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