High Reliability Organisation

High Reliability Organisation (HRO) and Resilience Engineering (RE) are two research traditions which have attracted a wide and diverse readership in the past decade. Both have reached the status of central contributions to the field of safety while sharing a similar orientation. This is not without creating tensions or questions, as expressed in the call of this special issue. The contention of this article is that these two schools introduce ways of approaching safety which need to be reflected upon in order to avoid simplifications and hasty judgments about their relative strength, weaknesses or degree of overlapping. HRO has gained strength and legitimacy from (1) studying ethnographically, with an organisational angle, high-risk systems, (2) debating about principles producing organisation reliability in face of high complexity and (3) conceptualising some of these principles into a successful generic model of " collective mindfulness " , with both practical and theoretical success. RE has gained strength and legitimacy from (1) harnessing then deconstructing, empirically and theoretically, the notion of 'human error', (2) argued for a system (and complexity) view and discourse about safety/accidents, (3) and supported this view with the help of (graphical) actionable models and methods (i.e. the engineering orientation). In order to show this, one has to go beyond the past 10 years of RE to include a longer time frame going back to the 80s to the early days of Cognitive Engineering (CE). The approach that is followed here includes therefore a strong historical orientation as a way to better understand the present situation, profile each school, promote complementarities while maintaining nuances.

The purpose of the current parallel concurrent mixed-methods study was to determine if a time delay is caused by the participative leader while engaged in the complex urgent-task environment of a high-reliability organization (HRO). Current research in this area predominantly revolves around the medical field, but the current study was used to examine other industries involved in high-reliability operations. It was noted through the research that in the medical trauma field, teams do not form a maturity, because they quickly assemble and disband. The maturity factor is a key component in the decision to use authoritarian or participative leadership. The study used a qualitative approach by employing Fiedler’s least preferred coworker scale and developed a variable of follower effectiveness to understand the relationship between the leader and follower as different leadership styles were used. A qualitative approach to the data was used to explore the follower’s feeling of value to the leader. Using the measures, a Spearman correlation and scatter plot assessments within SPSS analyzed the quantitative data. A thematic approach was used to analyze the qualitative data. In the study, data was used to successfully identify that the participative leader does not create a time delay in the time-urgent chaotic portion of a high-reliability organization.

Karl Weick is the influencial social psychologist who in 1979 wrote the book The Social Psychology of Organizing.  Sometimes organizations run into trouble and their reactions make things worse.  On the other hand, there a number of organizations that the authors call high reliability organizations (HROs) that are able to successfully manage in highly unreliable but critical domains where the unexpected can easily occur.  HROs include nuclear power plants, aircraft carriers, wilderness firefighting crews, air traffic control systems, nuclear aircraft carriers, hospital emergency departments, hostage negotiation teams, etc.  Mainstream organizations sometimes come face to face with the unexpected and face disaster.  “A person or unit has an intention, takes actions, misunderstands the world; actual events fail to coincide with the intended sequence; and there is an unexpected outcome” (p. 2).

The aim of this article is to explore the contribution of powerful actors of organisations to the construction of safety in high-risk systems. Accident investigation reports and empirical research of daily operations of high-risk systems target organisational issues since the 1990s. However, although in safety research one can observe a series of disciplines contributing to advance knowledge in this direction, such as sociology, management or political science, nothing much is available in the field of strategy. Yet, the argument of this article is that it is useful to also frame the study of safety and accident as a one which needs a strategic angle of analysis. In a first section, safety research is briefly introduced, then in a second section the field of strategy, including studies of strategic failures. Reasons for the relative absence of an interest in strategy and safety are advanced and argued. One conclusion is as a consequence the need to advance our knowledge on the topic of safety from the point of view of the psychology and sociology of executives and top managers, in relation to strategy. In a last section, illustrations of how strategic decision-making matters tremendously to our understanding of safety is introduced and discussed, distinguishing strategic mistakes, failures and fiascos. Outlines of a research agenda are described. Overall, this article proposes to reformulate the notion of 'latent causes' of disasters as various degree of strategic breakdown.

This short piece is a slightly extended version of my contribution to Andrew Sherman's book "One Percent Safer" (Sherman, 2020). It follows a request by Luis Wustemann to develop practical guidance based on the topic of my contribution. I would like to thank them for the opportunity to promote these ideas.

