This is a review that was written previously for the HEACH website. In the meantime another version has been done including some more discussion, but lacking some of the contents below.

Please note that an updated version of the book has been released, titled "Managing the Unexpected: Resilient Performance in an Age of Uncertainty" (ISBN 0787996491)

Review for the first edition:
The authors of this book work as (associate) professors of Organizational Behaviour and Psychology/Human Resource Management at the University of Michigan. This book sums up the insights they gained during their studies of so-called High Reliability Organizations (HRO). What is it that makes these organizations "safer", "better", "more reliable" or just "different"? But, luckily for us, they don't stop at this analysis, but draw lessons from case studies and offer do-able (simple and more difficult) ways of changing things in your own company in order to become more of an HRO. Starting right after you put the book down.

The most important thing that sets an HRO apart from other companies, according to Weick and Sutcliffe, is their "mindfulness". This mindfulness is reached by HRO though five processes:
1. Preoccupation with failure,
2. Reluctance to simplify,
3. Sensitivity to operations,
4. Commitment to resilience, and
5. Deference to expertise.

These principles (mindful management and the five underlying processes) are put down and explained right in the first chapter, using the railway case study of Union Pacific's merger with Southern Pacific - which didn't go well as UP screwed up majorly, gridlocking the entire system in October 1997. Excellent reading, not just for railway people of course.

After this exciting first chapter, the book "dips" slightly, because chapters 2 and 3 are basically repetitions of the phenomenon mindfulness and its five processes, by focussing on other case studies, this time taken from the select circle of HRO's: aircraft carriers and nuclear plants. I found it hard to hold my attention fully while reading those chapters, because of the repetition (although some things are elaborated upon in fine ways). But I guess that it wouldn't do major harm if you just skimmed these two chapters and proceeded to chapter 4.

Yet, I'd like to raise a concern about the last part of chapter 3 (from page 67 onward). Here the authors focus majorly on "Commitment to resilience". Nothing wrong with that of course, but they sing so highly the praises on "firefighting" (p. 70, as opposed to structurally working on safety) that this piece of text is very, very dangerous when taken out of context. It sounds a bit as if structural, systematic working on quality and safety is something HROs don't do a lot... Which simply is not true, and this may be the structural shortcoming in this book: the authors focus só much on the five processes that set HROs apart from most other organizations that they neglect to tell what HROs do beforehand and in addition. They do have thorough analyses; invest a lot in competence of their staff; do build "defences in depth" and so on… It's not that they're just alert and ready to act… So, it's not a case of "this instead of", but "both and", something one might take wrong from these passages.

Actually, I almost get the feeling that the authors fell in the trap they described themselves: over-simplification. By focussing so strongly on the 5 virtues of HROs they almost forget entirely to tell what else there is: a complex combination of these 5 processes with other elements as defences in depth, competence, communication, risk analysis. Also, the authors don't manage to fulfill entirely the promise of explaining the second part of Chapter 3's title ("A Closer Look at Process and Why Planning Can Make Things Worse"). Actually, I think they partly fail here because they tend too much to absolutes (probably in order to make their point clear), while the keyword of course is "can". Just promise me to remember the following quote and I trust you will do fine with this section: "HROs do not ignore foresight and anticipation, but they are mindful of its limitations" (p. 77).

By the way, I fully subscribe to the tendency that runs between the lines in chapter 3: Total Quality Management is not so muc the system, but most of all attitude, alertness, competence, communications etcetera. The "system" is just a tool.

Chapter 4 then, offers kind of a mini-audit or self-check you (and your co-workers) can perform to see where your organization's strong and weak points are on the way to become an HRO. Interesting and helpful, but again repetitive…

But then the book reaches its full height again in Chapter 5, which describes "Organizational Culture and the Unexpected". A most interesting chapter, not at least because the authors finally discuss something entirely new - culture and how to change/improve it - but in relation to the five aforementioned processes. This all is linked to the theory of Schein (what is and what makes corporate culture) and James Reason's work on safety culture. The elements from Reason's work, like a reporting, learning and just culture are explained by using the Moura mine disaster as a case study. The chapter is then closed with a list of 15 "leverage points" which you can use on your way to creating a safer culture in your organization. This chapter is nothing short from essential reading!

Chapter 6 is another highly recommended one, turning back to the UP case study and what has changed since the collapse in October 1997, we're confronted with the question if they are on the right way to become a more mindful organization. The second half of the chapter is devoted to tips how to manage for more mindfulness in your organization, offering a huge toolbox with tips.

By the way, each chapter is concluded by a summary, which makes it very easy to freshen up your mind in an efficient way. Even despite the repetiveness, I think this book is an essential one for everyone into safety or quality management!

To close, some interesting quotes (and just a selection, the book makes many excellent quotes!):

Executives often manage the unexpected by blaming it on someone, usually someone else. (p. 13)

What is unique about […] HROs is that they do these things mindfully in the belief that safety is not bankable. HROs are clear that you can't "fix" the safety problem, store up safety, and then move on to something else. (p. 32)

[…] when people fail, they tend to be candid about what happened for a short period of time, and then they get their stories straight in ways that justify their actions and protect their reputations. And when official stories get straightened out and get repeated, learning stops. (p. 57/58)

It has been well established that managers tend to attribute failure to external factors that are beyond their conrol but attribute success to their own efforts. What is striking in HROs is their tendency to reverse this pattern. (p. 176)

And although HROs take pride in their success, their feelings of pleasure are short-lived because they know that along with success comes complacency, a temptation to reduce margins of safety, and inattentiveess. (p. 177)