Sense and Reliability: A Conversation with Celebrated Psychologist Karl E. Weick

The Flawed View of Organizations

Most people assume organizations are monolithic and predictable, leading to routine and conformity.
This view is flawed because organizations face unpredictable challenges that demand creativity and imagination.
The assumption of stability in a constantly changing business environment is dangerous.
Unpredictable events can paralyze individuals and organizations, hindering their ability to survive.

High-Reliability Organizations (HROs)

Karl E. Weick's research focuses on HROs, such as nuclear power plants, aircraft carriers, air-traffic-control teams, firefighting units, and hospital emergency departments.
HROs operate under trying conditions and have fewer accidents than expected.
The key difference between HROs and other organizations is the sensitivity and mindfulness in reacting to weak signals of change or danger.
Most companies are unprepared for the unpredictable and overestimate their knowledge of future events and people's actions.
Ignoring unexpected possibilities and the unintended consequences of decisions can lead to disaster.
Example: The launch of New Coke in 1985, where Coca-Cola failed to predict consumer behavior and received 8,000 letters a day from angry consumers.
HROs detect weak warning signs and take strong, decisive action.

HRO Response to Weak Signals

Nuclear power plant board operators pay attention to small, unexpected events that may foreshadow larger system problems.
They note when automatic systems don't respond as expected or when unusual data regarding plant parameters crops up.
They recognize when a procedure is inappropriate and navigate to a different one.
This watchful updating facilitates management of the unexpected due to a preoccupation with failure.
Workers make judgments, adjustments, and comparisons to keep their days dull and normal.
Obsessiveness is true of all HROs, and can make them unpleasant places to work in.
The minute a nuclear-plant worker says, "Hey, this job is boring," there is the danger that he'll stop making the fine-tuned adjustments needed to keep the job unexciting.
It can be catastrophic when things get exciting in a nuclear power plant.
Example: Ford's recall office during the Pinto crisis in the 1970s ignored weak signals and missed the fact that bolts on the cars' rear axles had punctured the gas tanks of the Pintos involved in those crashes, leading to disaster.

Cultivating Mindfulness

Organizations can become more mindful by adopting practices used by HROs.
HROs are fixated on failure, committed to resilience, and sensitive to operations.
Managers focus on the front line, where the work gets done.
They defer to expertise and refuse to simplify reality.
Leaders must complicate themselves to keep their organizations in touch with the realities of the business world.
Organizations are active and half create their environments.
Executives should acknowledge the messiness of reality.

"Believing is Seeing"

We can only see what we are prepared to see.
The story of child abuse recognition: Pediatricians and radiologists in Boulder, Colorado, only recognized child abuse when social workers joined their teams and provided solutions.
The greater the repertoire of responses, the more ready you are to deal with reality, and the more you can acknowledge its complexity.
There is a growing concern about greed and CEO conduct because we now have a better idea of what to do about it through governance.

Obsession with Failure

Non-HROs tend to isolate failure, blame individuals, and not learn from mistakes.
Few failures can be traced to a single individual.
Excess surgical deaths in hospitals are often due to understaffing, poor handoffs of information, and low frequency of performing a particular operation.
Failures are easier to recover from if spotted early.
Organizations can encourage members to face up to failure and become preoccupied with it.
The story of Wernher von Braun sending champagne to an engineer who confessed to short-circuiting a missile demonstrates the importance of admitting mistakes.
Employees at HROs cultivate a fascination with failure by refusing to take shortcuts or simplify reality.
Workers check entire systems for valves, piping, or reroutes that may have been added since the drawings were completed.
What's missing from the blueprints could cause serious surprises.
Successful companies often refuse to simplify reality and go behind the blueprints.
Examples: Wal-Mart, Ideo, and American Zoefrope Productions.

Leadership and Managing the Unexpected

Newcomers often catch things that old-timers miss.
Generalist executives with heterogeneous work and industry experiences can cope with problems in original ways.
Examples: Lou Gerstner, Mike Walsh, and Larry Bossidy.
Generalists can construct a richer, more useful version of what's going on than specialists can.
Their broad experiences can help them not to get paralyzed by a "cosmology episode."

