High Reliability Organisations (HROs) and Safety Mindfulness
As part of research into ‘Resolving the Organisational Accident’, an EU aviation research project, called Future Sky, initiated by the association of European Research Establishments in Aeronautics (EREA), has been examining the topic of ‘Safety Mindfulness’.
The concept is that if front-line staff are aware of the possible threats they can anticipate and mitigate most of them. However there is a traditionally a time delay after new threats emerge before all operational personnel received information on the threat. This Safety Mindfulness research “aims to provide much faster and effective processes to give operational people these types of information”.
The authors of their first report on the concept are Nick McDonald, Tiziana Callari and Daniele Baranzini (all from Trinity College Dublin) and Rogier Woltjer and Björn Johansson (of FOI). NLR are programme managing the research and the project manager is Barry Kirwan of Eurocontrol. It also includes contributors from KLM.
Another Future Sky project has recently investigated the concepts of organisational safety intelligence (the safety information available) and executive safety wisdom (in using that to make safety decisions). We discussed that study in our article: Safety Intelligence & Safety Wisdom
1) Origins of Mindfulness
a) High Reliability Organisations (HROs)
The Safety Mindfulness Concept develops the original Mindfulness concept from Weick and Sutcliff (2007) and aims to…:
…develop and demonstrate a practical method of maintaining Safety Mindfulness in operational situations, by maintaining the (top-down) feed-forward of risk information from safety to operations, (bottom-up) feedback from operations to safety people, and (horizontal) safety information sharing in the operational layer, which includes supervisors.
Weick and Sutcliff developed the High Reliability Organisation (HRO) concept were an:
HRO can be referred to as a set of organising processes that allow an organisation to continuously operate under trying conditions, reduce the impacts of accidents, and help with the recovery process.
HROs strive to avoid errors by stressing a commitment to consistently safe and reliable operations.
Mindfulness is a collective capability comprises five HRO processes (Weick, et al. 1999; Weick and Sutcliffe, 2007) that the Future Sky team summarise as:
(1) Preoccupation with failure (regularly and robustly discussing potential threats to reliability),
(2) Reluctance to simplify interpretations (developing a nuanced understanding of the context by frequently questioning the adequacy of existing assumptions and considering reliable alternatives),
(3) Sensitivity to operations (integrating the understanding into an up-to-date big picture),
(4) Commitment to resilience (recognising the inevitability of setbacks and thoroughly analysing, coping with, and learning from them) and
(5) Under-specification of structure (deferring to expertise rather than authority when making important decisions).
The Future Sky authors note that:
A fundamental idea in Weick’s writing is that organisations that encourage the sharing of narratives and storytelling will be more reliable than an organisation that does not, as “people know more about their system, know more of the potential errors that might occur and they are more confident that they can handle those errors that do occur because they know that other people have already handled similar errors” (Weick, 1987, p. 113).
Weick goes as far as seeing storytelling and upholding narratives as a substitute for trial and error, pointing to the fact that in many organizations, error is not an option as it would have disastrous outcomes. Instead, near misses and successful performance or recovery is used to illustrate the kind of behaviours that is encouraged by the members of the organization.
We observe that this is far wider and deeper than simply submitting and processing formal safety reports.
The Future Sky Safety Mindfulness concept is intended to:
…address the weak areas of the current [Weick and Sutcliff] concept, by integrating lessons learnt in previous research projects/experiences, resulting in tools/applications and approaches that will offer tangible safety benefits…
b) Individual Mindfulness
The researchers note that:
The concept of mindfulness was originally developed as an individual concept in the psychological literature…
More recent theoretical work on organizational mindfulness has begun to link it to Eastern mindfulness [which has its basis in Buddhist thought].
The concept of individual mindfulness is the fundamental building block of collective mindfulness, and can be seen as an individual’s situation awareness of risks related to a work situation. This means not only that the individual is aware about the possible threats/risks (or has heard about them), but is actively thinking about them in the situation.
c) Collective Mindfulness
The researchers say that:
Currently the term mindfulness is not widely used in an operational environment, but phrases such as situational awareness or risk awareness – which are elements of mindfulness – are. (Joyner and Lardner, 2008).