In 1984, Charles Perrow (CP) released a landmark book entitled Normal Accident (NA), in which he defended the argument of the inevitability of accident in certain type of high risk systems. The aim of this paper is, thirty years after the book’s publication, to reconsider this book and offer a new interpretation. Indeed, in hindsight, the message of the book seems today as compelling as ever. Accidents and catastrophes have continued to occur over the last three decades. However, the technological determinism of the book has been criticised and shown to be too restricted to account for the social nature of these phenomena. In opposition to his structuralist view, some authors have argued an extended socio-technological model of the normality of accidents. Indeed, Charles Perrow himself  often complained about the misuse of his own technological rational to interpret accidents. Consequently, he has regularly used instead a wider, macro-social, critical and power view of organisations and society to interpret accidents. This second posture was clearly in the background of the 1984 book, but has often been neglected, unnoticed or overlooked by commentators, proponents and critics.  This paper aims to highlight this second underlying message of the book. This second message could arguably be today, in retrospect, the book’s most valuable and compelling contribution to our understanding of accidents and safety and a basis for contemporary research.

This chapter is about managing sociotechnological risks. It is in the 70s that the notion of ‘high-risk’ (or ‘safety critical’) systems started to be distinguished and grouped into an independent category including industries such as the nuclear, aviation, marine, petrochemical or the railways. Any attempt such as this one to introduce this background in a few pages is necessarily restrictive, partly unfair but also a simplified account. And, there are of course many different strategies to do so. One option is to consider the field through the scientific disciplines involved, say sociology, engineering, psychology, ergonomics, management, etc. A second one, quite related to the first, is to introduce pioneers who, from different disciplinary backgrounds, produced seminal contributions used as shared references among various research communities interested in the safety of complex sociotechnological systems. A third one is to look into industry (aviation, nuclear or petrochemical) in order to illustrate and to differentiate the diversity of problems related to sociotechnological risks and how they materialise. Another option is to identify core concepts that sometimes cut across a range of disciplines, authors and industry which offers also good insights into the issues involved with sociotechnological risks. In any case, it is a very challenging task. The intention in this chapter is to combine a bit of these strategies in order to offer the reader a broad vision, and to follow editors’ guidelines specifying the following structure: first, key concepts, second, major debates and third open questions/perspectives.

Our current era is one of profound changes and uncertainties, and one issue is to understand their implications for high-risk systems and critical infrastructures (e.g. nuclear power plants, ships, hospitals, trains, chemical plants). Normal Accidents (NA), Perrow's classic published in 1984, is a useful guide to explore the contemporary epoch, in the third decade of the 21 st century. One reason is that this landmark book has triggered a sustained interest by scholars who have debated, challenged, rejected, refined or expanded its core thesis over almost now 40 years. With La Porte, Sagan, Vaughan and Hopkins' contributions into what can be described as the "standard NA debate" in the late 20 th century and the more recent "new controversies and debates" by Downer, Pritchard or Le Coze in the early 21 st century, the book can still resonate with current changes in the 2020s. These changes include phenomena as large, massive, intertwined, consequential and diverse as the advent of internet and of digital societies, the increase of transnational flows of diverse nature (people, data, capital, images, goods) and the ecological crisis captured by a notion such as the anthropocene. Taking stock, historicising and revisiting NA with such debates and changes in mind leads to characterise a Post NA narrative.

In this book, I argue that there is a need to revisit Perrow’s seminal contribution, Normal Accidents. I discuss conceptual and empirical changes in the past three decades and show the relevance of thinking our current situation with the help of this classic book when confronted to these changes; hence, the prefix “post”.

Structure as an analytical category has a long trail of debates in safety over 40 years but has never been the topic of a dedicated study, until Hopkins' work on the issue of centralised organisational structures. The notion of structure has had different meanings including structure as coupling and complexity (1), as redundancy (2), as self-correcting (3), as underspecified (4), as management system (5), as degree of centralisation (6), as macro social configuration (7). I come back in the first section of this article on this in order to situate Hopkins' argument. To do so, I use the insights from organisation theory on the complex relationships between structure, culture, power, technology, goal and environment. Hopkins' view is that "structure creates culture" which depends on the degree of centralisation (6). In a second section, I go one step further to situate Hopkins' argument, coming back on four decades of publications in order to bring the distance needed to characterise his message, its context (in particular, its rejection of safety culture) and retrospective rational. One conclusion is that his argument allows safety research to explicitly target top management decisions while offering a sociological and practical perspective. However, to elaborate his argument, Hopkins makes a certain number of simplifications which are discussed. I finally add that structure as a degree of centralisation is an opportunity to move one step closer to strategy. This complementary move is needed when one studies empirically daily operations of high-risk systems.

