Theoretical and operational challenges of “high-reliability organizations”: air-traffic control and aircraft carriers

This is an empirical and theoretical examination of high reliability organizations. The empirical referents are the U.S. Navy's nuclear aircraft carriers and the air traffic control system of the U.S. Federal Aviation Administration. Three modes of organizational behavior are observed ranging from routine or bureaucratic to high-tempo to emergency. Each mode has distinctive authority patterns, communications pathways and leadership perspectives. Since 1984, an interdisciplinary group of scholars at Berkeley has been involved in making observations of and theorizing about “high reliability organizations” (HROs), which operate technical systems that are very beneficial, costly, and hazardous. Major operational errors in these organizations are likely to produce catastrophic consequences; therefore, HROs take on the dual goals of sustaining delivery at maximum capacity and operating in nearly error-free fashion. They are so effective that the probability of serious error is very low. Other kinds of organizations systematically use trial-and-error learning. HROs, however, have less confidence in this process for conducting hazardous operations, because their next error may be their last trial. This paper draws on experience with two of the Navy's nuclear aircraft carriers and the Federal Aviation Administration's air-traffic control system. Current theories derive primarily from studies of “failure-tolerant,” trial-and-error operating bureaucracies. Is this literature a sure guide to HROs? Do the phenomena challenge contemporary thinking about complex organizations? “High-reliability” operations reveal a range of theoretical (and operational) surprises. The remainder of this discussion explores a single dimension of this theoretical arena.