The Self-Designing High-Reliability Organization: Aircraft Carrier Flight Operations at Sea
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Abstract
Recent studies of large, formal organizations that perform complex, inherently hazardous, and highly technical tasks under conditions of tight coupling and severe time pressure have generally concluded that most will fail spectacularly at some point, with attendant human and social costs of great severity.1 The notion that accidents in these systems are normal, that is, to be expected given the conditions and risks of operation, appears to be as well grounded in experience as in theory. 2 Yet there is a small group of organizations in American society that appears to succeed under trying circumstances, performing daily a number of highly complex technical tasks in which they cannot afford to fail. We are currently studying three unusually salient examples whereby devotion to a zero rate of error is almost matched by performance -utility grid management (Pacific Gas & Electric Company), air traffic control, and flight operations aboard U.S. Navy aircraft carriers.