We acknowledge with deep gratitude, generous and extensive help with previous versions of this manuscript from Sue Ashford, Michael Cohen, Dan Denison, Jane Dutton, Les Gasser, Joel Kahn, Rod Kramer, Peter Manning, Dave Meader, Debra Meyerson, Walter Nord, Linda Pike, Joe Porac, Bob Quinn, Lance Sandelands, Paul Schaffner, Howard Schwartz, Kathie Sutcliffe, Bob Sutton, Diane Vaughan, Jim Walsh, Rod White, Mayer Zald, and the anonymous reviewers for Administrative Science Quarterly.

Collective mind in organizations: Heedful interrelating on flight decks.

http://seg.fsu.edu/Library/From%20sectoral%20systems%20of%20innovation%20to%20socio-technical%20systems,%20Insights.pdf

From sectoral systems of innovation to socio-technical systems: Insights about dynamics and change from sociology and institutional theory

https://orbit.dtu.dk/files/158016663/SAFESCI.PDF

Risk management in a dynamic society: a modelling problem

Organizing for high reliability: Processes of collective mindfulness.

Simulation is a technique-not a technology-to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner. The diverse applications of simulation in health care can be categorised by 11 dimensions: aims and purposes of the simulation activity; unit of participation; experience level of participants; health care domain; professional discipline of participants; type of knowledge, skill, attitudes, or behaviours addressed; the simulated patient's age; technology applicable or required; site of simulation; extent of direct participation; and method of feedback used. Using simulation to improve safety will require full integration of its applications into the routine structures and practices of health care. The costs and benefits of simulation are difficult to determine, especially for the most challenging applications, where long term use may be required. Various driving forces and implementation mechanisms can be expected to propel simulation forward, including professional societies, liability insurers, health care payers, and ultimately the public. The future of simulation in health care depends on the commitment and ingenuity of the health care simulation community to see that improved patient safety using this tool becomes a reality.

https://qualitysafety.bmj.com/content/qhc/13/suppl_1/i2.full.pdf

The future vision of simulation in health care

The HRO project is cast within a broader socio-political context, by first, reviewing its practical origins, its conceptual/logical framework, and a summary of the project's provisional findings, including a brief observation about the importance of a ‘culture of reliability.’Then some socio/political implications for HROs are explored as they assume the status of large technical systems (LTSs) and become quasi-public institutions. This paper ends with a reflection on the challenges of institutional trustworthiness that confront HRO operators, managers, and overseers.

High Reliability Organizations: Unlikely, Demanding and At Risk

Recent studies of large, formal organizations that perform complex, inherently hazardous, and highly technical tasks under conditions of tight coupling and severe time pressure have generally concluded that most will fail spectacularly at some point, with attendant human and social costs of great severity.1 The notion that accidents in these systems are "normal," that is, to be expected given the conditions and risks of operation, appears to be as well grounded in experience as in theory. 2 Yet there is a small group of organizations in American society that appears to succeed under trying circumstances, performing daily a number of highly complex technical tasks in which they cannot afford to "fail." We are currently studying three unusually salient examples whereby devotion to a zero rate of error is almost matched by performance -utility grid management (Pacific Gas & Electric Company), air traffic control, and flight operations aboard U.S. Navy aircraft carriers.

/pdf/the-self-designing-high-reliability-organization-aircraft-3frpan1r1j.pdf

The Self-Designing High-Reliability Organization: Aircraft Carrier Flight Operations at Sea

We live in a time when institutions of all kinds are instruments of great power and are often the objects of deep suspicion. Not surprisingly, scholars and political commentators have noted that the public increasingly distrusts many of those organizations. Indeed, for some of them, the crisis of trust is especially acute, coloring and constraining virtually all their actions and choices. How might they respond not only to maintain but also to enhance the level of trust they are accorded? The Problem of Trust In proposing answers to that question, we draw heavily from a study commissioned by former Secretary of Energy James D. Watkins (SEAB, 1993). Recognizing that the Department of Energy (DOE) was one of the institutions facing a serious deficit of trust, Watkins established a task force to explore how the DOE might take steps to increase public trust and confidence in the agency's programs for managing commercially generated radioactive waste as well as the huge volume of radioactive and toxic wastes associated with the manufacture of nuclear weapons. (See gray box on page 343 for a description of those programs.) Watkins' successor, Hazel R. O'Leary, has continued to place building trust among her highest priorities (DOE, 1994). In many respects, Watkins and O'Leary had to address issues common to most organizations. For example, how can trust be sustained when strong ideological and policy differences about the organization's central direction, mission, and goals divide key stakeholder groups from each other as well as from the agency itself? In other respects, however, maintaining (and recovering) trust in its radioactive waste management activities presents special and unavoidable challenges for the DOE.(1) 1. There is increasing hostility to current or future operations based on learning about past agency practices.(2) 2. Operations are beneficial but hazardous in their design, that is, the work is intrinsically dangerous. 3. Hazards are likely to extend well after benefits have been gained. 4. Overall success or failure of the operations may not be well understood for perhaps three or four work generations. 5. There is reasonably rapid change in the technical aspects of the work, either in the core technologies or in information about the environment where they are deployed. Of course, organizations other than the DOE confront many, if not all, of these same challenges. This article should, therefore, be of particular interest to those who manage or must deal with such agencies or firms. Much of the work on trust carried out so far focuses on the relations between individuals in general social settings, between employees and managers in corporate life, between parties in economic exchanges, or between citizens and broad institutions of governance.(3) Surprisingly little attention has been paid to the relationship of trust between citizens and stakeholders, on the one hand, and administrative agencies or firms, on the other. A serious analytical shortfall exists in our understanding of the bases for institutional trustworthiness and about the conditions that would reduce serious deficits in public trust and confidence - a situation akin to betrayal in individual relations. Because of this analytic shortfall, terms such as trust and confidence, which are understood intuitively, elude crisp and precise definition. Thus they can be used with wonderful rhetorical ambiguity.(4) The following notions provide the initial conceptual touchstone for our discussion here (SEAB, 1993; see also La Porte, 1994, Keller and La Porte, 1994): * Trust is the belief that those with whom you interact will take your interests into account, even in situations where you are not in a position to recognize, evaluate, and/or thwart a potentially negative course of action by "those trusted." * Confidence exists when the party trusted is able to empathize with (know of) your interests, is competent to act on that knowledge, and will go to considerable lengths to keep its word. …

https://polisci.berkeley.edu/sites/default/files/people/u3825/LaPorte%20Hazards%20and%20InstTrust.pdf

Hazards and Institutional Trustworthiness: Facing a Deficit of Trust

The culture of high reliability: quantitative and qualitative assessment aboard nuclear-powered aircraft carriers

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1468-5973.1994.tb00045.x

Todd R. La Porte

Papers

High Reliability Organizations: Unlikely, Demanding and At Risk

The Self-Designing High-Reliability Organization: Aircraft Carrier Flight Operations at Sea

Hazards and Institutional Trustworthiness: Facing a Deficit of Trust

The culture of high reliability: quantitative and qualitative assessment aboard nuclear-powered aircraft carriers

A Strawman Speaks Up: Comments on The Limits of Safety