Stronger isn't always better: The issue of culture in HROs

When you look at many of the high reliability organizations (HRO’s) such as Fire Departments, NASA, the U.S. Military, and Hospitals you notice one thing that they have in common: a strong culture. We refer to these organizations as high reliability organizations because even though their work is considered high risk (i.e. complex, ambiguous, and dangerous), they are able to manage this risk appropriately and maintain a relatively safe environment. Often, a strong culture (one where organizational members have shared norms, values, and beliefs tied to organizational values) helps these organizations run like well-oiled machines.

However, having a strong culture doesn’t necessarily point to a safe culture. Cultures with formally defined hierarchies must overcome the hurdle of rank when reporting errors. Often status differences can lead to a lack of clear communication during critical times. For instance, in a study of air line safety, it was found that more accidents occurred with the more experienced pilot is placed in the command position. At first this may seem counterintuitive. However, a closer look yields more insight.

When a high ranking individual is in 2nd command, they are not concerned with offending the pilot in 1st command when identifying mistakes or potential troubles. On the other hand, when a lower ranking individual must point out mistakes to the captain in command, they often use mitigated speech to avoid offending or embarrassing the higher ranking individual.

HRO’s are successful and safe when weak signals of potential trouble are acknowledged and trusted from all employees no matter of rank. This applies to airline pilots but also status differences between nurses and surgeons, captains and firefighters, and managers and employees.

A 2001 Agency for Healthcare Research and Quality white paper, Making Health Care
Safe identified four components of a culture of safety:

• Acknowledgement of the high-risk, error prone nature of an organization's activities
• Blame-free environment where individuals are able to report errors and close calls without punishment
• Expectation of collaboration across ranks to seek solutions to vulnerabilities
• Willingness on the part of the organization to direct resources to address safety concerns.



The impact of National Culture



In his book Outliers, Malcolm Gladwell unravels the story of Korean Air. In the years of 1988-1998, Korean Air had a loss rate (lost planes per departures) more than 17 times higher than an average American Airline, United Airlines. It was, by all accounts, thought to have one of the worst reputations in the airline world.

Many of the problems with Korean Air flights could be traced to nuances within the South Korean culture, mainly speech patterns between individuals of differing status. In South Korean culture, it is unheard of to question or criticize a superior. Therefore, lower ranking pilots only “suggested” weak signals and these suggestions were rarely spoken a second time even when it was clear that danger was approaching.

According to Hofstede’s research on cultural variability, South Korea scores extremely high on the power distance index. This index measures the culture’s emphasis on status differences, rank and authority. In a report issued by Boeing, a clear correlation was found between a country’s rate of plane crashes and its score on Hofstede’s dimension of power distance. In other words, those countries with more emphasis on status differences also had a higher rate of airline accidents. From this example we see that national culture can have a strong influence on organizational culture.


When Korean Air realized that they needed a turn-around, they brought in an outsider, David Greenberg from Delta Air Lines. The first thing Greenberg did was make English the official language of Korean Air. This was an attempt to separate organizational culture from a regimented national culture. By freeing pilots of the status gradients of their native language, they were able to speak clearly about problems and issue commands rather than suggestions in times of crisis. By 2006, Korean Air had turned itself around and has operated with an unblemished record since 1999.

See also:

Anatomy of a System Accident: The Crash of Avianca Flight 052

Strategic Ambiguity and Missile Strikes: The New Doctrine of the United States of America

Recent news reports indicate that U.S.-led missile strikes in the tribal regions between Pakistan and Afghanistan are on the rise. The purpose of the attacks are to continue the assault on Taliban and Al-Qaeda militants thus thwarting further terrorist attacks in the United States and around the world. In a news article and audio report on NPR, several experts from various military and civilian higher education institutions weigh in on the ambiguity surrounding the increase in missile strikes. Some want Pakistan to openly condone the strikes while others indicate that such an act would open other countries up to similar strikes, U.S.-led or otherwise.

