HRO 9p Collision at Sea-The HRO Perspective-No Simplification
After addressing Sensitivity to Operations in my prior post, I now focus on No Simplification (i.e., Reluctance to Simplify). It is the second of Weick and Sutcliffe’s (2007) three principles of HRO devoted to problem anticipation. They are:
Operations (Sensitivity to Operations),
No Simplification (Reluctance to Simplify), and
Failure (Preoccupation with Failure)
* Weick, K.E., Sutcliffe, K.M. (2007). Managing the unexpected: Assuring high performance in an age of complexity. Jossey-Bass.
The challenge for operationalizing Reluctance to Simplify is that the term is counterintuitive. Who is being reluctant? Why are they reluctant? What aren’t they simplifying? How do they choose what to simplify (all organizations simplify things) and what to complicate? All organizations need simplifications so their members can focus on the things their leaders deem important. As the adage goes, if everything is a priority, then nothing is a priority. Asking people to focus on too many things at once risks overwhelming them so HRO requires thoughtful choices about what to simplify and where to seek more complexity. An individual’s focused attention is a precious commodity (Kahneman, 2003).
* Kahneman, D. (2003). Maps of bounded rationality: Psychology for behavioral economics. American Economic Review, 93(5), 1449-1475.
Reluctance to Accept Simplification
Weick & Sutcliffe observed that organizations seeking High Reliability “manage for the unexpected … by being reluctant to accept simplifications” (p.11, emphasis in the original). There are two problems with accepting this conclusion at face value. First, while suitably parsimonious for academic purposes, what does it mean to be reluctant to accept simplifications? The clue for deeper understanding is the use of “reluctant.” For me, reluctance conveys a struggle based on deliberation not mindless negation. In organizations practicing HRO, the leadership carefully considers what to simplify and what to leave more complicated (“complexify”?).
The second problem with “reluctance to accept simplifications” is how do organizational leaders decide what they can safely simplify and what requires more data and detail? Organizations don’t spring forth from a void with fully-formed ideas of where to avoid simplifications. If your understanding of HRO is based on observing organizations functioning at a very high level or you have never observed an organization *starting* to practice HRO, seeing them identify problems and learn where complexity adds value, you are missing something important about HRO practices.
Complicate What’s Important
An alternative way to articulate Reluctance to Simplify is “develop nuanced understanding of what you’ve decided is important.” That requires working backward from an organization’s most valued outcomes. It also requires analysis of things gone wrong in pursuit of those outcomes that involves questions like:
What actions and knowledge are necessary for achieving those outcomes?
Are there multiple ways to get the knowledge to cross check?
Once you’ve decided what’s important to know and do, do people in the organization have the training they need to perform those actions and interpret the data they collect to make decisions?
The answers to these questions should be based in a) your training program and b) regular audits of that training. Training that lacks evidence in the form of tests, oral interviews, qualification reviews, practical factor demonstrations, and periodic observations isn’t a program. It’s people talking at an audience.
Describing a process for determining what’s important in an organization, how to understand it from many angles, and how much complication to accept is beyond the scope of this post. Many organization’s have inherited a system from their predecessors so newcomers initially need to just focus on learning it. Just be careful not to discard parts of the existing system (“simplifying” it) because you don’t like them or they seem difficult. In the remainder of this post, I will review the key characteristics of a system that develops multi-layered perspectives through data and people, anticipating outcomes, and following up on problems.
Noticing More-A Multilayered Approach
Organizations practicing HRO seek to notice more of what’s going on, particularly small things that don’t “seem right,” and take less of what happens in the organization for granted. They construct a detailed understanding of their operations through anticipating outcomes of their actions, testing their assumptions frequently, and collecting data to assess, not confirm, the accuracy of their expectations.
A multilayered understanding of operations has two components: data and people. They overlap because the data comes in the form of reports and actions of people based on their roles in the system and formal procedures. They are distinct because what the people think and how they communicate what they think to the right people can never be fully described by formal processes. I begin with collecting the data necessary to enact Reluctance to Simplify.
Data
The data that supports a multilayered and rich understanding of what is going on in organizations practicing HRO are anchored in the processes, records, and conditions of the organization. The importance of processes and records is obvious. The data won’t be useful if it is not collected consistently and reviewed periodically. Just as important as processes are the conditions under which people work. If the conditions of work don’t support the procedures (e.g. not enough time), the data won’t be recorded and reviewed effectively. If managers never review the data and comment on it, people will decide it’s not important.
Data supporting less simplification include checks of equipment and processes, cross checks using secondary sources of information, written records, reports from workers, and validation of those reports through audits. Audits of processes and records are necessary for testing assumptions about the completeness and value of the processes and records that you decided were important. Audits are a ruthless test of assumptions.
