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p.31 High reliability organizations (HROs) are harbingers of adaptive organizational forms for an increasingly complex environment. It is this possibility that warrants an effort to move HROs more centrally into the mainstream of organizational theory... HROs warrant closer attention because they embody processes of mindfulness that suppress tendencies toward inertia... We will argue that HROs are important because they provide a window on a distinctive set of processes that foster effectiveness under trying conditions.
The processes found in the best HROs provide the cognitive infrastructure that enables simultaneous adaptive learning and reliable performance... by explicating a set of cognitive processes that continuously reaccomplish reliability, we supply a mechanism by which reliable structures are enacted.
p.32-33 What stood out about TMI [JLJ - Three Mile Island] was that its technology was tightly coupled due to time-dependent processes, invariant sequences, and limited slack. The events that spread through this technology were invisible concentrations that were impossible to anticipate and that cascaded in an interactively complex manner. Perrow hypothesized that any system in which elements were tightly coupled and interactively complex would have accidents in the normal course of operations precisely because of this combination of lack of control and inability to comprehend what was happening.
p.35 consider Woods' (1988,p. 132) description of cognition in complex systems... "[To be] opportunistic and flexible in order to detect and to adapt to events which require revision of situation assessment and plans... problem solvers need to revise their understanding of the situation, their evidence collection and evaluation tactics, or their response strategy when new events are detected and evaluated. Failures to revise in any of these ways produce what are seen as fixation failures." ...reliable outcomes now become the result of stable processes of cognition directed at varying processes of production that uncover and correct unintended consequences.
Unexpected events require revisions of assessments, plans, and tactics but this revision is possible only because processes of "understanding," "evidence collection," "detection," "evaluation," and "revising" themselves remain stable in the face of new events. These stable cognitive processes do the "detecting," the variable patterns of activity do the "adapting to events which require revision."
p.36 Our point is simply that each time a routine is re-enacted, it unfolds in a slightly different way, a point also made by March and Olsen (1989, p. 38), Feldman (1989, p. 130), and Nelson and Winter (1982). In an unknowable, unpredictable world, ongoing mutual re-adjustment is a constant, and it is this adaptive activity that generates potential information about capability, vulnerability, and the environment (e.g., Landau & Chisholm, 1995, p. 70). That information is lost unless there is continuous mindful awareness of these variations.
p.36-37 When people in HROs focus on failures, tendencies to simplify, current operations, capabilities for resilience, and temptations to overstructure the system, these concerns cover a broader range of unexpected events. As shown in Figure 1, these separate concerns are tied together by their joint capability to induce a rich awareness of discriminatory detail and a capacity for action. We label this capability mindfulness, following Langer (1989, 1997). It is this enriched awareness, induced by the distinctive concerns of HROs with potentials for catastrophe, that facilitates the construction, discovery, and correction of unexpected events capable of escalation (Rochlin, 1989,pp. 164-165).
p.37 In Langer's model, the rich awareness associated with a mindful state is expressed at the individual level in at least three ways: active differentiation and refinement of existing categories and distinctions (Langer, 1989, p. 138); creation of new dis-continuous categories out of the continuous streams of events that flow through activities (Langer, 1989, p. 157); and a more nuanced appreciation of context and of alternative ways to deal with it (Langer, 1989, p. 159). In our extension of this model to the group level, we assume that awareness is expressed in at least these same three ways as byproducts of the five cognitive processes we discuss later.
p.37 awareness is more than simply an issue of "the way in which scarce attention is allocated" (March, 1994, p. 10). Mindfulness is as much about the quality of attention as it is about the conservation of attention.
p.37 Mindfulness in HROs is distinctive because it is closely related to the repertoire of action capabilities (Westrum, 1988,p. 8). The close relationship between mindfulness and the action repertoire in HROs is a key to their effectiveness.
p.37-38 the richness of a state of mindfulness is determined by the richness of the action repertoire. The richness of that action repertoire, in turn, is determined partly by the extent to which the cognitive processes are stable and continue to develop and partly by the extent to which the repertoire of variable routines that uncover and manage unexpected events continues to expand. HROs that are less effective (e.g., Osborn & Jackson, 1988) have a more limited range of action repertoires, use fewer of the cognitive processes associated with effective failure-avoidance, and update and enlarge their action repertoires less often.
p.38 Mindfulness is less about decision making, a traditional focus of organizational theory and accident prevention, and more about inquiry and interpretation grounded in capabilities for action.
p.38-39 A state of mindfulness appears to be created by at least five processes that we have induced from accounts of effective practice in HROs and from accident investigations:
- Preoccupation with failure
- Reluctance to simplify interpretations
- Sensitivity to operations
- Commitment to resilience
- Underspecification of structures
p.39 Effective HROs... remedy a paucity of data with richer analysis of the data they do gather (Bierly and Spender, 1995,p. 644).
p.42 To restrain temptations to simplify, HROs cultivate requisite variety and assume that it takes a complex system to sense a complex environment.
p.42 Schulman (1993b) defines requisite variety as "conceptual slack" by which he means "a divergence in analytical perspectives among members of an organization over theories, models, or causal assumptions pertaining to its technology or production processes" (Schulman, 1993b, p. 364). This divergence of perspectives is not about what the organization is doing, but rather about how it is going about it. Divergent perspectives provide the organization with a broader set of assumptions that sensitize it to a greater variety of inputs.