It has been argued by Weick and Sutcliffe that:
…HROs derive their ability to successfully manage critical conditions of complexity, dynamism and error-intolerance from organisational mindfulness.
Organisational mindfulness is described as an organisation’s “enduring characteristic”.
Mindful organisations are:
…very sensitive to variations in their environment and continually update safety assumptions and perspective. Mindfulness is focused on a “clear and detailed comprehension of emerging threats and on factors that interfere with such comprehension” (Weick, and Sutcliff, 2007, p.32).
The researchers comment that collective mindfulness is socially constructed:
…there must be social aspects present including trust and a deference to expertise over authority, as well as more cognitive tendencies such as a reluctance to simplify, and a sensitivity to operations.
d) Mindful Organizing
The researchers describe how there are three organisational layers in organisations that contribute to mindfulness:
- Senior executives, who take a ‘top down approach’
- Middle management who “play a crucial role in creating organisational mindfulness by reconciling the need for anticipation and careful causal analysis with the need for flexibility and improvisation…. They act as “translators” of real-time data from the front lines for the top administrators…creating structures that can guide front line actions. (Roe, and Schulman, 2008)”.
- Front-line staff who habitually: “face high variability and uncertainty in their task environment and are required to recognise and act on emerging and weak signals”.
2) Future Sky Mindfulness Concept
This consists of:
- A model of situation awareness
- Temporal and Specificity aspects
- Learning cycles
a) Safety Mindfulness Principles
The Future Sky team adopt the 5 HRO principles, interpreting then as below:
(1) Preoccupation with failure and success: We argue that we should also pay attention to factors/aspects that supported success stories should be considered as a preoccupation with maintaining reliable performance. This would include appreciation for work strategies that operators use to get their work done in everyday situations…
(2) Reluctance to simplify interpretations: …we will work…to understand what knowledge is currently shared, and what knowledge can leverage to build…a collective mindfulness system. This is necessary to bring to bear all relevant information that can support a valid interpretation.
(3) Sensitivity to operations: [This] is about seeing what is actually done regardless of what is supposed to be done (work ‘as is’ rather than work ‘as imagined’)… All levels/roles of the system have distinctive “operational”/organisational goals to be pursued. Critical attention will be focused on how the [three layers]…feed the system with [new] information/local knowledge, and how the system…will inform the operational people.
(4) Commitment to resilience: We will formalise how this expanded knowledge will become part of collective knowledge for the organisation to learn how to get out of a tricky situation quickly. The lessons learnt will be formalised and become part of the current process/practices. This new flow of information collected in the form of lessons learnt/recommendation will support effective organisational adaptation and change.
(5) Under-specification of structure: We will address how decisions can be supported and how feedback from different decisions can be shared, to enhance the collective knowledge-base of decision making.
b) Model of Situational Awareness
Fundamentally, collective mindfulness is about being proactive, about having the best and most up-to date information when carrying out the task. It is about having a “shared” perception…comprehension…and the projection…status in the near future.
In the proposed Safety Concept, this is to be realised in four ways as illustrated by their ‘Situation Awareness Bubble’.Namely:
- Looking to the future and anticipating events: “Those in the management layer (both safety and operational management) will tend to consider bigger events and disturbances which are less likely but can have more dramatic consequences”.)
- Monitoring and diagnosing the present: “This may require a collaborative leadership style to enable, facilitate and draw out the collective mindfulness – to overcome individual vs group boundaries. The sharing of knowledge in the organisation needs to be promoted to support the understanding of the organisation as a whole”.
- Deciding and acting: “making the right decision…as well as activating prepared actions or adjusting…. This involves dimensions of self-awareness and others’ awareness”.
