To reduce friction on clicking through and reading more, I thought I’d just include the summary here. I’ll put my notes in a followup comment. (Note that I don’t expect all of this to translate to an AI research lab)
High Level takeaways
You can’t plan for everything. Something unexpected will always happen, from hurricanes to product errors.
Planning can actually get in the way of useful responses, because people see the world through the lens of their plans and interpret events to fit their expectations.
The more volatile your work environment, the more important it is to respond well in the moment.
To make your organization more reliable, anticipate and track failures. Determine what they teach you.
Focus on operations, rather than strategy.
To become more resilient, emphasize learning, fast communication and adaptation.
The person making decisions about how to solve a problem should be the person who knows the most about it – not the person who’s highest in the hierarchy.
To build awareness, audit your organization’s current practices.
To make your organization more mindful, don’t oversimplify.
Real mindfulness may require changing your organizational culture
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Abstract
Learning from High Reliability Organizations
Things you don’t expect to occur actually happen to you every day. Most surprises are minor, like a staff conflict, but some aren’t, like a blizzard. Some test your organization to the verge of destruction. You can’t plan for the unexpected, and in many cases, planning actually sets you up to respond incorrectly. You make assumptions about how the world is and what’s likely to happen. Unfortunately, many people try to make their worldview match their expectations, and thus ignore or distort signs that something different is happening. People look for confirmation that they’re correct, not that they’re wrong.
Planning focuses organizational action on specific, anticipated areas, which shuts down improvisation. When people plan, they also tend to “repeat patterns of activity that have worked in the past.” That works well if things stay the same – but when they change and the unexpected erupts, you are left executing solutions that don’t really fit your new situation
Consider organizations such as hospital emergency departments or nuclear power plants, which have to cope with extraordinary situations on a regular basis. These organizations have learned to deal regularly with challenging, disruptive events. They have adapted so that they react appropriately to the unexpected. They recognize that planning can only take an organization so far. After that, the way it responds to crisis determines its success. Your company can learn from the way these “high reliability organizations” (HROs) respond to crises, and, more generally, you can use their organizing principles in your own organization. Five core principles guide these HROs. The fi rst three emphasize anticipating problems; the last two emphasize containing problems after they happen
1. Preoccupation with failure. Attention on close calls and near misses (“being lucky vs. being good”); focus more on failures rather than successes. 2. Reluctance to simplify interpretations. Solid “root cause” analysis practices. 3. Sensitivity to operations. Situational awareness and carefully designed change management processes. 4. Commitment to resilience. Resources are continually devoted to corrective action plans and training. 5. Deference to expertise. Listen to your experts on the front lines (ex. authority follows expertise).
2. HROs are “reluctant to accept simplification” – Simplification is good and necessary. You need it for order and clarity, and for developing routines your organization can follow. However, if you simplify things too much or too quickly you may omit crucial data and obscure essential, information you need for problem solving. Labeling things to put them in conceptual categories can lead to dangerous oversimplification. NASA’s practice of classifying known glitches as “in-family” and new problems as “out-of-family” contributed to the Columbia disaster. By miscategorizing the damage to the shuttle as a maintenance-level “tile problem,” people downplayed its importance. To reduce such labeling danger, use hands-on observation. When things go wrong, don’t count on one observer; make sure people from varied backgrounds have time to discuss it at length. Re-examine the categories your organization uses and “differentiate them into subcategories,” so nothing gets hidden or blurred
3. HROs remain “sensitive to operations” – Stay focused on the actual situation as it is happening. Of course, aircraft carrier crewmembers, for instance, should align their actions with the larger strategic picture – but they can’t focus there. They must keep their focus on the airplanes that are taking off and landing on their deck. They have to pay attention to “the messy reality” of what’s actually happening. To improve your focus, refuse to elevate quantitative knowledge above qualitative and experiential knowledge. Weigh both equally. When you have “close calls,” learn the right lessons from them. Close calls don’t prove that the system is working because you didn’t crash. Close calls show that something’s wrong with the system since you almost crashed.
4. HROs develop and maintain “a commitment to resilience” – When the pressure is off, you might be able to believe that you’ve developed a perfect system that will never have to change. HROs know better. They regularly put their systems under incredible stress and unforeseen circumstances do arise. HROs know they have to adapt continually to changing circumstances. Resilience consists of three core capabilities. Your organization is resilient if it can “absorb strain” and keep working, even when things are hard, if it can “bounce back” from crises and if it can learn from them. HRO leaders celebrate when their organizations handle crises well, because it proves their resilience. Encourage people to share what they know and what they learn from crises. Speed up communication. Emphasize reducing the impact of crises. Practice mindfulness. Keep “uncommitted resources” ready to put into action when a crisis erupts. Structure your organization so that those who know what to do in a specific situation can take the lead, rather than hewing to a set hierarchy.
5. HROs practice “deference to expertise” – Avoid assuming that a direct relationship exists between your organization’s formal hierarchy and which person knows best what to do in a crisis. Often specific individuals possess deep expertise or situational knowledge that should leapfrog the hierarchy, so put them in charge of relevant major decisions. To increase your organization’s deference to expertise, focus on what the system knows and can handle, rather than taking pride in what you or any other individual knows and does. Recognize that expertise is “not simply an issue of content knowledge.” Instead, it consists of knowledge plus “credibility, trust and attentiveness.” Recognize and share what you know, even when people don’t want to hear it – but also know your limits and hand off authority when you reach them.