p.48 In a system held together by close attention to consequences, "wanting something leads to doing something connected to the want, and doing something leads to consequences related to the intention" (March & Olsen, 1986,p. 17).
p.50 We started with the observation that HROs are important because they are harbingers of adaptive organizational forms for an increasingly complex environment. They provide a window on a distinctive set of processes directed toward fostering effectiveness that can unfold in all organizations.
p.51 Mindfulness both increases the comprehension of complexity and loosens tight coupling. People preoccupied with failure comprehend more of the potential complex interactions in a system and create alternative paths for task performance that loosen couplings. People who simplify reluctantly pay close attention to the details of complexity rather than abstract them away and see more components that can be rearranged in more ways to avoid tight invariant sequences. People who maintain sensitivity to operations see more interconnections and comprehend more complexity in the moment which enables them to make adjustments that loosen time-dependencies, introduce redundancy, and in general, loosen tight coupling. People who develop capabilities for resilience stay attuned to unfolding events for longer time intervals which increases the likelihood that they will be able to comprehend puzzling interaction.
p.51 Resilient systems also create slack resources and alternative means to a goal, both of which loosen couplings.
p.54 Schulman (personal communication, 6/25/97, p. 2) has distilled his research on Diablo Canyon into these two propositions: "(1) The major determinant of reliability in an organization is not how greatly it values reliability or safety per se over other organizational values, but rather how greatly it disvalues the mis-specification, mis-estimation, and misunderstanding of things; (2) All else being equal, the more things that more members of an organization care about mis-specifying, mis-estimating and misunderstanding, the higher the level of reliability that organization can hope to attain."
If HROs strive to reduce mis-specification, then they need structural and cognitive mechanisms that encourage the sensing and organization of detail. These mechanisms need to be complex in order to register complexity. But they also need to keep that complexity unintegrated to preserve that detail.
p.54 There may be a fine line between messes that promote requisite variety and messes that undermine it. Effective HROs manage this tension artfully. More importantly, effective organizations in general may be those that are wise enough to accept the reality of paradox in organizational life and bold enough to define their effectiveness in terms of its preservation.
p.56 the concept of requisite variety has been central in previous discussions of HROs and it remains central in our analysis.
p.57 Divergent perspectives may reduce the incidence of disaster when they occur within an organization (Schulman speaks of members of an organization) or when tasks are not decomposable, but increase the likelihood of incidence when they cross boundaries and connect multiple organizations or when tasks are decomposable.
p.57-58 Requisite variety may have the potential to increase disasters when corporate cultures emphasize,
(1) accuracy rather than plausibility: A culture that values accuracy may influence people to withhold judgments and communication until they have "precisely the same information" and can demonstrate "the validity of their analysis." Since accuracy is difficult to demonstrate in a dynamic partially understood environment, norms that favor accuracy may silence the reporting of imprecise hunches about anomalies that could cumulate into crises.
(2) advocacy rather than active listening: If people define their job as "convincing others of the validity of their own set of information" rather than listening to others to determine the validity of their own information, then advocacy replaces analysis and synthesis. As a result, subtle cues that are ordinarily registered when requisite variety is high, go unacknowledged and the errors they point to are left unattended and remain available for cumulation.
(3) constant rather than periodic exchange of information: A culture in which information "exchanges are constantly being made," may make it harder to detect small changes than one in which exchanges are periodic. With periodic exchanges, contrasts between past and present become more clear-cut than is the case when exchange is continuous. With more frequent reporting, there is less change to report and more of a tendency to assimilate a current report to an earlier report (Hutchins, 1991). Errors that begin to cumulate in a single direction go unnoticed when exchange is continuous. This suggests that there may be an optimal frequency or periodicity for information exchange that varies from organization to organization. But it also suggests that continual talk is problematic as a blanket formula for increased reliability.
(4) complete consensus rather than partial "working" consensus: A culture that encourages people to seek a "single agreed-upon description" and to "reach complete consensus" ignores the reality of diversity in experiences and the impossibility of anything more than general agreement. Pressure for consensus is dangerous because it stifles the reporting of anomalies and because it takes time to attain it, time during which conditions can worsen and origins become harder to uncover.
p.58 Thus, high requisite variety may not improve reliable performance unless it is developed intra-organizationally as part of a context that encourages plausible judgment, active listening, periodic information exchange, and a working consensus. Departures from any of these potential boundary conditions may turn a system that uses variety to destroy variety into one in which variety amplifies variety.
p.61 Mindfulness, with its rich awareness of discriminatory detail, enables people to manage juxtapositions of events they have never seen before. But the ways in which they do this are still not fully understood. Our analysis represents an effort to further this understanding.
p.61-62 The purpose of our analysis has been to consolidate conceptually a body of work that begins to articulate the social infrastructure of reliability. The language of a near miss, having the bubble, migrating decisions, conceptual slack, resilience, normal accidents, redundancy, variable disjunction, struggle for alertness, performance pressure, situational awareness, interactive complexity, and prideful wariness, describes how people organize around failures in ways that induce mindful awareness. That mindfulness, in turn, reveals unexpected threats to well being that can escalate out of control. And that, in our estimation, is a central theme for mainstream organizational theory.
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