High Reliability Organizing in High Risk Industries Banner - Artwork by E. Steele, for the Wildland Fire Lessons Learned Center

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Jan 23, 2009:
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Key Learnings

Solutions from the individual; errors from the organization
We believe that, while the solution begins at the level of the individual, errors begin at the level of the organization. We further believe that any approach or model must be true to both the primary research of the respective sciences and the primary experience of individuals who face these crises. The crisis a person may face has a spectrum from straightforward uncertainty in the choice of procedure for a situation to critical live or die situations. We also believe that the approach used for live or die situations should derive from those same principles used in routine operations for uncertain, deadly situations, "What you do everyday is what you do in an emergency" (Joe Martin, Battalion Chief, Los Angeles City Fire Department, Retired).

I, me, mine – Why can’t you see what I see?
What makes this subject difficult to discuss is the idiosyncratic nature of these common experiences. We each experience the same event differently. As a fire captain told the author, “There are a thousand things happening on scene; you can only see a hundred and act on ten. I will see a different hundred and act on a different ten. It doesn’t mean I am right or that you are wrong. It only means we are different.” Descriptions must span the awareness of the situation, the individual's response, and the organization's support for individual action with the use of a common language. Contributing to this difficulty in sharing information are the clichés, jargon and slang commonly used in a system or culture that, while making sense to that group, camouflages the nuance and deeper principles of these shared experiences and actions. We seek to overcome such difficulties through open, aggressive communication and discussion by developing a common language with shared definitions.

The Indeterminate Problem: Threat, uncertainty, time dependence
These situations derive from threat and uncertainty in time dependent situations. Threat Wildfire presents itself in a spectrum from threat to one's image or reputation to direct and imminent threat to life or limb. Uncertainty also has a spectrum that ranges from that of a novice, the situation is common but new to any beginner, to experiences that have never before occurred and were previously unimaginable. Time dependence does not have the characteristics of a spectrum but does have a common description in that insufficient time exists to collect necessary data, make a decision, or carry out an action. This author defines the indeterminate problem as this triad of threat, uncertainty, and time dependence.

One boy has half a brain; two boys have no brain – Nonlinearity for beginners
Linear systems increase in direct proportion to the stimuli. Nonlinear systems may accelerate, decelerate, or change trajectory with the observer unable to predict which. The nonlinearity of the system complicates the situation and, when nonlinear systems couple or combine, they create complexity. If complex systems bifurcate into two independent paths they are said to be sensitive to initial conditions; they have become a chaotic degradation. Despite such complexity, many times the dynamic initiator of the event has passed and complexity derives from the sequelae or consequences response. "After all, an earthquake is just a big victim generator," James "Jim" Denney, Captain, Los Angeles Fire Department (Retired) and OSS Group (1947- 2006).

The projection of thought into the stochastic environment
The stochastic environment is one that appears to operate at random but with the occasional appearance of rules. We have explored the science and practicality of human responses to the indeterminate problem with Jim Holbrook's question, "Is it possible to project thought into an unstable environment?" This has led us to neuroanatomy, physiology, psychology, and sociology while with the intent of identifying methods that come naturally to people. While some look for structured responses, people have a naturalistic approach we can use. Problem solving is pleasurable, people routinely do puzzles and games. "It's in their inherent nature that people are drawn to a problem and, while around the problem, they begin to solve it," Gary Provansal, Division Chief, San Bernardino County Fire Department.

Conclusions

Failure Kills
Working in areas where safety can turn on an action or word makes one continuously question if what just worked has also started a failure. A bias develops, error bias, that what one just did is wrong which creates vigilance toward error. A team of people with error bias view corrections and criticisms as life saving rather attacks on one’s credibility.

Success Kills
What we do works. Success, when repeated, produces the illusion that things work “as is” and we have no need to change. However, this is like traveling down a narrow canyon that has no obstructions but finding it drops away in a waterfall at the end. We also may attribute our success to characteristics that may actually be latent causes for failure and catastrophe. Success may lead us to rely on the wrong thing. People may consider as useful some characteristics such as abusive yelling to motivate people, which increases the difficulty in identifying and changing these potentially lethal situations.

Negative Space- Can it save us?

Failure of the system must be discussed as part of the definition of HROs. We discuss the negative space around a system like artists describe the negative space in a painting, the space that is not the subject. Just as negative space brings attention to the subject, negative space, that which is not HRO, brings attention to what is HRO. We must not only describe what an organization is, but what it is not.

In high risk organizations failure can bring loss of life. We can design against it or have vigilance to early heralds of what is not safe, not solely to ensure safety but to consider safety and success as a unity of results and a result of the combined efforts of many people. "Your success is my success and your failure is my failure," Dywane Thomas, RCP, (Chief Warrant Officer, US Marine Corps, retired).

The Individual Acts; The Organization Supports
While the response lies with the individual, the organization must support the individual. Proactively, this support comes from training and education, interactively from resources and attributes, and retrospectively from non-blaming lessons learned studies. This behavior, internalized rather than imposed, is routinely found in military combat and, in earlier economic environments, in business (e.g., the Great Depression). These traits are fading, the mission we have adopted is to identify successful traits, recapture them, and incorporate them in today's organizations by internalizing them into the individual rather than imposing them.

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