Aviation Safety must adopt High Reliability concepts: mindFly

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Aviation is a high risk industry where even a small error can lead to losses to human lives , property and reputation. Industries like the Nuclear, Oil and Gas etc. which are also high risk industries need to manage  unexpected events which can be disorganizing. It takes both anticipation and resilience to manage unexpected disruptions, a combination which is known as mindful organizing.

Organizations that are able to manage and sustain almost error-free performance despite operating in hazardous conditions where the consequences of errors could be catastrophic), with a positive safety culture are known as High Reliability Organizations (HRO). ‘What distinguishes reliability-enhancing organizations, is not their absolute error or accident rate, but their effective management of innately risky technologies through organizational control of both hazard and probability […]’ (Rochlin, 1993, p. 17)

There are five characteristics of HROs that have been identified as responsible for the “mindfulness” that keeps them working well when facing unexpected situations.

  • Preoccupation with failureHROs treat anomalies as symptoms of a problem with the system. The latent organizational weaknesses that contribute to small errors can also contribute to larger problems, so errors are reported promptly so problems can be found and fixed. The panel investigating the Columbia shuttle disaster concluded,” NASA’s system for tracking anomalies for flight readiness reviews failed”.
  • Reluctance to simplify interpretations: HROs take deliberate steps to comprehensively understand the work environment as well as a specific situation. They are cognizant that the operating environment is very complex, so they look across system boundaries to determine the path of problems (where they started, where they may end up) and value a diversity of experience and opinions. In the Columbia shuttle disaster, the simplification was NASA’s mistaken judgement that the foam shedding 82 sec into the flight was “almost in family”and a maintenance issue. NASA basically simplified a 22 year history of unintended, recurring foam shedding into a judgement that puff of smoke at the base of the left wing did not affect the mission success. Instead, it presumed shedding was normal and could be back on ground even though, after all these years, it still remained in the dark about why foam continued to shed. The investigation board criticized NASA for its tendency to oversimplify.
  • Sensitivity to operations: HROs are continuously sensitive to unexpected changed conditions. They monitor the systems’ safety and security barriers and controls to ensure they remain in place and operate as intended. Situational awareness is extremely important to HROs. The Columbia accident investigation board concluded that for all of its “cutting edge technology” and imaginative plans for the technology and space exploration, NASA had shown very little understanding of its own organisation.
  • Commitment to resilience: HROs develop the capability to detect, contain, and recover from errors. Errors will happen, but HROs are not paralyzed by them. HRO’s overcome error when independent people with varied experience interdependently generate and apply richer set of resources to a disturbance swiftly and under the guidance of negative feedback. The crew of United Airlines 232 which experienced an engine explosion causing it to disable all flight controls, used all available resources onboard to manage the flight path and bring the aircraft to the ground.
  • Deference to expertise: HROs follow typical communication hierarchy during routine operations, but defer to the person with the expertise to solve the problem during upset conditions. During a crisis, decisions are made at the front line and authority migrates to the person who can solve the problem, regardless of their hierarchical rank. In the Columbia accident, the investigation board concluded that ” In highly uncertain circumstances, when lives were at risk, management failed to defer to its engineers and failed to recognize that different data standards and processes were more appropriate.

Effective leadership evaluations are key to the development and maintenance of a high reliability organization. Organizations that do not set specific and measurable goals, and do not change the way leaders are evaluated on those goals, do not sustain results. High reliability organizations hardwire evidence-based leadership evaluation tools, such as report cards and 90-day action plans, into their organizations and prioritize goals. This way, leaders are constantly challenging and improving upon themselves and how they respond to problems. This will ultimately drive a shared sense of resilience throughout the organization.

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