Although it is probably the best-known Prospective Hazard Analysis (PHA) tool, Failure Mode and Effects Analysis (FMEA) is far from the only option available. This paper introduces one of the alternatives: The Structured What-If Technique (SWIFT). SWIFT is a flexible, high-level risk identification technique that can be used on a standalone basis, or as part of a staged approach to make more efficient use of bottom-up methods like FMEA.

In this paper we describe the method, assess the evidence related to its use in healthcare using a systematic literature review, and suggest ways in which it could be better adapted for use in the healthcare industry. Based on the limited
evidence available, it appears that healthcare workers find it easy to learn, easy to use, and credible. Especially when used as part of a staged approach, SWIFT appears capable of playing a useful role as component of the PHA
armamentarium.

This chapter examines the topic of managing the unexpected. It starts with coming back on the engineering, human factors, managerial and governance (safety) principles that once combined coherently, corresponds to one strategy when one wants to characterise the management of the unexpected. A second strategy is to rely on the production of the social sciences of the past thirty to forty years to discuss the problem of definition then of conceptualisation of the unexpected in the context of high-risk systems. Following this second strategy, four threads are identified which help characterise the unexpected, corresponding to four rationales established by three authors who pioneered the field, Barry Turner, Charles Perrow and Jens Rasmussen. These rationales correspond to the ideas of 1) technology out of control, 2) executives (and regulatory) failure, 3) fallible (cognitive) constructs and 4) emergent properties (due to self-organised adaptive agents). They are named using four major intellectual figures of the social sciences,

BACKGROUND: Fishbone diagrams have been widely promoted as a systems-focused hazard analysis tool for use in root cause analysis, but they suffer from a number of structural weaknesses, including a unidirectional structure that only takes into account forces that promote an accident (ignoring those that make the accident less likely or less severe) and a means of displaying these forces that does not convey any difference in strength of influence. In a separate but related issue, many healthcare organizations suffer from a lack of change management expertise.

PROPOSED SOLUTION: To address these concerns, I present a novel technique, the Lovebug diagram, which draws from both Fishbone diagrams and force-field analysis (an approach to analyzing planned change). This new technique adds value to both its progenitor methods, while retaining their key strengths and ease of use. It can be used both prospectively, to assess planned changes, and retrospectively to assess unplanned (accidental) departures from the status quo.

DISCUSSION: The Lovebug diagram is a more powerful analytical tool than its progenitor methods; however, overall adoption of systems-focused tools for root cause analysis remains suboptimal. Additional research is needed to determine how best to promote a truly systems-focused approach to healthcare root cause analysis. Beyond this retrospective use of the technique, it represents a simple tool to assist healthcare organizations with prospective change management.

Available from: http://cri.sagepub.com/content/early/2013/10/25/1356262213510855.abstract

Although it is probably the best-known prospective hazard analysis (PHA) tool, failure mode and effects analysis (FMEA) is far from the only option available. This article introduces one of the alternatives: The structured what-if technique (SWIFT). SWIFT is a flexible, high-level risk identification technique that can be used on a stand-alone basis, or as part of a staged approach to make more efficient use of bottom-up methods like FMEA. In this article we describe the method, assess the evidence related to its use in healthcare with the use of a systematic literature review, and suggest ways in which it could be better adapted for use in the healthcare industry. Based on the limited evidence available, it appears that healthcare workers find it easy to learn, easy to use, and credible. Especially when used as part of a staged approach, SWIFT appears capable of playing a useful role as component of the PHA armamentarium.

This article provides a historical and critical account of James Reason’s contribution to safety research with a focus on the Swiss cheese model (SCM), its developments and its critics. This article shows that the SCM is a product of specific historical circumstances, has been developed over a ten years period following several steps, and has benefited of the direct influence of John Wreathall. Reason took part in intense intellectual debates and publications in the 1980s during which many ideas circulated among researchers, featuring authors as influent as Donald Norman, Jens Rasmussen, Charles Perrow or Barry Turner. The 1980s and 1990s were highly productive from a safety research point of view (e.g. human error, incubation models, high reliability organisation, safety culture) and Reason has considerably influenced it with a rich production of models, based on both research and industrial projects. Historical perspectives offer interesting insights because they can question research, the conditions of its production, its relevance and, sometimes, its success, as for the SCM. But, because of this success, critics have vividly argued about some of the SCM limitations, including its simplistic vision of accidents and its degree of generality. Against these positions, the article develops a ‘critique of the criticism’, and the article concludes that the SCM remains a relevant model because of its systematic foundations and its sustained use in high-risk industries; despite of course, the need to keep imagining alternatives based on the mix of collective empirical, practical and graphical research which was in the SCM background.