- Looking to the past: “i.e. learning from the past experiences, and lessons, to strengthen/reinforce what has worked well and what needs to be changed/adjusted. Narratives and storytelling are means for understanding possible organizational patterns using a bottom-up approach. This learning process needs to build on both qualitative and quantitative sources which can provide as comprehensive systemic picture of risk as possible”.
c) Temporal and Specificity Aspects of Mindfulness
There is the most immediate communication, between front-line staff, to pass time critical information. “Such information has immediacy, is highly contextual, and is understood by those who receive it,” say the researchers.
Other information is passed ‘up’ to supervisors for consideration, either to be passed higher, passed sideways to other departments or briefed back ‘down’ to all front-line staff.
At a third level is communicating via the Safety Management System. “Such information is analysed and judged not only on its own importance, but also relative to all other risks in the overall ‘risk picture’.”
The researchers suggest these time-frames can therefore be summarised as:
- Immediate – from real-time to days – data and information are ‘raw’
- Considered – from days to a month – data and information are ‘homogenised’
- Analysed – from months to years – data and information are generalised
d) Learning Cycles (Feedforward / Feedback Loops)
The Future Sky Safety Mindfulness Concept is based around these top-down, bottom-up and horizontal information streams.
The challenge is to create continuous knowledge loops within/across the different layers of the organization.
The intent is fully integrated information-sharing across the organisation as illustrated below:
The continuous loop of knowledge/information are described as the ‘engine of mindfulness’.
Discussion and Next Steps
Despite focusing on Weick’s idea of Mindfulness the researchers do note that, while popular…
…they have proven difficult to implement, and so far there is no accepted measure of organizational mindfulness.
This is possibly because they have remained ‘ideals’ and principles rather than concrete proposals on how to support or even engineer better mindfulness into organisations. The FSS Safety Mindfulness concept will address the still open issue for concretising [sic] the approach and supporting safety mindfulness as a living process in organisations.
The research team then planned to validate their concept in their second year of research (2016):
This will involve an extensive field study using a multi-case approach, where different domains/organisations will be analysed to understand how we can deliver an operationally effective safety mindfulness model/approach which can enable the reduction of complexity in organisations.
At MUAC the intent was to:
First an introduction of the problem area will be provided, and the allied research questions will be outlined. Then the field research will be presented, and the results discussed.
At Alitalia the plan…:
…aims at verifying Safety Mindfulness levels by enhancing organizational capability and performance in the internal safety reporting systems and processes.
The researchers say in their follow-on report that in both organisations opportunities for improvement were identified (though the details of each study are not public):
In MUAC there is an opportunity to enhance timely feedback of risk related information back into the operation, creating opportunities to share information, stimulating active awareness and learning.
In Alitalia there is no clear process for managing problem solving and improvement in an accountable way.
In the third year of the project (2017):
…the Alitalia case is expected to make good progress in terms of implementation, testing the model as a template for implementing Mindful Self-Regulation. At the same time the prospects for implementation will be explored in detail in MUAC, again testing, in principle, the applicability of the model and learning from experience in Alitalia. This creates a powerful multiple case study approach in which the two case studies can be compared and contrasted in two phases.
The researchers also note the need for a mindfulness maturity model that goes beyond the traditional SMS maturity models.
UPDATE 16 February 2017: See also our article Consultants & Culture: The Good, the Bad and the Ugly
UPDATE 1 March 2017: Safety Performance Listening and Learning – AEROSPACE March 2017
Organisations need to be confident that they are hearing all the safety concerns and observations of their workforce. They also need the assurance that their safety decisions are being actioned. The RAeS Human Factors Group: Engineering (HFG:E) set out to find out a way to check if organisations are truly listening and learning.
The result was a self-reflective approach to find ways to stimulate improvement. See also: Why Leaders Who Listen Achieve Breakthroughs
Elsewhere, Malcolm Brinded discussed leadership and how good safety performance and good business performance go hand in hand:
- easyJet’s experience of our first safety culture survey by Siân Blanchard and David Cross of easyJet. It particular this discussed a collaborative approach to safety across organisations, in what easyJet has termed ‘the Luton Stack’.
