punishment
- Implementation of corrective actions following accident investigation outcomes
- Staff empowerment to abandon work on safety grounds
- Personal accountability for safety supported
- Learning orientation
- On-going technical training
- Root cause and accident type analysis as a matter of course to identify trends
- Open lines of communication-based on outcomes
- Regular updating of procedures commensurate with knowledge
- Mindful leadership
- Audit commissions on a proactive basis to highlight system problems (can be as a result of incidents in similar industries
- ‘Bad news’ stories communicated bottom-up
- Regular site visits to engage with staff on the ‘front line’
- Resources invested in safety management and profits balanced with safety
Mindfulness, Enactment and Resilience
In Managing the Unexpected (Weick & Sutcliffe, 2007), HRO’s are viewed in the effect people have on other people’s behaviours – exploring not just mindfulness or enactment, but collective mindfulness and collective enactment as applicable in an organisational setting.
By ‘Mindfulness’, what we refer to is a 'mental orientation which seeks to constantly evaluate the environment' - as opposed to ‘mindlessness’ or a simple/single assessment which leads to a chosen (continual) plan which runs its course. While we hear a lot about mindfulness as a new buzzword in terms of mental health at the moment, in terms of the HRO, Mindfulness is applied at an organisational level. Such organisations employ mindfulness and are able to recover quickly from problems or incidents - they are resilient. In an organisation which employs Mindfulness in its operations, small failures are tracked, oversimplification is resisted and the organisation is sensitive to its operations, maintaining a capability for resilience, and uses changes in expertise to its advantage.
Enactment occurs when a person engages both the circumstances and environment to create a new situation and environment - this can be constraining if limiting the ability of the person to think, or it can alternatively expand the pool of possible solutions. In short, by enacting or engaging the problem, both the problem and an individual’s perception of the problem is changed.
The HRO perspective further shares much in common with resilience engineering (the ability of systems to survive and return to normal operation despite challenge) which has been applied in several high-risk systems including the aviation, petrochemical and nuclear industries. The resilience engineering perspective offers several principles that organisations could follow to ‘engineer’ a safety culture and enhance their reliability and greatly overlap with the processes that are characteristic of HROs.
Applying HRO Principles in Traditional Organisations
Together with cultural constraints whereby workers will tend to resolve problems with their supervisors or colleagues as opposed to reporting them, (hence limiting open communication and fostering an environment of learning from mistakes), traditional organisations face competing priorities in balancing safety with profitability in the face of constant market pressures and conflicting goals.
Balancing safety objectives and production demands has long been a concern to traditional organisations. While there is today much research to support health and safety as a profit generator in the long run, a further barrier to traditional organisations operating in line with HRO's is felt in the fact that the consequences of errors in the former will not be as far-reaching, hence leaving management more reluctant to commit to the necessary investment. In contrast, however, it has also been proposed that resilience can be engineered by including the key characteristics of the HRO as outlined above into operational processes.
Foster a learning culture - focus on organisational resilience and high reliability
Consolidating the five key features of the HRO, Roberts and Bea, 2001 identified three characteristics organisations can implement to enhance their reliability:
- Aggressively seek to know what you do not know - invest resources in the training of staff to raise levels of competency; analyse accidents and near misses for 'types' of accidents or potential accidents and incorporate a system of deference to knowledge
- Balance efficiency and reliability - incorporate incentive schemes to balance efficiency with profits; empower employees to make short-term safety decisions for long-term profit
- Communicate - establish effective communication channels so everyone is aware of the 'bigger picture' and so that knowledge can be efficiently accessed in the case of an emergency; define and communicate specific situational procedures
I think we call all agree that there are certain features of the HRO that traditional organisations can emulate - generally, if not in the minutiae of day-to-day operations. And while an MRO (Mid Reliability Organisation...to coin a phrase) certainly lacks the grandeur of HRO terminology, we can strive to adopt the key features inherent in the HRO - characteristics that are, at their root, borne out of a commonsense approach towards safety and will see production and profit improvements over the longer term.
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