IEEE Technology and Society Magazine - June 2018 - 65

possible, HROs complete immediate investigations of
small incidents and quickly discuss lessons learned [4].
Through their interactions, the people in an HRO cre-
ate a "collective mind," a concept to describe the ways
in which the conscious attention of many individuals is
linked together into a structure of social cognition [7].
This increases reliability in three ways [7]: 1) connecting
across time by bringing knowledge forward from previ-
ous parts of a process, 2) incorporating more and more
tasks into the framework of cognition, and 3) connect-
ing new and old employees, allowing bi-directional
learning, as experienced employees interact with new
employees who see the system with a fresh perspective.
Using "collective mind," Weick and Roberts argue that a
complex cognitive structure is the only way to compre-
hend the complexity of a large technological system,
since no individual can grasp it [7].
Some of the first studies to develop the concept of
HROs examined power systems, specifically that of
Pacific Gas and Electric. In [5], Roberts examines how
training helps operators cope with varied system condi-
tions. Grid operators at Pacific Gas and Electric train
using recent issues from actual operations, while the
nuclear plant operators spend one week per month
training, allowing them to stay up-to-date with unique
and/or dangerous conditions [5]. At Pacific Gas and
Electric, Roberts noticed frequent training, redundancy,
and distributed decision-making, which were then used
to generally describe HROs.
About ten years later, during the electricity market
restructuring in California, HRO researchers revisited
Pacific Gas and Electric. They witnessed what is now
commonly called the California Electricity (or Energy)
Crisis. Schulman and his co-authors pose the following
question in their studies: how do technical systems with
many players maintain reliability [9]? They argue that
electricity restructuring is a good test case for two rea-
sons [9]: 1) reliability should be undermined based on
early research, and 2) it challenges whether complexity
and tight coupling cause failure. The authors argue that,
despite rolling blackouts and the declaration of bank-
ruptcy by Pacific Gas and Electric, "the lights by and
large actually stayed on - and reliably stayed on" [9].
I disagree with the authors' assessment of this point.
The utilities and operators struggled valiantly during the
crisis and achieved impressive results. However, Schul-
man et al. understate the impacts. Weare explains that:
■ [t]he lights flickered throughout the crisis... In 2000,
electricity was turned off to customers with special
interruptible contracts on 13 other days. During
2001, "load shedding" occurred on 31 days. On nine
of these days customers experienced involuntary
rolling blackouts for a total of 42 hours of outages.
During these nine outages, California experienced
JUNE 2018

∕

High Reliability Organizations
can be designed to compensate
for human fallibility and
technological failures.
an average shortfall of... enough energy to power
over 450,000 households. On the worst day, Janu-
ary 18, the equivalent of almost one million house-
holds lost electricity [10].
This description does not meet the basic expecta-
tions of "high reliability."
Schulman and his co-authors coin the phrase "high
reliability network" to describe the constellation of utili-
ties, generation owners, and the independent system
operator [9]. Unlike HROs, the authors show that high
reliability networks engage in trial-and-error, based on
reliability standards and actual operating conditions,
and follow rules of thumb to ensure that the system's
performance remains within the specified requirements
[9], [11]. Roe writes that "[r]eliability here lies in resilience - the ability of managers to respond in ways that
buffer or accept variance in inputs and then act to coun-
ter the variance in order to produce output fluctuations
at manageable levels" (emphasis added) [11]. Unfortu-
nately, reliability and resilience, though related, are not
the same. (Reference [12] has an extended discussion
on different definitions of resilience.)
In summary, the HRO framework claims that orga-
nizations can be designed to compensate for human
fallibility and technological failures. The normal acci-
dent framework claims that reliability cannot be guar-
anteed due to fundamental system characteristics.
These frameworks are frequently compared to one
another, since both examine failures in complex sys-
tems. Rosa summarizes three major contradictions
between the HRO framework and the normal accident
framework. The latter expects infrequent, but "nor-
mal," accidents while the former expects virtually acci-
dent-free operation [13]. Both frameworks predict
some accidents; the question is how to define "infre-
quent," which neither framework specifies [13]. The
normal accident framework posits that redundancy is
a cause of failure, while the HRO framework argues
that redundancy decreases accidents [13]. The normal
accident framework rests on asymmetrical social and
political power structures and the HRO framework
focuses on a culture of reliability [13]. To Rosa, the
two frameworks are "blindfolded observers feeling dif-
ferent parts of an elephant" [13], where the elephant

IEEE Technology and Society Magazine

65



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