High Reliability Organizing (HRO):
The Third Component of a Safe and
Productive Unit
Presented at the Pacific Northwest Fire Operations Workshop
Portland, OR – March 17, 2010
by David Christenson
Already an HRO?
Three Components of A Safe And Productive Unit
3 HRO Principles:
 Track small failures
 Resist oversimplification
 Sensitive to operations
 Maintain capabilities for resilience
1
Flexible
Learning
Be willing to share
concerns
Just
Respect feedback
Reporting
2
 Take advantage of shifting locations of expertise
Safety Culture
Be a student
Rules don’t and
can’t cover every
situation
Building on Strengths
Fundamental to success in
HRO implementation are the
connection of people and the
trust necessary for optimal
knowledge flow.
Thrive or Survive?
Study: Since the year 2000 about seventyfive percent just survive at work.
My Experience
 Since 1978 my experiences have taught me that:
The tools of:
 Organizational Learning
 Leadership Development
 and High Reliability Organizing
Are effective ways to begin connecting people
and engaging them in their work.
1978- 1982
1994
Human Factors & Org. Learning
Roberts
Weick
Sutcliffe
Vulnerable --- Fallible
Pressure
Social
Political
Economic
Peer
Human Factors
Stress
Fatigue
Ego
Challenges that Call for HRO
Roberts & Rousseau, 1989
 Hypercomplexity
 Tight Coupling
 Extreme Hierarchical Differentiation
 Multiple Decision-Makers in a Complex
Communication Network
 High Degree of Accountability
 Need for Frequent, Immediate Feedback
 Compressed Time Constraints
 High Workforce Mobility
Swiss Cheese Model
James Reason’s Epidemiological Model Analogy
The Field Guide to Understanding Human Error
by Sidney Dekker, 2006
Swiss Cheese Model vs. Metaphor
Conditions
Conditions
Recognition Primed Decision-Making
Gary Klein
S CA 2007
S CA 2003
Recognition Primed Decision-Making
Gary Klein
New: Critical Thinking Skills Training
A deliberate, systematic awareness of
the process and products of one’s own
thinking
Targets the common errors of:
Overlooking important
details
Misinterpreting information
Making incorrect
assumptions
Critical Thinking
Improving the probability of a desirable
outcome by improving your judgment
Combine Both Recognition Primed
Decision-Making and Critical Thinking
Recognition/ Metacognition
Critical Thinking Through Dialog
 Teamwork and Communications Improve
 Determine the acceptability of a belief or
action
 Q & A about alternative possibilities
 Improves understanding of the situation
and plan
 Learn more about beliefs, assumptions and
interests
 Generate more successful decisions
and create novel solutions
AARs & Sand Tables
Dynamic Decision-Making
Principles of HRO
1. Tracking Small Failures
2. Resisting Oversimplification
3. Sensitive To Operations
4. Maintaining Capabilities For Resilience
5. Taking Advantage Of Shifting Locations Of
Expertise
Weick & Sutcliffe, Managing the Unexpected 2001
HRO Audits & Implementation
 Fundamental to success in HRO
implementation are the connection of people
and the trust necessary for optimal knowledge
flow.
 Is the HRO information arriving in the context
of a fertile learning environment where people
are connected, engaged, and where
knowledge flows?
Context
“To treat information as context-free, that
is, independent of circumstances, places
us at risk for mindless thoughts,
decisions, and behaviors. Placing
information within context leads to
mindfulness.”
Ellen Langer, publishing Mindfulness. in 1989, and The Power
of Mindful Learning in1997
We All Needed To Learn Quickly
Connected
“Mindlessness develops from automatic
behaviors, repetition, and use of a
single perspective.” (Langer 1989)
Mindfulness welcomes new information,
becomes inclusive of the process used
and the environment actors are in,
rather than only on the outcome.
Soft Aspects?
 Connection improves both
individual and group
performance
 So paying attention to creating
an optimal work environment
requires paying attention to the
so-called soft aspects
 Such as the meaning of work and the way
people treat each other.
So What?
Connection in positive work relationships
provides:
 A sense of well-being, minimizes stress,
and makes us more trusting.
Without connection:
 People feel lonely, isolated, confused and
become distrusting, disrespectful and
dissatisfied. ..Corrosive environments.
Dr. Edward Hallowell at Harvard Medical School.
Costs
“The Gallup Organization conservatively
estimates the annual economic cost to
the American economy from the
approximately 22 million American
workers who are extremely negative or
“actively disengaged” to be between
$250 and $300 billion.”
Vision + Value + Voice = Connection
 Vision when everyone is united by common values,
proud of their unit’s reputation, and motivated by their
mission
 Value exists in an organization when everyone
understands the basic psychological needs of people,
behaves in ways that appreciates their positive, unique
contributions, and acts to help them achieve their
potential.
 Voice exists in an organization when everyone seeks
the ideas of others, share ideas and opinions honestly,
and safeguards relational connections.
“Next step”
in the evolution of organizations
Beyond masters of
task excellence
Beyond “star
systems”
…we in it shall be
remembere’d,
We few, we happy few,
we band of brothers:
Inspirational Leadership
 Leaders know that
one of their main
responsibilities is to
inspire the people they
lead.
