Risk mitigation in large-scale systems: Lessons from high reliability organizations

California Management Review

Volumn , Issue 4, 1997, Pages 152-162

  Grabowski, Martha ^a   Roberts, Karlene ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

EID: 0031512352     PISSN: 00081256     EISSN: None     Source Type: Journal    
DOI: 10.2307/41165914     Document Type: Article

References (58)

1. M.R. Grabowski and K.H. Roberts, "Human and Organizational Error in Large Scale Systems," IEEE Transactions on Systems, Man and Cybernetics, 26/1 (January 1996): 1-16.
2. See, for example, D.M. Rousseau and Carolyn Libuser, "Contingent Workers in High Risk Environments," California Management Review, 39/2 (Winter 1997): 103-123.
3. P. Kapasouris, D. Serfaty, J.C. Deckert, J.G. Wohl, and P. Pattipati, "Resource Allocation and Performance Evaluation in Large-Human Machine Organizations," IEEE Transactions on Systems, Man, and Cybernetics, 21/3 (1991): 521-532.
4. See, for example, R. Mayntz and T.P Hughes, eds., The Development of Large Technical Systems (Boulder, CO: Westview Press, 1988); C. Perrow, Normal Accidents: Living with High Risk Technologies (New York, NY: Basic Books, 1984).
5. See, for example, R. Mayntz and T.P Hughes, eds., The Development of Large Technical Systems (Boulder, CO: Westview Press, 1988); C. Perrow, Normal Accidents: Living with High Risk Technologies (New York, NY: Basic Books, 1984).
6. This is illustrated by D. Katz and R.L. Kahn, The Social Psychology of Organizations, 2nd edition (New York, NY: Wiley, 1978), and J.G. Miller, Living Systems (New York, NY: Wiley, 1978).
7. This is illustrated by D. Katz and R.L. Kahn, The Social Psychology of Organizations, 2nd edition (New York, NY: Wiley, 1978), and J.G. Miller, Living Systems (New York, NY: Wiley, 1978).
8. J.C. Ammons, T. Govindaraj, and E.M Mitchell, "A Supervisory Control Paradigm for Real-Time Control of Flexible Manufacturing Systems," Annals of Operations Research, 15 (1988): 313-335; S.Y. Nof, A.B. Whinston, and W.I. Bullens, "Control and Decision Support in Automatic Manufacturing Systems," IEEE Transactions, 12/2 (1980): 156-169; W.B. Rouse, "Intelligent Decision Support for Advanced Manufacturing Systems," Manufacturing Review, 1/4 (1988): 236-243.
9. J.C. Ammons, T. Govindaraj, and E.M Mitchell, "A Supervisory Control Paradigm for Real-Time Control of Flexible Manufacturing Systems," Annals of Operations Research, 15 (1988): 313-335; S.Y. Nof, A.B. Whinston, and W.I. Bullens, "Control and Decision Support in Automatic Manufacturing Systems," IEEE Transactions, 12/2 (1980): 156-169; W.B. Rouse, "Intelligent Decision Support for Advanced Manufacturing Systems," Manufacturing Review, 1/4 (1988): 236-243.
10. J.C. Ammons, T. Govindaraj, and E.M Mitchell, "A Supervisory Control Paradigm for Real-Time Control of Flexible Manufacturing Systems," Annals of Operations Research, 15 (1988): 313-335; S.Y. Nof, A.B. Whinston, and W.I. Bullens, "Control and Decision Support in Automatic Manufacturing Systems," IEEE Transactions, 12/2 (1980): 156-169; W.B. Rouse, "Intelligent Decision Support for Advanced Manufacturing Systems," Manufacturing Review, 1/4 (1988): 236-243.
11. W.B. Rouse, Design for Success: A Human-Centered Approach to Designing Successful Products and Systems (New York, NY: John Wiley and Sons, 1991).
12. B. Chandrasekaran, R. Bhatnagar, and D.D. Sharma, "Real-Time Disturbance Control," Communications of the ACM, 34/8 (1991): 32-47.
13. G. Beroggi and W.A. Wallace, "Closing the Gap: Transit Control for Hazardous Material Flow," Journal of Hazardous Materials, 27 (1991): 61-75; R.D. Burns, "Safety and Productivity Improvement of Railroad Operations by Advanced Train Control Systems," IEEE/ASME Joint Conference (1989); M.R. Grabowski and S.D. Sanborn, "Knowledge Representation and Reasoning in a Real-Time Operational Control System: The Shipboard Piloting Expert System," Decision Sciences, 23 (1992): 1277-1296.
