How feasible is high-reliability perfection and does it actually make a difference? In his latest blog for SHP, Dom Cooper unpacks the theory’s implementation and impact.
Credit: Oliver Buchmann/Unsplash
High-reliability organisations (HROs) are those that are largely failure-free, having succeeded in avoiding catastrophes despite a very high level of risk and operational complexity. The signature of an HRO is not that it is completely error-free, but that errors don’t disable it[i].Typically, these include high-hazard operations such as nuclear plants, air-traffic control systems and military aircraft carriers where a catastrophe would be horrific and costly.
HROs are distinguished by the way they manage the unexpected: through [1] a heightened preoccupation with failure (e.g., all near-misses are investigated); [2] a reluctance to simplify (e.g., comprehensive solutions are embraced); [3] a heightened sensitivity to operations (e.g., every aspect of current operational performance is known); [4] a deference to expertise (e.g., seniority is trumped by expert knowledge); and [5] a commitment to resilience (e.g., potential adverse events are anticipated by constantly asking “what if?”).
HRO theory has not evolved significantly over the past 20 years, and it still lacks a framework to explain why it succeeds[ii]. Despite this, its reputation is such that many industries aspire to adopt HRO principles, particularly healthcare, emergency services, transportation, the defence industry, government and energy. This begs the question of whether the reputation is deserved, and if so, what is it that actually makes the difference?
A major aim of HROs is to install a system-level approach to human-error reduction and process improvement. Common implementation activities include some form of basic human-error prevention training for all staff; leadership training for supervisory levels; peer-to-peer coaches in the use of error prevention techniques (e.g., identifying human-error traps); root cause analysis of all potential and actual error events; providing relevant and regular feedback of good catches and lessons learned; and increased error reduction communications through regular workgroup briefings. Many readers will know these are simply the basics of good safety management[iii]. As we all also know, how well these things are executed at the ‘coalface’ will always determine their impact.
BP tried to morph into an HRO two decades ago: it developed and issued a leader’s field guide with an educational toolkit, aimed at creating “collective mindfulness” among employees and supervisors. The HRO process did not exert its intended impact because: [a] it relied on education; [b] due to cost-cutting, BP failed to fully resource what was required to change the entire organisation’s practices and processes to suit; [c] it excluded the involvement of BP’s executive management team while pushing responsibility for the HRO culture changes down to mid-level managers[iv]. We all know what happened to the Texas City refinery in 2005 and the Deepwater Horizon drilling rig in 2010.
Evidence of error and incident reduction from implementing HRO principles is very thin on the ground, to the point of being almost non-existent, suggesting the HRO reputation is not warranted, or the HRO status only applies to extremely high-risk ventures that have avoided a catastrophe (the latter being the singular mark of success) over several years or decades.
A longitudinal study of the Federal Aviation Administration (FAA) shows it took incremental policy changes over a 97-year period to achieve small statistically significant effects between commercial aviation accident reduction and HRO characteristics[v]. I doubt anyone wants to wait that long, but it does point to policy changes being necessary to implement the HRO principles, with the attendant senior management commitment implications we are all used to.
There is also some limited evidence to show that serious safety events were reduced in some healthcare facilities over a 2-9 year period[vi] but any cause-and-effect relationships to HRO principles are unclear. This means, for example, the changes could simply have been the result of good leadership and employee engagement, both of which have been proven to improve safety performance[vii].
There is no comprehensive theoretical framework to help explain how HRO principles and processes optimise performance and reduce errors, and it is very unclear what the link is between HRO principles and performance improvement in complex operations[viii]. Currently, there is no evidence linking the implementation of the core HRO principles to reduced errors in any industry[ix]. Recent speculation[x] suggests that a culture of reliability is the key HRO ingredient that leads to “collective mindfulness” (i.e., group norms).
Applying Occam’s razor (which states that the simplest explanation is most likely the correct one), could it be that strategies based on HRO principles make little difference? More important is an organisation’s laser-like focus on reducing error using standard safety management processes, combined with high risk-aversion leading to an extremely low tolerance for risk.[xi]?
What is clear, is that the basics of safety management are shown to be vital to actual improvements. This includes good leadership; genuine employee engagement; identifying human-error traps, hazards and risks; thoroughly investigating near-misses and actual incidents and regularly communicating any lessons learned. I applaud those who have put in the safety management basics while adopting HRO principles, but I cannot help wondering why these are not already in place before industries/facilities even consider HRO as an option.
[i] Weick, K. E. & Sutcliffe, K. M. (2001). Managing the Unexpected (Vol. 9). San Francisco: Jossey-Bass.
[ii] Lekka, C. (2011). High reliability organisations: A review of the literature. Health & Safety Executive, 1-34. CRR899
[iii] van Kampen, J., Lammers, M., Steijn, W., Guldenmund, F. & Groeneweg, J. (2023). What works in safety. The use and perceived effectiveness of 48 safety interventions. Safety Science, 162, 106072.
[iv] Hopkins, A. (2021). A Practical Guide to Becoming a “High Reliability Organisation”. Australian Institute of Health & Safety.
[v] O’Neil, P. D. & Kriz, K. A. (2013). Do High‐Reliability Systems Have Lower Error Rates? Evidence from Commercial Aircraft Accidents. Public Administration Review, 73(4), 601-612.
[vi] Veazie, S., Peterson, K. & Bourne, D. (2019). Evidence brief: implementation of high reliability organization principles.
[vii] Cooper, D. (2015). Effective safety leadership: Understanding types & styles that improve safety performance. Professional Safety, 60(02), 49-53.
[viii] Boin, A. & Schulman, P. (2008). Assessing NASA’s safety culture: the limits and possibilities of high‐reliability theory. Public Administration Review, 68(6), 1050-1062.
[ix] Tolk, J. N., Cantu, J. & Beruvides, M. (2015). High reliability organization research: a literature review for health care. Engineering Management Journal, 27(4), 218-237.
[x] Cantu, J., Tolk, J., Fritts, S. & Gharehyakheh, A. (2020). High Reliability Organization (HRO) systematic literature review: Discovery of culture as a foundational hallmark. Journal of Contingencies and Crisis Management, 28(4), 399-410.
[xi] Bhandari, S. & Hallowell, M. R. (2022). Influence of safety climate on risk tolerance and risk-taking behavior: A cross-cultural examination. Safety Science, 146, 105559.
Click here to read Dom’s take on UK mental health statistics and here to read his article on whether incident investigations are caused solely by the system or person.
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For me HRO’s have had to obsess about near misses, leadership, engagement etc. because when failure strikes it does so catastrophically. My observation of many of these industries is at times they are surrounded by lower hazard industries, or that they outsource failure elements such as baggage handling in the airline industry, cleaning in healthcare and even FM in the energy sectors. This allows the HRO to maintain an aura of achievement whilst avoiding an understanding of true risk exposure.
You’ve ever seen the damage done to an aircraft by a baggage handler cutting a corner too tight and running his trailers into the nose of an airline jet? Those nose cones are expensive because behind them is the weather radar that has to pass through that specialized material and then sense what energy coms back. Man that cancels the flight until they can get a new one installed. In all, it is like $650,000 mistake (factor in not only replacement cost for the nose cone but also the mechanics time and lost revenue for the aircraft while it is… Read more »
If you read Karl Weick properly it’s not about organisations it is about organising.
The principle has come a long way from the original concept for the US Navy. to about individual awareness and risk intelligence. It’s an individual check on a persons heuristics and hubris.