managing-the-unexpected

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

by Karl E. Weick and Kathleen M. Sutcliffe

University of Michigan business school professors Weick and Sutcliffe studied common management attributes of “high reliability organizations” (HROs) such as aircraft carriers and nuclear power plants, where glitches can have deadly consequences. “The key difference between HROs and other organizations in managing the unexpected often occurs in the earliest stages, when the unexpected may give off only weak signals of trouble… Managing the unexpected is about alertness, sensemaking, updating, and staying in motion.”

One of the main themes in this book is mindfulness. “To manage the unexpected is to be reliably mindful, not reliably mindless. Obvious as that may sound, those who invest heavily in plans, standard procedures, protocols, recipes, and routines tend to invest more heavily in mindlessness than in mindfulness… What people forget is that plans act the same way as expectations. They guide people to search narrowly for confirmation that the plan is correct… By contrast, mindfulness is essentially a preoccupation with updating… The rudiments of mindfulness are a willingness to doubt that one’s current picture is complete, a willingness to inquire further to remove some of those doubts, and a desire to update situational awareness on a continuing basis.”

The authors identified “five hallmarks” of high-reliability organizations:

  • Preoccupation with failure
  • Reluctance to simplify interpretations
  • Sensitivity to operations
  • Commitment to resilience
  • Deference to expertise

Sensitivity to operations means that senior management is not insulated from the day-to-day operations. On an aircraft carrier, “the captain, who is in charge of the carrier, and the commander of the Air Wing, who is in charge of the aircraft, are positioned physically to observe all steps of the operations… The entire ship is attuned to launching and recovering aircraft.”

Regarding deference to expertise, “although the captain’s commands usually take precedence, junior officers can, and do, change these priorities when they believe that following an order will risk the crew’s safety… Decisions migrate down but they also migrate up. If people in HROs get into situations they don’t understand, they’re not scared to ask for help.”

The authors write about having a “flexible culture… that adapts to changing demands… The key assumption behind the call for a flexible culture is that information tends to flow more freely when hierarchies are flattened and rank defers to technical expertise. Hence, flexibility and decentralization go hand in hand.” The authors also stress the importance of credibility and trust. “They are important elements in preventing jurisdictional antagonisms that could threaten operations at the plant.’”

“The best HROs increase their knowledge base by encouraging and rewarding error reporting, even going so far as to reward those who have committed them… A seaman on the nuclear carrier Carl Vinson reported the loss of a tool on the deck. All aircraft aloft were redirected to land bases until the tool was found, and the seaman was commended for his action—recognizing a potential danger.”

“People need to feel safe to report incidents or they will ignore them or cover them up… There is always bad news, and if you get none, someone is hiding something… One of the best ways to encourage subordinates to report bad news is to respond in the following way. When someone brings bad news to your attention say: Really? Tell me more. What do you think we should do about it? Thanks for bringing this to my attention.”

Incident reviews are learning opportunities. “When people fail, they tend to be candid about what happened for a short period of time, and then they get their stories straight in ways that justify their actions and protect their reputations. And when official stories get straightened out and get repeated, learning stops.”

HROs respect diverse viewpoints to avoid groupthink. “If people work in a varied, complex environment, those people need varied complex sensors to register the environmental complexities. Simple expectations produce simple sensing, which misses most of what is there. Simple sensors overlook both hints of the unexpected and a wider range of options to deal with it… A loan officer who has made good and bad loans is a more complex sensor, able to sense more variety in his environment of clients, than is an officer who has made only good loans. A top management team whose members represent different functional backgrounds is a better sensing mechanism than is a team composed wholly of finance people, legal people, or engineers.”

“Social organizations tend to gather information selectively to justify decisions… The tendency to seek confirmation and shun disconfirmation is a well-honed, well-practiced human tendency. That’s why HROs have to work so hard and so continuously to override this tendency and remain alert.”

Here are a few more noteworthy points:

  • “Consolidate explanations… Separate tiny explanations may hide the existence of one big problem.”
  • “When you relabel a close call as a near miss, you make it clearer that the event was evidence of danger in the guise of safety… A near miss is also a near hit. A close call is also a close what? That’s the point.”
  • “When people discuss confusing events they sometimes think they have to convince others of the validity of their own perspective and fail to listen respectfully and attentively to what others say. When this happens advocacy replaces analysis, both richness and mindfulness are lost, and containment suffers.”
  • “Build excess capacity… The lean, mean organization may sparkle in the short run, but it may also crash and burn at the first unexpected jolt because leanness strips the organization of resilience and flexibility… Improve resilience by harnessing knowledgeable people into ad hoc networks that self-organize to provide expert problem solving.”

“When HROs practice good management… they tend to act in ways that loosen the grip of expectations on their perception and interpretation. In doing so, they tend to see more. And they tend to see more, earlier, when they can do something about it.”

Weick, Karl E., and Kathleen M. Sutcliffe. Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco: Jossey-Bass, 2001. Buy from Amazon.com

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