The Nimrod Review - Official Documents

High Reliability Theory
18.16
Chapter 18 – Accident Theory and High-Risk Technologies
High Reliability theorists take a slightly more optimistic view of the world. Proponents argue that organisations
operating high-risk technologies, if properly designed and managed, can compensate for inevitable human
shortcomings. 22 In other words, extremely safe operations are possible, even with extremely hazardous
technologies, if appropriate organisational design and management techniques are followed. 23 A multidisciplinary
group of scholars at the University of California at Berkeley has conducted useful empirical
research focused on three hazardous organisations that it argues are ‘high reliability’ organisations which
have achieved “nearly error free operations”: the Federal Aviation Administration’s (FAA) air-traffic control
system, the Pacific Gas & Electrical Company’s electric power system (which includes the Diablo Canyon
Nuclear Power Plant), and the peacetime flight operations of two US Navy Aircraft Carriers. The researchers
have (in their words) “…begun to discover the degree and character of effort necessary to overcome the
inherent limitations to securing consistent, failure free operations in complex social organisations.” 24
18.17 In their book ‘Managing the Unexpected’, 25 Weick and Sutcliffe refer to High Reliability organisations. i.e.
which operate under very trying conditions all of the time, as practising a form of organising that reduces the
brutality of audits (major incidents) and speeds up the process of recovering. 26 Their view is that the hallmark
of a High Reliability organisation is not that it is error-free but that errors do not disable it, 27 such a state of
affairs being brought about by ‘mindful management’ i.e. good management of the unexpected. 28 They are
also of the view that people in High Reliability organisations try to guide themselves towards ‘troublesome’
perceptions and away from ‘soothing’ ones in order that they can see more, make better sense of what they
see, and remain more attuned to their current situation; and that they achieve this through a combination
of being pre-occupied with failure; being reluctant to simplify; having sensitivity towards operations; having
a commitment to resilience, and having a deference to expertise. Collectively, the authors state that these
principles can influence the design of processes and move the system toward a state of ‘mindfulness’:
“[M]indfulness is different from situational awareness in the sense that it involves the
combination of ongoing scrutiny of existing expectations, continuous refinement, and
differentiation of expectations based on newer experiences, willingness and capability
to invent new expectations that make sense of unprecedented events, a more nuanced
appreciation of context and ways to deal with it, and identification of new dimensions of
context that improve foresight and current functioning. 29
Contrasting the two schools of thought
18.18 Both sets of theorists share the same goal, i.e. effective safety management at both an individual and an
organisational level, but differ about the degree to which it is ultimately possible to avoid errors, incidents,
accidents, and catastrophes. Both strive to achieve the ‘dynamic non-event’ that represents ‘reliability’ in
high-risk technologies. It is ‘dynamic’ because processes remain within acceptable limits due to moment-tomoment
adjustments and compensations by the human operators. It is a ‘non-event’ because safe outcomes
claim little or no attention. The paradox is rooted in the fact that accidents are salient, while ‘normalcy’ is
not. 30
22 See Columbia Accident Investigation Board Report, Volume 1, page 180, paragraph 7.2.
23 See Scott D Sagan, The Limits of Safety, 1993, page 13.
24 Ibid, page 15.
25 Karl Weick and Kathleen Sutcliffe, Managing the Unexpected, 2007. (Jossey-Bass publishing).
26 Ibid, page 1.
27 Ibid, page 21.
28 Ibid, page 17.
29 Ibid, page 32.
30 James Reason, The Human Contribution, 2008, pp239-240. Commenting on Weick K.E. (1987) ‘Organisational culture as a source of high reliability.’
California Management Review, 29: 112-127.
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