Cosmology Episode

Cosmology episode: When people suddenly feel that the universe is no longer a rational, orderly system.
Example: The Centers for Disease Control's encounter with hantavirus in 1993.
People suffer from the event and lose the means to recover from it.
Everything seems strange; a person feels like he has never been here before, has no idea of where he is, and has no idea who can help him.
Panic ensues, and the individual becomes more and more anxious until he finds it almost impossible to make sense of what is happening to him.
Continual merging, divesting, recombining, and changing of responsibilities and bosses creates intense cosmological episodes for businesspeople.
Many people have trouble locating themselves on organizational charts.
Alertness to weak signals can help managers avoid this psychological crisis.
Paying close attention to details can restore a sense of mastery.
The puzzle was eventually solved when epidemiologists discovered that recent climatic changes had produced an explosion in the rodent population that carried the virus, which increased the likelihood that humans might be exposed to hantavirus.

Action and Sensemaking

People who get in trouble during crises try to think everything through before taking action.
The world keeps changing, and analyses get further and further behind, so you've got to constantly update your thinking while you're sitting there and reflecting.
Sensemaking: The transformation of raw experience into intelligible world views.
Like mapmakers capturing an unfamiliar place on paper.
There is no one best map of a particular terrain.
Sensemaking lends itself to multiple, conflicting interpretations, all of which are plausible.
Organizations should be open to different interpretations, all of which can lead to possible action.
Action, tempered by reflection, is critical in recovering from cosmology episodes.
Action helps flesh out interpretations and rework them.
Leaders should leap in order to look, or to leap while looking.
The story of the Hungarian soldiers lost in the Alps who used a map of the Pyrenees to get out safely illustrates that almost any strategic plan can help discover what's going on and what should be done next.
In crises, leaders have to act in order to think-and not the other way around.

Standards of Rationality

Organizations hold executives to unobtainable standards of rationality, clarity, and foresight.
This triggers a vicious psychological circle: leaders have rotten experiences because they keep coming up short, which reinforces low self-esteem.
Managers get demoralized and don't contribute what they could.
Leaders should accept that they're not as rational, deliberate, and intentional as they claim to be.
Many executives place a lot of hope in unrealistic goals.
People further down in the organization are actually doing all the improvising and patching and scrambling to make plans work.
People at the top don't have any idea how much the people in the middle are breaking their backs to keep the organization going.

Sensemaking and Storytelling

We tell ourselves stories in order to live, know more, and compete better.
In a crisis, stories help us not to panic.
Someone spins a story, and the moral is something like, "Don't worry, I have seen something vaguely like this before."
People don't need much to get moving - just a little kernel of meaning.
The most powerful stories are created and spread through informal gossip.
Gossiping is a way to rehearse different stories before they become formalized and spread out across the organization.
Gossip helps prepare an organization for the unexpected and can serve as a prelude to sensemaking and action.
Leaders don't need much factual information to get going.
Example: The story of the locomotive engineer who starved to death on the tracks of Union Pacific, which employees began to call it the Utterly Pathetic railroad expresses frustration with the railroad's incompetence during a period of intense upheaval.

Plans and Overplanning

Plans are overrated and can make things worse.
Most plans are too specific, creating the illusion that they grasp everything.
Plans make people not look for things that disconfirm them.
Plans are the opposite of gossip in that they lure us into the trap of overlooking the unexpected.
They deceive us into thinking that we know more than we do.
Plans heighten the tendency to postpone action when something unexpected happens.
Example: Training at a nuclear power plant where employees waited for a long time before taking action because they were searching their memories for where they had seen this situation before in the training session.
The reactor was getting hotter and hotter and hotter, so the company would have been better off if its employees had only had a few guidelines, just enough to keep them moving in times of crisis.
Plans are important, but not for micromanaging the unexpected.
Plans are signals, games, excuses for interactions.

Galumphing

Galumphing: A kind of purposeful playfulness, improvisation, whereby organizations try out different possibilities.
It keeps people from becoming too complacent and helps executives see things in a new way.
Wildland firefighters are most likely to get killed or injured in their tenth year on the job because they start to think they've seen it all.
Firefighters should constantly be encouraged to imagine different possibilities.
In wilderness fire training, it is crucial to learn how to escape from flames when you are in danger of entrapment. One way to do this is to drop your tools so that you can pick up speed.
In very recent training, therefore, firefighters play at dumping their packs; they explore what it feels like to run both encumbered and unencumbered.
It helps them enlarge their repertoires and gain confidence in alternative ways of acting.
It is particularly critical in high-reliability organizations, where the last thing anyone wants is for people to let down their guard because they think they've seen everything.