In the past two decades, Andrew Hopkins has been a very successful analyst of technological disasters and an acclaimed storyteller. In this article, I argue that he is also a theorist, and that he has developed over 40 years a normative sociological model of safety for studying major events. To do so, I first situate his contribution through a historical perspective going back to the 1970s and 1980s, a time during which Hopkins established core elements of a research program on catastrophic events subsequently deployed in late the 1990s onwards. Initially inspired in the 1970s and 1980s by the crime of the powerful, white-collar crime literature and a Marxist socio-legal perspective of society, he developed what I define as a white-collar crime model of accident (WCC-MA). He then moves in the 1990s and 2000s on to a more organisational and practical sociology of safety elaborated in his retrospective accounts of disasters. To ground this assertion, I explain how his storytelling success results from the invention of a specific narrative structure which is based on a repeated sequence of description (1), assumption (2), explanation (3), comparison (4), recommendation (5) and counterfactual reasoning (6), applied to many articulated topics. From there, I extract a (normative) sociological model of safety built over two decades, and then discuss some of the findings of this study.

Safety-critical systems such as offshore platforms, hospitals, aircrafts, nuclear power plants, refineries, bridges, dams, mines etc rely on a myriad of artefacts and actors to operate safely. It is an admirable political, technological, social and economic endeavour re-enacted everyday all over the world. But sometimes, when a bridge collapses, a building burns, an offshore platform explodes, a nuclear reactor melts down, a train derails, a ship sinks or a plane crashes, we are reminded how precarious such successes are and we are also reminded of the diversity of practices across countries, sectors and companies. To study these operations, to understand their complexities, to develop practical solutions, safety science has matured over 40 years. And, because of their immense complexity, high-risk systems have been investigated through the lenses of different research traditions. The 1980s and 1990s were foundational decades in this respect because many of the core programs within safety science have been structured ever since by influential networks of researchers. They have developed ideas, methods and concepts including, among others, safety culture, cognitive engineering, safety regulations, high-reliability organisations or normal accident. These networks of authors created lenses through which we grasp safety-critical systems, their mode of operating but also their ways of failing. If traditions have created, framed and shaped the contours of safety science, they are also historically situated in a different era, the end of the 20 th century. What about their relevance for a world which has tremendously changed at the turn of the 21 st century? The intention of this book is to explore this question, to step back, and to connect these established traditions with insights by a new generation of researchers within, across and beyond these traditions. These writers indeed apply, adapt, extend, challenge, combine or reformulate these traditions when confronted to our increasingly digitalised, globalised and networked world.

A critical step is a human action that will trigger immediate, irreversible, and intolerable harm to an asset if that action or a preceding action is performed improperly. Critical steps occur anytime an action involves a substantial transfer of energy, the movement of solids, liquids, and gases, or the transmission of data and information that, if not performed under control, could cause serious harm to one or more important assets. Accidents occur when front line production personnel lose control of such transfers during work through human error. In some industries, such as nuclear power and aviation, the management of human performance must necessarily be proactive, not waiting until a performance problem occurs to address it. Some human activities have to go right the first time, every time.

The Institute of Medicine’s report, To Err is Human, brought healthcare practitioners awareness to reduce errors that
harm patients. The Joint Commission, a non-profit accreditation agency for over 20,000 health care organizations in
the United States, set a goal to learn about and emulate highly reliable organizations that operate safely in high-risk
conditions and adopted high reliability organizations (HRO) in healthcare as it relates to patient safety. In general, it
appears that within the healthcare field, the initial concern and interest of applying HRO theory was patient safety,
leadership and creating a culture (or an environment) of safety. The literature suggests that within the HRO healthcare
environment, the tool of choice is a ‘survey.’ The research presented is a systemic literature review of HRO related
publications in healthcare focused on the implementation of HRO theory from 1999 to present. The majority of
research findings suggest few Industrial Engineering (IE) tools are used, which leads us to believe the efficacy of
Engineering Management (EM) tools can do much within this sector of healthcare

