Complex organizations such as Nuclear facilities, Air Traffic Control Centres, Nuclear Carriers, NASA, some hospitals etc. are run as High Reliability Organisations (HRO’s). Perron and Reason see it as unavoidable that errors in complex systems will always happen, HRO is a tool to avoid as much as possible such errors and the consequences of it.
An example of what can happen to a complex system that was not run as a HRO is the incident with the Costa Concordia which carried about 4000 people. Another example of a very complex system, were however HRO was in place, is the nuclear Aircraft Carrier USS Enterprise with a crew of 5000 which was in service for fifty years with only one incident and that was not a coincidence or just luck.
In a High Reliability Organisation it is recognized that people make mistakes. Everybody should work hard to try to prevent such human errors but knows at the same time that this will not always be possible and that on any moment a fault can be made.
Respect - One should respect the opinions of the other members of an organization or team, from low to high ranks. Others should be encouraged to voice their opinion.
Caution - A cautious approach is a must to avoid errors and create incidents.
Mindfulness - There are five characteristics of HRO’s that have been identified as responsible for the “mindfulness” that keeps them working well when facing unexpected situations:
- Proactive anticipation on incidents
- Reluctance to simplify interpretations
- Sensitivity to operations
- Commitment to resilience
- Deference to expertise
Openness - An open culture is of utmost importance for a safe and high reliability organization or work space.
Reporting - Every incident, never mind how small it might be, should be reported and registered. The results should be analyzed on a regular basis to discover trends and identify problem areas.
If the bridge team of the El Faro had been run as a HRO that accident probably would have never happened, it was so unnecessary. The problem is how to implement HRO in somewhat less complex systems like the El Faro and generally in shipping. A good start would be to teach HRO in the nautical schools and the more posh Academies and to give post-graduate courses on the subject, all with the intention to work towards a better and safer marine environment.