Auditing Your Organization for Mindfulness
You can’t shut your organization down and redesign it as an HRO, so find ways to redesign it while it is functioning. Start by auditing your current practices from numerous perspectives. These audits themselves will increase mindfulness. Ask questions to get people talking. As you review past crises as learning opportunities, you’ll start developing resilience. Study how much people in your organization agree and where agreement clusters. People at HROs tend to agree across their organizations’ different levels, so you have a problem if managers and front line workers disagree. Heed the areas where people disagree most about what to do or how the organization should function. See which aspects of reliability are strengths for you. Do you anticipate problems better (good planning)? Or are you better at containing them (good responsiveness)? Determine which audit findings are upsetting and “where you could be most mindful.”
Ask:
Where are you now? – Examine how mindful your firm is now. Do you actively pay attention to potential problems? Does everyone agree what is most likely to go wrong? Do you all attend to potential problem areas to make the firm more reliable?
How mindless are you? – Do you pressure people to do things the same way all the time or to work without needed information or training? Do you push people to produce without independent discretion? Such practices lead toward mindlessness.
Where do you need to be most mindful? – Things are likelier to go unexpectedly wrong when your processes are “tightly coupled” and “interactively complex,” as in a nuclear power plant. Look for these qualities to see where you need to be most intensely mindful. If you can work in linear units that you fully understand without feedback from one unit to the next, you need comparatively little mindfulness. But, if your processes demand coordination and cooperation, or if you’re a start-up and don’t yet have all of your systems fully in place, feedback must flow. That’s when you need mindfulness most.
Does your organization obsess over failure? – Encourage people to envision things that might go wrong and head them off. Ask yourself how consciously you seek potential failures. When something happens that you didn’t expect, does your organization figure out why? When you barely avoid a catastrophe, do you investigate why things almost went wrong, and learn from them? Do you change procedures to reflect your new understanding? On a simpler level, can people in your organization talk openly about failure? Do they report things that have gone awry?
Does your organization resist simplification? – Rather than assuming that your organization knows itself and has the correct perspective, challenge the routine. This won’t always make for the most comfortable workplace, but you must pay attention to real complexity. What do you take for granted? (Your goal is to be able to answer “nothing.”) Push people to analyze events below the surface. To deepen their understanding, people must trust and respect each other, even when they disagree.
Does your organization focus on operations? – Thinking about the big strategic picture is a lot of fun – but to be resilient, you need to monitor what is actually happening now, rather than assuming things are running smoothly. Seek feedback. Make sure people meet regularly with co-workers organization-wide, so they get a clearer overall picture.
Are you committed to becoming more resilient? – HROs show their commitment to resilience by funding training so people can develop their capacities. You want people to know as many jobs and processes as possible. Besides formal training, encourage people who meet “stretch” goals, use knowledge and solve problems.
Does your organization defer to expertise? – How much do people want to do their jobs well? Do they respect each other and defer to those who know an issue best?
Building a Mindful Organizational Culture
If you’re the only person in your company dedicated to mindfulness, the dominant “organizational culture” will swamp your good intentions. To make your organization more like an HRO, help it adopt an “informed culture” with these “four subcultures”:
1. A “reporting culture” – People share their accounts of what went wrong.
2. A “just culture” – The organization treats people fairly. Define “acceptable and unacceptable” action and do not punish failures that arise from acceptable behavior. When something goes wrong, seek reasons, not scapegoats.
3. A “flexible culture” – If your work is very variable, like fighting fires, don’t depend on a rigid, slow hierarchy. Foster individual discretion and variation instead of uniformity.
4. A “learning culture” – Increase everyone’s capacity; provide opportunities for people to share information.
Your organization’s culture manifests at several levels. It ascends from the level of physical objects, which can symbolize a corporate personality, to linked processes and then up to the level of abstractions, like shared values and assumptions. “Artifacts are the easiest to change, assumptions the hardest.” Top managers must consistently model and communicate the changes they want. State your desired beliefs and practices, give employees feedback and reward those who succeed.
As you move into implementing new activities, follow a “small wins strategy,” focusing on attainable goals. Start with the “after action review” in which people compare what they did in a crisis to what they intended to do, why it differed and how they’ll act in the future. Encourage people to share details, rather than glossing over specifics. Support those who try to be more mindful, since being mindless is so much easier. Help them by verbally reframing objectives. For example, reword current “goals in the form of mistakes that must not occur.” Define what having a “near miss” means and what constitutes “good news.” If no accident report is filed, is that good – or does it mean things are being brushed under the rug? Train people in interpersonal skills and encourage skepticism. To raise awareness of potential glitches, ask employees what unexpected occurrences they’ve seen. Meet with people face to face to get the nuances they communicate nonverbally.
In the appendix of High Reliability Orgs, and AI Companies, I transcribed a summary of the book Managing the Unexpected, which was the best resource I could find explaining how to apply lessons from the high reliability literature to other domains.
To reduce friction on clicking through and reading more, I thought I’d just include the summary here. I’ll put my notes in a followup comment. (Note that I don’t expect all of this to translate to an AI research lab)