Safety rules are unavoidable in hazardous work and are often codified insights from accidents and fatalities. Safety rules research predominantly focuses on factors that influence compliance and violation of rules (a rationalist view), but rarely examines how members draw from safety rules to take action and gain experience. This study draws from and extends an adaptation view of safety rules, which considers how members use safety rules as " tools " to inform action. The study compares how two wildland firefighting workgroups incorporate safety rules into communication practices, and specifically, how they ventriloquize them. From a communication perspective, ventriloquization directs attention to ways safety rules enable members to make sense of hazards, navigate authority, and develop experience. The findings contribute an explanatory workgroup model for how members adapt safety rules into action according to workgroup norms, complementary relationships, and practices, which extends our understanding of adaptive action and learning in hazardous work organizations.

It has long been recognized that medical care itself has the potential to cause harm.2 However, general acknowledgement that much iatrogenic injury may be due to preventable human error or system failure appears to have been slow in the coming. Healthcare is a risky business. Simply being in an acute hospital in Massachusetts carries, on average, a 200-fold greater risk of dying from the care process than being in traffic, and a 2000-fold greater risk than working in a chemical industry, or flying on a plane.

In November 1999, the Institute of Medicine (IOM) published a landmark report entitled “To Err is Human: Building a Safer Health System.” Produced by the IOM’s Committee on Quality of Health Care in America, the report estimated that 44,000 to 98,000 Americans die in hospitals each year as a result of medical errors. Nonfatal “adverse events” (injuries caused by medical management rather than by the underlying condition of the patient) are ten- hundredfold more numerous than deaths due to errors. The IOM Report estimated that total national costs for adverse events (lost income, lost household production, disability, health care costs) are between $38 billion and $50 billion annually. Based on the IOM Report and assuming similar care, in Massachusetts we can expect between 1000 and 2000 preventable deaths a year.

Release of the IOM Report generated enormous coverage in the media, and intense focus on this issue has continued unabated. There is substantial evidence that the majority of health care errors are preventable, and are the result of systemic problems rather than poor performance by individual providers. Proposals have surfaced in Congress and from the White House to
implement the IOM’s recommendations, and several bipartisan-supported Congressional hearings have fueled discussion and debate on the subject.

In Massachusetts, where much of the work in patient safety has been pioneered, there is proposed legislation which includes a near miss reporting system, changes in mandated reporting systems and the creation of a new state agency to coordinate and support patient safety efforts and research. It also calls for confidentiality protection to encourage sharing of sensitive data. It is vital that all stakeholders, government, the professions, healthcare administrators, industry and consumers be involved at all stages and that mechanisms for ongoing, effective consultation and communication be provided at local and state levels.

There are ethical, humanitarian, and financial imperatives to find out what is going wrong, to collate, and analyze the information, and to devise and implement strategies to better detect, manage, and prevent these problems. Despite clear policy guidance and compelling ethical rationale, which support disclosure of adverse events, there are legal, regulatory and cultural barriers that perpetuate the current situation. Patients and families sometimes are not being told about adverse events that have led to bad outcomes or injuries.

This report concludes with a set of recommendations that encourages open debate on patient safety initiatives in Massachusetts. The Commonwealth can help create a culture of safety. If the fear of litigation continues to countervail the efforts to improve patient safety, transformation from the present unsatisfactory situation into a culture promoting safety for our patients may never be fully realized.

The following discussion is intended to provide background from a number of perspectives on the impact of the role of the state on patient safety. Several options for state level action in Massachusetts are presented. These include:
• Recommendation 1: Create and endow a Patient Safety Center for the Commonwealth
• Recommendation 2: Structure a leadership vehicle for the future development of patient safety programs
• Recommendation 3: Mandatory adoption of error prevention strategies
• Recommendation 4: Implement Incident Reporting
Recommendation 5: Provide and ensure appropriate confidentiality protection
• Recommendation 6: Study alternatives to the current medical liability and accountability systems

Root cause analysis is perhaps the most widely used tool in healthcare risk management, but does it actually lead to successful risk control? Are there categories of risk control that are more likely to be effective? And do healthcare risk managers have the tools they need to support the risk control process? This systematic review examines how the healthcare sector translates risk analysis to risk control action plans and examines how to do better. It suggests that the hierarchy of risk controls should inform risk control action planning and that new tools should be developed to improve the risk control process.