Reluctance to Simplify: JSM-MC ALNIC Collision
As noted in the NTSB report of the collision between the USS John S McCain (JSM) and Tanker ALNIC MC (https://www.ntsb.gov/investigations/accidentreports/reports/mar1901.pdf), it is a routine U.S. Navy practice to station the Sea and Anchor Detail (SAD) prior to entering port. The SAD significantly complicates operations on the Bridge and at other important ship control stations by adding watchstanders, modifying responsibilities, and invoking special procedures. The complexity added by these additions and changes is deliberate. It is used intentionally to create more layers of understanding, cross-checking, and control of ship’s navigation in the riskier environment associated with entering port (covered a prior post).
Additional examples of reluctance to simplify on U.S. Navy ships are qualifications (specifically mentioned in the NTSB report and my blog posts on the collision), maintaining detailed material status of ship control systems (evaluated by the NTSB and possibly the leadership of the JSM, we can’t tell from the reports), other audits (not mentioned by the reports), and crew rest (evaluated by the NTSB, very important in aviation, and an oft cited problem in the Surface Navy).
Reluctance to simplify has a parallel with the Cognitive Flexibility Theory for developing expertise (Spiro, Coulson, Feltovich, and Anderson, 1988). Expert base their assessments of a situation on multiple sources of data, seeking sources of disconfirmation and paying close attention to things that “don’t add up.” In the same way, higher reliability comes from being reluctant to simplify operations, using multiple sources of data to present an imperfect samples of information. The samples provide multiple views of a situation from diverse, sometimes conflicting, perspectives. Simplifications leave things out. They make it easier to ignore what doesn’t “fit.” Complex operating environments require complex thinking (Ashby’s law of requisite variety, 1958).
* Spiro, R. J.; Coulson, R. L.; Feltovich, P. J., Anderson, D. (1988). Cognitive flexibility theory: Advanced knowledge acquisition in ill-structured domains. In Tenth Annual Conference of the Cognitive Science Society (pp. 375-383). Hillsdale, NJ: Lawrence Erlbaum. [Reprinted in R. B. Ruddell & M. R. Ruddell (Eds.), Theoretical models and processes of reading (4th ed.). Newark, DE: International Reading Association, pp. 602-616.]
* Ashby W.R. (1958) Requisite variety and its implications for the control of complex systems, Cybernetica 1(2), 83-99.
Don’t Forget the People
Data, procedures, job descriptions, prescribed areas of responsibility, and standard reports are necessary for creating multi-layered understandings, but they aren’t sufficient. People are involved in every aspect of data collection and review, procedures, enacting job descriptions, taking (or not) responsibility, and making standard reports. Data can be misinterpreted and incomplete, procedures can contain errors or gaps or not be followed, people don’t always do what is in their job descriptions (either because they don’t understand how or don’t care), and standard reports don’t always convey what decision makers need to know because they are, well, “standard.” Many problems aren’t standard. Many organizational accident investigations have revealed that the people involved had data they didn’t understand, but didn’t recognize the problems as they were developing.
The two greatest “people” contributions to Reluctance to Simplify are cultivation of diverse perspectives (“skepticism toward received wisdom” in Weick and Sutcliff’s parlance (Weick and Sutcliffe, 2007, p.11)) and what the U.S. Navy calls a “questioning attitude.”
Key attributes of cultivating diverse perspectives are:
NO subject or issue is considered “undiscussable” (this is a very high bar that few organizations meet);
People don’t dismiss contrary ideas, but rather encourage and actively consider them;
People feel that their concerns are taken seriously by their peers and superiors;
Comments and criticisms are not just desired, they are required. In some areas of the U.S. Navy, briefs and training that do not end with questions or points that need to be clarified are considered inadequate;
All audits include recommendations for improvement, a form of challenging the status quo.
The second “people” contribution to Reluctance to Simplify is developing a questioning attitude. This means insisting that people develop their own, independent beliefs about situations and communicate them courageously, even if there is a risk people will make fun of them. People are encouraged to identify problems, point out anomalies, and speak up when a superior issues an order they don’t understand or consider unsafe. This is really hard to do. You can’t order people to have a questioning attitude.
Conclusion
There are no shortcuts to a Reluctance to Simplify. Something doesn’t have to be a problem or result in a disaster to be a candidate for less simplification. It could be an outcome that wasn’t expected, a report that wasn’t received, data that weren’t reviewed, or records that were insufficient to forestall an undesired outcome.
“HROs accumulate unnoticed events that are at odds with what they expected … [and] notice these accumulated events sooner, when they are smaller … They pay attention to discrepancies, alternate meanings, and resolutions” (Weick and Sutcliffe, 2007, p.19).
In my next post, I will operationalize the Weick and Sutcliffe principle of Failure (Preoccupation with Failure).
