Culture of Safety excellence and high reliability Organizations (HROs)

What is an HRO/Culture of Safety Excellence?

In High Reliability Organizations, the principal objective

is not to fail. 

In the case of biosecurity and biosafety, this means not

having lapses in biosafety and biosecurity.  With this in

mind, HROs, and hence facilities dealing with

pathogens, should organize to:

  • Prevent catastrophic failure
  • Fail gracefully
  • Recover rapidly

Examples of HROs are power grids, air traffic control

systems, aircraft carriers, nuclear power plants,

hospital emergency departments, wildfire fighting crews.

Organizations that do this well follow these five principles:

  • Preoccupation with Failure: they track small failures and near misses, and constantly imagine how the system could fail in order to put in place fixes and contingencies before the system fails;
  • Reluctance to Simplify: they understand that interactions between teams of people with machines in complex, dangerous and changing environments require complex approaches;
  • Sensitivity to Operations: by closely following operations, they observe small signs and variances and are better able to understand their significance, thereby being able to take corrective actions before these variances cascade into catastrophe;
  • Commitment to Resilience: they design systems and capabilities to be resilient in the event of changing environments or failure.  This usually requires redundancy;
  • Deference to Expertise: they respect true expertise (not experience or seniority per se) in relation to the issue at hand, at all levels and at each stage – they let problems migrate to the expertise.

In addition, these organizations create a learning culture – where everyone is encouraged to suggest how operations could be improved and made safer, and every incident and ‘near miss’ is analyzed through After Action Reviews.  This means that management must encourage reporting of accidents and near misses, which, in turn, necessitates that reviews are not used to assign blame but limit themselves to learning lessons. 

An allied characteristic is that HROs do not attribute human error as a cause of accidents: rather human error is seen as a symptom of an underlying system fault.  Pressures of work created by efficiency/thoroughness trade-offs (e.g. speed vs safety trade-off) will always mean that there will be ‘human error’: reducing the scope for ‘human error’ requires understanding the aspects of the system that tend to create these trade-offs and hence the ‘errors’.

Finally, HROs do not delegate safety.  Changing behaviors and hence culture requires not just the technical means to do so, but also the authority to mandate it and to set the tone for where the institution sets the balance between safety and the organization’s other business priorities.  Thus top management – indeed all management from top to bottom – must be involved in safety for a culture of safety to take hold.

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