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Wiley's copyright policies do not allow me to post the published version of the paper, but they do allow me to send out individual copies. So if you don't have access to the Journal of Healthcare Risk Management and would like a copy of this article, please email me at:
alan [dot] j [dot] card [at] gmail [dot] com

This essay exposes three overarching arguments against the individual blame approach: unjust (subjective and inaccurate), ineffective (organizational myopia and inertia), and dangerous (impede organizational learning and contribute to latent error accumulation). For each argument, the paper explains in what way the no-blame strategy offers a better alternative. The final section touches on the limits and difficulties of the blame-free strategy.

Root cause analysis is perhaps the most widely used tool in healthcare risk management, but does it actually lead to successful risk control? Are there categories of risk control that are more likely to be effective? And do healthcare risk managers have the tools they need to support the risk control process? This systematic review examines how the healthcare sector translates risk analysis to risk control action plans and examines how to do better. It suggests that the hierarchy of risk controls should inform risk control action planning and that new tools should be developed to improve the risk control process.

Fuel cells generate electricity and heat during electrochemical reaction which happens between the oxygen and hydrogen to form the water. Fuel cell technology is a promising way to provide energy for rural areas where there is no access to the public grid or where there is a huge cost of wiring and transferring electricity. In addition, applications with essential secure electrical energy requirement such as uninterruptible power supplies (UPS), power generation stations and distributed systems can employ fuel cells as their source of energy. The current paper includes a comparative study of basic design, working principle, applications, advantages and disadvantages of various technologies available for fuel cells. In addition, techno-economic features of hydrogen fuel cell vehicles (FCV) and internal combustion engine vehicles (ICEV) are compared. The results indicate that fuel cell systems have simple design, high reliability, noiseless operation, high efficiency and less environmental impact. The aim of this paper is to serve as a convenient reference for fuel cell power generation reviews.

http://www.sciencedirect.com/science/article/pii/S1364032111004709

In the International Strategic Management (ISM) field of research, a frequently studied problem is the impact of distance (both geographical  and cultural) on organizational effectiveness and reliability. In high reliability organizations (HROs), the operator is one who addresses operational issues, often acting far (hierarchically and physically) from the managerial level, alone or as part of a team. This article discusses issues related to 1) the coordination mechanisms used by a multinational organization to ensure reliability; 2) the characteristics possessed by the operator and 3) the training strategies that should be used to develop their skills; lastly 4) a discussion of the relationship between the group agent (team) and organizational reliability.

High reliability concepts are tools that a growing number of hospitals are using to help achieve their safety, quality, and efficiency goals. Hospitals do most things right, much of the time. But even very infrequent failures in critical processes can have terrible consequences for a patient. Creating a culture and processes that radically reduce system failures and effectively respond when failures do occur is the goal of high reliability thinking.

At the core of high reliability organizations (HROs) are five key concepts, which we believe are essential for any improvement initiative to succeed:
• Sensitivity to operations. Preserving constant awareness by leaders and staff of the state of the systems and processes that affect patient care. This awareness is key to noting risks and preventing them.
• Reluctance to simplify. Simple processes are good, but simplistic explanations for why things work or fail are risky. Avoiding overly simple explanations of failure (unqualified staff, inadequate training, communication failure, etc.) is essential in order to understand the true reasons patients are placed at risk.
• Preoccupation with failure. When near-misses occur, these are viewed as evidence of systems that should be improved to reduce potential harm to patients. Rather than viewing near-misses as proof that the system has effective safeguards, they are viewed as symptomatic of areas in need of more attention.
• Deference to expertise. If leaders and supervisors are not willing to listen and respond to the insights of staff who know how processes really work and the risks patients really face, you will not have a culture in which high reliability is possible.
• Resilience. Leaders and staff need to be trained and prepared to know
        how to respond when system failures do occur.

This talk shows how hospital leaders have taken these basic concepts and used them to develop and implement initiatives that are key to enhanced reliability.

The talk will review how the concepts have been used to:
• Change and respond to the external and internal environment
• Plan and implement improvement initiatives
• Adjust how staff members do their work
• Implement improvement initiatives across a range of service types and
        clinical areas
• Spread improvements to other units and facilities

Applying high reliability concepts in your organization does not require a huge campaign or a major resource investment. It begins with leaders at all levels beginning to talk honestly about the challenges, sharing day transparently, and thinking deeply about how the care they provide could become more reliable.

