Sense and Reliability

Some organizations can't risk making any mistakes.

What can they teach us about managing the unexpected?

The Idea in Brief

Stable. Secure. Predictable. Many of us describe our organizations in these reassuring terms. But companies face numerous unpredictable challenges that strain our imaginations and creativity. A complacent view spells danger: When the unpredictable does happen, we become too paralyzed to survive the experience.

How to better manage the unpredictable? Take lessons from high reliability organizations. HROs-nuclear power plants, hospital emergency rooms, firefighting units-constantly operate under trying conditions. Yet they have surprisingly few accidents. Why? Mindfulness: the power to detect-and act on-even weak signals of impending danger.

The Idea in Practice

Hallmarks of Mindfulness

To anticipate and survive the unexpected:

Fixate on failure. Be obsessed with tiny details and events on the front line-where your organization's work gets done. Fixate on what you seldom see: complete failure.

In a classic misreading of a signal, Ford failed to notice that the Pinto's axle bolts punctured its gas tank in rear-end collisions-setting the car ablaze. Finding no "traceable cause" of the problem, Ford didn't recall the vehicle.

Encourage everyone to speak up about failures. Since few failures stem from one individual, don't assign blame. Instead, learn from mistakes and spot failures early-when they're small and easier to recover from.

Refuse to simplify reality. "Keep it simple, stupid" underestimates organizations' complexity. Rather than taking shortcuts, seek more details that might be missing.

If workers have to shut down a nuclear power plant's air supply because of an emergency signal, they don't consider the plant blueprints reliable guides to the air-supply system. Instead, they check the whole system for what may have been added since the drawings were completed. What's missing from the blueprints could cause the worst surprises.

Hire generalists. Employ executives with diverse backgrounds. They cope with problems more creatively than specialists, construct a richer version of what's going on, and bounce back more quickly from surprises.

Leap while looking. When you encounter a "cosmology episode"-an event that makes everything feel strange and irrational-don't try to think everything through before acting. The world keeps changing and your analyses will fall further behind. There's also no one correct interpretation of the event. To get moving again, take action-tempered by reflection. Action enables you to think and to edit multiple interpretations down to a manageable number.

When a platoon of soldiers got lost in the Alps, one soldier found a map in his pocket that the troops used to get out. Later, they realized the map depicted the Pyrenees. The lesson? When you're confused, almost any strategy can help you discover what to do next.

Don't overplan. Establish just enough guidelines to keep people moving. Most plans are too specific; their details create the illusion that the plan is trustworthy. Plans lure us into overlooking the unexpected and heighten the tendency to postpone action during crises.

Fidelity between a nuclear plant's control-room mock-up and its actual control room caused employees to freeze during a real emergency, as they searched their memories for where they'd seen the same situation during training. Meanwhile, the reactor got hotter and hotter.

Copyright (C) 2003 Harvard Business School Publishing Corporation. All rights reserved.

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Further Reading

Article

Predictable Surprises: The Disasters You Should Have Seen Coming

Harvard Business Review

March 2003

by Michael D. Watkins and Max H. Bazerman

Watkins and Bazerman build on the concept of mindfulness by describing a three-step process for recognizing an impending change or crisis, prioritizing it in our organizations, and mobilizing resources to stop it. By rigorously following these steps, we stand a better chance of lowering three barriers that prevent us from foreseeing calamity: the psychological biases blinding us to problems we haven't personally experienced; organizational silos fragmenting and distorting information and dispersing accountability; and political pressures causing us to overvalue some groups' interests while slighting others'.

To manage the unpredictable, we must begin by quickly detecting and responding to even weak warning signs. Start by asking the obvious-but rarely asked-question: "What potential disasters are brewing in our company?" Then ferret out threats invisible to insiders. How? Use techniques such as scenario planning (asking knowledgeable insiders and outsiders to review current crisis-response strategies and analyze external trends); risk analysis (estimating future events' probabilities and various outcomes' potential costs and benefits); incentives (compensating people in ways that promote information sharing); and networking (having external and internal advisers test and refine early impressions).

Book

Managing the Unexpected: Assuring High Performance in an Age of Complexity

Jossey-Bass

2001

by Karl E. Weick and Kathleen M. Sutcliffe

In this book, Weick and Sutcliffe first laid out the ideas that Weick discusses in "Sense and Reliability." The authors start things off by maintaining that although traditional managerial practices such as planning are designed to manage unexpected threats, they often only make things worse. To organize for high performance, we must all view our organizations as settings in which the potential for error and disaster is overwhelming. That is, we must think and act like high reliability organizations (HROs).

Managing the Unexpected explains how to manage under constantly trying conditions. The authors reveal how HROs create a collective state of mindfulness that enhances executives' ability to discover and correct errors before they escalate into crises. By examining the practices used to apply mindfulness, the book shows how to anticipate and respond to threats with flexibility rather than rigidity. The authors include numerous case studies demonstrating mindful practices, enabling readers to assess and implement mindfulness in their own organizations.