In the report, an expert in international law at John Hopkins University, Ruth Wedgwood asserts that perhaps the United States is deliberately being ambiguous. Perhaps they are even “strategically ambiguous”. Such a characterization of the language surrounding the increase missile attacks begins to connect current leader behavior in the U.S. military to the idea of strategic ambiguity as defined by Eric Eisenberg. In his book, “Strategic Ambiguities: Essays on Communication, Organization, and Identity”, Eisenberg discusses how organizations and individuals in organizations use language that is deliberately unclear to allow for multiple often conflicting interpretations. Although Eisenberg was referring to general ambiguity in language, other scholars chime in on the very issues related to the missile strikes in these tribal regions.

Strategically ambiguous communication, like that surrounding the missile strikes, allows for multiple plausible interpretations and provides for the ability for leaders to deny many of the interpretations. Many interpretations may attribute inaccurate motives to leaders, but the ambiguity of the message allows leaders to deny the most heinous of such interpretations. Again, the goal is not deception, but legal and plausible deniability if something were to go wrong.

In keeping with our current example, using language that is strategically ambiguous allows the troops in Pakistan and Afghanistan to continue to carry-out assaults on areas that are not fully under either countries sovereignty. Often the missile strikes are carried out by drones and later verified by ground troops. In this case, because the U.S. is keeping their rhetoric ambiguous, neither country can claim that they have overstepped their authority and neither country wants to openly condone or condemn the attacks. Bloggers and experts alike say that this sort of limbo puts the U.S.-led coalition in danger of swift action on the part of either country. Although that is possible, it is likely that until one of the countries attempts to clarify the ambiguity the status quo will remain.

Managing Expectations to Manage the Unexpected

Crises inherently involve unanticipated events. And one way that leaders often shape how people around them think about crises is by talking about expectations. For example, much of the recent talk initiated and perpetuated by leaders within the U.S. government incorporates aspects of expectation management.

Take, for instance, President Barack Obama’s Feb. 24 address before a joint session of Congress. In his speech, which dealt largely with his plans to bolster the economy, Mr. Obama incorporated several elements of expectation management. Specifically, after discussing his immediate plans for economic recovery, Mr. Obama’s rhetoric shifted to describe plans with a decidedly futuristic orientation. To illustrate with a simple example, let’s consider the president’s use of two phrases: “short term” and “long term."

For starters, Mr. Obama used the phrase “short term” twice while mentioning “long term” six times. But what is compelling from an expectation-management perspective is that both times that he said “short term,” he immediately juxtaposed “short term” with “long term.” Early in the speech, Mr. Obama compared the two, saying, “Short-term gains were prized over long-term prosperity.” Later, he said, “The recovery plan and the financial stability plan are the immediate steps we’re taking to revive our economy in the short-term. But the only way to fully restore America’s economic strength is to make the long-term investments that will lead to new jobs, new industries, and a renewed ability to compete with the rest of the world.”

In his recent column on Forbes.com, Shaun Rein describes Mr. Obama’s expectation-management strategy as one that business leaders should adopt in difficult times. Rein wrote, “President Obama has continually lowered expectations about his ability to right the economy quickly. This has given him time to maneuver and allowed for more upside potential … Managing the expectations of investors and employees is critical now. One of the biggest mistakes senior executives make is trying to put too positive a spin on a situation.” Indeed, business bloggers are also picking up on the importance of expectation management in the face of crises.

Bloomberg News columnist Caroline Baum focused instead on Mr. Obama’s optimism. In her Feb. 26 column, she wrote, “Chicago is home to, among other things, rational expectations theory, the idea that outcomes depend to some extent on what people expect to happen. It would have been hard to spend that much time in Hyde Park without some of Chicago rubbing off on Obama … If we expect the future to be better, rational expectations dictate that it will be.”

Taking a scholarly perspective, organizational theorists argue that people’s expectations regarding what constitutes the ordinary shape how they make sense of and ascribe meaning to the world around them. So in terms of leadership, it behooves leaders to manage expectations carefully, keeping in mind the power of suggestion and using talk to frame how others regard their environments. At the same time, however, it’s crucial to manage expectations in such a way that people are more likely—not less—to notice and publicize the weak signals and small deviations from normality that are all too often beacons warning of impending disaster.