- Safety intelligence and middle managers – the undiscovered country? by Corinne Bieder, Airbus/ENAC
UPDATE 22 March 2017: Which difference do you want to make through leadership? (a presentation based on the work of Jim Kouzes and Barry Posner). Note slide 6 in particular:
UPDATE 25 March 2017: In a commentary on the NHS annual staff survey, trust is emphasised again:
Developing a culture where quality and improvement are central to an organisation’s strategy requires high levels of trust, and trust that issues can be raised and dealt with as an opportunity for improvement. There is no doubt that without this learning culture, with trust as a central behaviour, errors and incidents will only increase.
UPDATE 12 April 2017: See our article: Leadership and Trust
UPDATE 14 May 2017: Destroy the hierarchical pyramid and build a powerful network of teams (essentially the key concept in the book Team of Teams, by General Stanley McChrystal, as discussed by Suzette Woodward) say the Corporate Rebels:
Out of the eight trends we see, this one is the most disruptive to an organization. But because of that, it might also be the one that has the most impact on the engagement of employees and the success of an organization.
In reality, our organizations are simply not a collection of clearly distinguishable departments and roles as shown in [atraditional organisation chart]. Therefore, we should stop designing them like this. No wonder that most of the progressive organizations we’ve visited moved away from this traditional organizational structure.
Many of the progressive organizations we visit welcome a so-called “Network of Teams”.
For this to happen, we should begin to tear down our familiar organizational structures so we can start rebuilding them along more fluid lines. We need to dissolve the barriers that once made organizations efficient but are now slowing them down.
Then let us design structures that actually work and aim to distribute authority and autonomy to individuals and teams. …establish[ing] flexible structures that allow individuals to gather as members of multiple teams within multiple contexts.
They say the key learnings to start the journey are:
- Create small, multidisciplinary teams and split them when they grow over 15 members;
- Have each team craft its own purpose within the organizational purpose;
- Make teams responsible for their own results and give them a (financial) stake in the outcome;
- Create transparency to foster a healthy dose of competition;
- Leverage the power of technology to create alignment.
UPDATE 19 May 2017: Representatives from 33 European air navigation service providers and the EUROCONTROL met in Frankfurt, Germany on 11 May 2017 for the biennial EUROCONTROL CEOs’ Safety Conference. In his keynote opening address, Joe Sultana, Director Network Manager, posed some questions to stimulate discussion on how ANSPs can maintain and improve their safety record:
- Understanding safety performance is difficult; what data do we really need to understand safety?
- Often ‘work as done’ differs from ‘work as imagined’;
- It’s hard to see things that change slowly over time; people adapt, adjust and make trade-offs;
- Anticipating the future is getting harder; how can we look around the corner to see what is coming?
- Simply tightening safety regulation won’t work on its own. Constraints are necessary but “work as done” shows the need for a degree of flexibility. So, how do we find the right balance with regulation and flexibility so as to build safe, resilient systems?
UPDATE 8 February 2018: The UK Rail Safety and Standards Board (RSSB) say: Future safety requires new approaches to people development They say that in the future rail system “there will be more complexity with more interlinked systems working together”:
…the role of many of our staff will change dramatically. The railway system of the future will require different skills from our workforce. There are likely to be fewer roles that require repetitive procedure following and more that require dynamic decision making, collaborating, working with data or providing a personalised service to customers. A seminal white paper on safety in air traffic control acknowledges the increasing difficulty of managing safety with rule compliance as the system complexity grows: ‘The consequences are that predictability is limited during both design and operation, and that it is impossible precisely to prescribe or even describe how work should be done.’
Since human performance cannot be completely prescribed, some degree of variability, flexibility or adaptivity is required for these future systems to work.
- Invest in manager skills to build a trusting relationship at all levels.
- Explore ‘work as done’ with an open mind.
- Shift focus of development activities onto ‘how to make things go right’ not just ‘how to avoid things going wrong’.
- Harness the power of ‘experts’ to help develop newly competent people within the context of normal work.
- Recognise that workers may know more about what it takes for the system to work safety and efficiently than your trainers, and managers.