I’ve had this book for a while, it’s getting a little dog-eared, I’ve found it very useful.
It’s got some jargon that was unfamiliar to me at first but it’s still a good book for a mariner.
Managing the Unexpected: Sustained Performance in a Complex World
Here’s the five principles of what the authors call High reliability organization
- Preoccupation with failure
- Reluctance to simplify interpretations
- Sensitivity to operations
- Commitment to resilience
- Deference to expertise
With regards to the deference to expertise, there’s another book I just finished reading lately and recommend:
The Knowledge Illusion: Why We Never Think Alone
I thought the book was a little longer then it needed to be but it’s an easy and entertaining read.
A couple of related items, made me think differently about how crew interact:
Young Men and Fire
This is the article by Karl Weick, one of the authors of Managing the Unexpected that led me to Young men and fire: The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster (pdf)
With regards to “Managing the Unexpected” what I got out of the book was the terminology.
No. 1 Preoccupation with failure
So I’m with bad chief, Bad chief seems to have no worries whatsoever, when I ask him how things are going, he tells me “The prop is turning and the lights are on”.
By contrast, I ask good chief the same question and he might tell me something like number 2 generator is leaking again but the 1st is working on and he also might say I’m concerned that if the schedule gets changed the parts we need to fix it right will miss the ship.
With the language from the book I can now succinctly say why I like good chief and I don’t like bad chief. Good chief is preoccupied with failure, bad chief is just reactive, going to wait for the lights to go out.
Or bad chief doesn’t want to probing into his department. but if he was preoccupied with failure he would want an outside view to help test his understanding of the situation.
Here is a link to the same article - better format
The Self-Designing High-Reliability Organization: Aircraft Carrier Flight Operations at Sea
Recenter studies of large, formal organizations that perform complex, inherently hazardous, and highly technical tasks under conditions of tight coupling and severe time pressure have generally concluded that most will fail spectacularly at some point, with attendant human and social costs of great severity. [ 1] The notion that accidents in these systems are “normal,” that is, to be expected given the conditions and risks of operation, appears to be as well grounded in experience as in theory. [ 2] Yet there is a small group of organizations in American society that appears to succeed under trying circumstances, performing daily a number of highly complex technical tasks in which they cannot afford to “fail.” We are currently studying three unusually salient examples whereby devotion to a zero rate of error is almost matched by performance–utility grid management (Pacific Gas & Electric Company), air traffic control, and flight operations aboard U.S. Navy aircraft carriers.
Of all activities studied by our research group, flight operations at sea is the closest to the “edge of the envelope”–operating under the most extreme conditions in the least stable environment, and with the greatest tension between preserving safety and reliability and attaining maximum operational efficiency. [ 3] Both electrical utilities and air traffic control emphasize the importance of long training, careful selection, task and team stability, and cumulative experience. Yet the Navy demonstrably performs very well with a young and largely inexperienced crew, with a “management” staff of officers that turns over half its complement each year, and in a working environment that must rebuild itself from scratch approximately every eighteen months. Such performance strongly challenges our theoretical under standing of the Navy as an organization, its training and operational processes, and the problem of high-reliability organizations generally.
It will come as no surprise to this audience that the Navy has certain traditional ways of doing things that transcend specifics of missions, ships, and technology. Much of what we have to report interprets that which is “known” to naval carrier personnel, yet is seldom articulated or analyzed. [ 4] We have been struck by the degree to which a set of highly unusual formal and informal rules and relationships are taken for granted, implicitly and almost unconsciously incorporated into the organizational structure of the operational Navy.
Only those who have been privileged to participate in high-tempo flight operations aboard a modern aircraft carrier at sea can appreciate the complexity, strain, and inherent hazards that underlie seemingly routine day-to-day operations. That naval personnel ultimately accept these conditions as more or less routine is yet another example of how adaptable people are to even the most difficult and stressful of circumstances.
Interesting that the article mentioned PG&E as an exemplar. This surprised me until I saw the date of 1987 for the article. For those not familiar with the later history of PG&E, they
– were convicted of 739 counts of criminal negligence in the starting of a 1994 wildfire
– blew up a neighborhood and killed 8 people in 2010
– were assessed responsibility for 12 wildfires in 2017
– are implicated (investigations not complete) in the devastating Camp Fire of 2018
I don’t know how well the HRO model as a big picture would hold up. The book as a whole even seems more like separate ideas than a single whole thing.
That said I’ve found many ideas in the book (the second edition) to be useful. The later edition (third) used fewer examples from on the ground operations (wildfire fighting for example) and more on business which seems far less pertinent to me.
How are the mighty fallen…
California Attorney General said that if the investigation shows their sloppy maintenance caused the Camp Fire (the one that wiped out the whole town of Paradise) he’s going after them for implied-malice murder or involuntary manslaughter (86 dead, 3 missing). PG&E said “it is determined to doing everything it can to reduce wildfire risks.” [CNN].
PG&E confesses (sort of):
PG&E Admits Probably Caused Fire
The whole article may be behind a paywall, but here’s the significant paragraph:
Though the cause of the fire is still under official investigation by California officials, PG&E said it “believes it is probable that its equipment will be determined to be an ignition point of the 2018 Camp Fire.” Attempts to determine the fire’s cause center on the 56-mile Caribou-Palermo electric transmission line. In its report, PG&E said inspections of the line found equipment that needed repair or should have been replaced.
The transmission line “de-energized” at 6:15 AM, an employee saw a fire at 6:30, and the official start of the fire was 6:33. Later observation saw part of the tower separated.
How have the mighty fallen…