Vision represents
the cultural element
of inspiring identity
Inspirational Leadership
 Human value in a culture is:
 About treating people with
respect and dignity
 About empowering them to
achieve their potential.
 Leaders need to identify and
remove the obstacles that
make people feel devalued.
Delete What Devalues
 Eliminating disrespectful,
condescending and rude
behavior.
 Going easy on criticism.
 Minimizing unnecessary rules
and excessive controls.
 Eliminating excessive signs of
hierarchy.
 Getting rid of devaluing
managers.
Add Elements that Enhance Value
 Making a human connection with as many
people as possible.
 Treating and speaking to employees as partners.
 Helping employees find the right roles.
 Educating, informing, and listening to employees.
 Decentralizing decision making.
 Recognizing the human need for work/life
balance
Leaders Increase Trust
 “Contrary to what most people believe, trust is not some
soft, illusive quality that you either have or you don’t;
rather, trust is a pragmatic, tangible, actionable asset that
you can create – much faster than you probably think
possible…I contend that the ability to establish, grow,
extend, and restore trust is not only vital to our personal
and inter-personal well being; it is the key leadership
competency of the new global economy.”
Stephen M. R. Covey, The Speed of Trust: The One Thing That
Changes Everything
Trust – The Hidden Variable
Strategy x Execution = Results
should be changed to show it by:
(Strategy x Execution) Trust = Results
 Following charts from: a study of trust in business by LogicaCMG and
Warwick Business School in 2005; another by Watson Wyatt,
WorkUSA study in 2002; and another study about trust in schools
presented by Stanford professor Tony Byrk, in 2004, published in
2002.
The 60% Tax (Very Low Trust)
In the organization…
In personal relationships…
•Unhealthy working environment
•Hostile behaviors (yelling, blaming,
accusing, name-calling) followed by
periods of brief contrition
•Unhappy employees and
stakeholders
•Intense political atmosphere with
clear camps and parties
•Excessive time wasted defending
positions and decisions
•Painful micromanagement and
bureaucracy
•Guarded communication
•Constant worrying and suspicion
•Mistakes remembered and used as
weapons
•Real issues not surfaced or dealt with
effectively
The 40% Dividend (World-class Trust)
In the organization…
In personal relationships…
•High Collaboration and partnering
•True joy in family and friendships,
characterized by caring and love
•Effortless communication
•Free, effortless communication
•Positive, transparent relationships
with employees and all stakeholders •Inspiring work done together and
characterized by purpose creativity
•Fully aligned systems and
and excitement
structures
•Completely open transparent
•Strong innovation, confidence, and relationships
loyalty
•Amazing energy created by
relationships
Inspiring trust
 Extending “smart trust,” restoring trust when it has
been lost, and developing a propensity to trust.
 “…where people begin to trust each other and
share ideas…(changes occur.)
 Cultivating “Knowledge Flow” increases
connection and people begin to make better
decisions, increase creativity, and inspire
innovation so they start thriving in a healthy
environment.”
Knowledge Flow
 The expanded connection
component called Voice
 Increases creativity and
innovation
 Sgt. Curtis Cullen’s idea for
the Rhino tank when it quickly
made its way to Gen. Omar
Bradley in time to liberate
France in WWII
 AIM-7F and Raytheon Missile
Systems
 After Action Reviews
What “Learning Organizations” Do
Learning organizations become
skilled at continuously:
1.) Creating, acquiring, interpreting,
transferring and retaining knowledge
2.) And at purposefully modifying their
behavior to reflect new knowledge and
insights
Definition by David Garvin in Learning In Action: A Guide
To Putting The Learning Organization To Work, 2000
A Litmus Test
Does my org. have a defined learning
agenda?
Is my org. open to discordant information?
Does my org. avoid repeated mistakes?
Does my org. lose critical knowledge when
key people leave?
Does my org. act on what it knows?
A Supportive Learning Environment
Psychological safety
Appreciation of
differences
Openness to new
ideas
Time for reflection
Leadership & Reinforcing Learning
Invite input
Ask probing questions
Encourage multiple
points of view
Provide time for reflection
Information to Knowledge
Learning Culture
Informed
“If timely, candid information generated by knowledgeable people
is available and disseminated, an informed culture
becomes a learning culture.”
Timely
Candid
Available
Disseminated
Weick & Sutcliffe, Managing the Unexpected 2001
HRO = A Mindset
Total Immersion In A Mindset That
Holds Our Foundations Together
Fundamental to success in HRO implementation are
the connection of people and the trust necessary for
optimal knowledge flow.
You can do this!
 Not everyone will right away
 Org. Learning, Leadership & HRO thinking,
behaviors and principles are worth the effort
 Quality – Likelihood of harm to your processes and
products will be reduced
 Safety – Likelihood of harm to your people and
your publics will be reduced
 Reliability – Absence or reduction of harm in
extreme, uncertain, or unexpected environments.
 Trust and confidence will increase internally and
externally
Questions? Need Resources?
Contact information:
 David Christenson
 Wildland Fire Lessons Learned Center
 National Advanced Fire & Resources Institute
dchristenson@fs.fed.us
www.wildfirelessons.net