The significance of a thorough understanding and analysis of hazards and threats in an industrial operation cannot be overstated, but equally important is the development of potential accident scenarios and the calculation of the probable costs of failure of all safety barriers and controls. Operations having a high consequence of failure at any step should be managed as a High Reliability Organization (HRO). The USDOE Pantex Plant, as the nation’s only nuclear weapon assembly point, is designed, managed and operated to be a HRO. Published characteristics of an HRO state that the organization performing highly hazardous operations must embrace two critical requirements; 1) stochastic analysis of hazards and threats, and 2) accident scenario development with economic consequence calculations. It is difficult and costly to perform the second requirement in order to accurately forecast cost impacts of a catastrophic accident. Due to the cost of this requirement, organizations are not always able to commit the resources necessary to do the work. This paper presents a preliminary analysis under development of the critical characteristics involved in modeling the economics of cleanup of blast fragmented dispersion of hazardous materials. The methodology, which utilizes and combines several tools, is presented as a model for cost estimation of barriers, controls, accidents and consequences. The model is able to determine accurately the consequences and associated costs of a catastrophic accident for justifying the costs of barriers and controls

Drawing from the theory of met expectations, this study aims to create new knowledge on the antecedents of follower trust in leaders in the context of high-reliability organizations. We hypothesize that highly self-controlled leaders instill more trust than leaders with less self-control, as the former tend to meet follower expectations. This work combines data from a field survey (N = 256) and a multi-wave field study (N = 106), using samples of professional firefighters to support our hypotheses that met follower expectations mediate the relationship between leader trait self-control and follower trust in the leader. Our research highlights the importance of met expectations in high-reliability contexts and demonstrates the value of leader trait self-control in building trustful relationships.

Abstract High reliability organizations (HROs) operate in hazardous, fast-paced, and complex environments yet avoid catastrophic accidents. Since the genesis of HRO theory in 1989, interest in HROs has grown beyond hazardous operations to many industries, including health care. This article reviews the literature to determine the extent to which changes made in health care organizations are aligned with HRO theory, and more specifically, with Roberts’ Six Actions, which are based on HRO theory. The results suggest that HRO theory remains of interest to health care organizations. Implications for engineering managers and opportunities for future research are suggested.

Arguments in science and technology studies have prompted us to rethink
the meaning of experimentation in the wider context of our everyday life,
though its dynamics have not been fully analyzed. This article argues that
the legacy of the sociocultural approach to learning, with special reference
to the Becker-Lave/Wenger dialogue, provides such a clue, and hence
proposes a framework—“experimental zone of learning”—for such purpose.
This zone is the outcome of the dynamic interface between constraints and
sociotechnical devices, and this framework enables analysis of the diversity
of such conditions, as well as their longitudinal changes through time.

This book deals with various topics related to learning and understanding in situ beyond the scope of the “situated cognition and learning” approach. The aim is to contribute to  a more socio-anthropologically extended framework that encompasses such theoretical approaches as risk research, high reliability organization studies, and science and technology studies (STS).
  Related papers: "Risk Management in the Wild" "Experimental Zone of Learning"available in English. Further explanations can be seen in the homepage of UTokyo BiblioPlaza, where the publications by the faculty of the university are presented.

The wisdom of learning from failure is incontrovertible. Yet organizations that do it well are extraordinarily rare. This gap is not due to a lack of commitment to learning. Managers in the vast majority of enterprises genuinely wanted to help their organizations learn from failures to improve future performance. In some cases they and their teams had devoted many hours to after-action reviews, postmortems, and the like.

Some key lessons from Nuclear Power that may be relevant to healthcare:

1. Leadership and accountability are inextricably linked.
2. Focus on outcomes.
3. When workers speak, leadership listens.
4. There are no isolated incidents.
5. Culture is the main driver of safe and reliable outcomes

High Reliability Organizations (HROs) face constant threats but manage to operate with relatively few accidents. The current study examines the reliability, factor structure, and discriminant validity of a new HRO Perception Scale. Results indicate the scale is reliable. The two-factor model, including self-efficacy and organizational risk response factors as part of the HRO Perception Scale, was supported. Finally, discriminant validity was established between the HRO Perception Scale and the Meyer & Allen Revised Organizational ...