14. G. Beroggi and W.A. Wallace, "Closing the Gap: Transit Control for Hazardous Material Flow," Journal of Hazardous Materials, 27 (1991): 61-75; R.D. Burns, "Safety and Productivity Improvement of Railroad Operations by Advanced Train Control Systems," IEEE/ASME Joint Conference (1989); M.R. Grabowski and S.D. Sanborn, "Knowledge Representation and Reasoning in a Real-Time Operational Control System: The Shipboard Piloting Expert System," Decision Sciences, 23 (1992): 1277-1296.
15. G. Beroggi and W.A. Wallace, "Closing the Gap: Transit Control for Hazardous Material Flow," Journal of Hazardous Materials, 27 (1991): 61-75; R.D. Burns, "Safety and Productivity Improvement of Railroad Operations by Advanced Train Control Systems," IEEE/ASME Joint Conference (1989); M.R. Grabowski and S.D. Sanborn, "Knowledge Representation and Reasoning in a Real-Time Operational Control System: The Shipboard Piloting Expert System," Decision Sciences, 23 (1992): 1277-1296.
16. M.S. Jaffe, N.G. Leveson, M.E.E. Heimdahl, and B.E. Melhart, "Software Requirements Analysis for Real-Time Process-Control Systems," IEEE Transactions on Software Engineering, 17/3 (1991): 241-258.
17. See H.W. Chesbrough and D.J. Teece, "When Is Virtual Virtuous? Organizing for Innovation," Harvard Business Review (January/February 1996), pp. 65-73.
18. In fact, Perrow reports that only one study specifically examined systems of organizations. C. Perrow, Complex Organizations: A Critical Essay, 2nd edition (New York, NY: Random House, 1979); C. Perrow, Complex Organizations: A Critical Essay, 3rd edition (New York, NY: Random House, 1986). More recently Roberts discussed functional and dysfunctional linkages of systems of organizations, and Grabowski and Roberts examined systems in the marine industry. M. Grabowski and K.H. Roberts "Human and Organizational Errors in Large Scale Systems," IEEE Transactions on Systems, Man, and Cybernetics, 26 (1996): 2-16; K.H. Roberts, "Functional and Dysfunctional Organizational Linkages," in C.L. Cooper and D.M. Rousseau, eds., Trends in Organizational Behavior, Volume 1 (New York, NY: Wiley, 1994); K.H. Roberts and M. Grabowski, "Human Systems in the Marine Industry," in Marine Navigation and Piloting: Minding the Helm (Washington, D.C: National Academy Press, 1994). Rees describes the formation of nuclear power generation companies in the United States into a system of sorts after the Three Mile Island accident. See J. V. Rees, Hostages of Each Other (Chicago, IL: University of Chicago Press, 1994). Many writers, such as Vaughan, allude to systems of organizations but their primary focus is elsewhere. D. Vaughan, The Challenger Launch Decision (Chicago, IL: University of Chicago Press, 1996).
19. In fact, Perrow reports that only one study specifically examined systems of organizations. C. Perrow, Complex Organizations: A Critical Essay, 2nd edition (New York, NY: Random House, 1979); C. Perrow, Complex Organizations: A Critical Essay, 3rd edition (New York, NY: Random House, 1986). More recently Roberts discussed functional and dysfunctional linkages of systems of organizations, and Grabowski and Roberts examined systems in the marine industry. M. Grabowski and K.H. Roberts "Human and Organizational Errors in Large Scale Systems," IEEE Transactions on Systems, Man, and Cybernetics, 26 (1996): 2-16; K.H. Roberts, "Functional and Dysfunctional Organizational Linkages," in C.L. Cooper and D.M. Rousseau, eds., Trends in Organizational Behavior, Volume 1 (New York, NY: Wiley, 1994); K.H. Roberts and M. Grabowski, "Human Systems in the Marine Industry," in Marine Navigation and Piloting: Minding the Helm (Washington, D.C: National Academy Press, 1994). Rees describes the formation of nuclear power generation companies in the United States into a system of sorts after the Three Mile Island accident. See J. V. Rees, Hostages of Each Other (Chicago, IL: University of Chicago Press, 1994). Many writers, such as Vaughan, allude to systems of organizations but their primary focus is elsewhere. D. Vaughan, The Challenger Launch Decision (Chicago, IL: University of Chicago Press, 1996).
20. In fact, Perrow reports that only one study specifically examined systems of organizations. C. Perrow, Complex Organizations: A Critical Essay, 2nd edition (New York, NY: Random House, 1979); C. Perrow, Complex Organizations: A Critical Essay, 3rd edition (New York, NY: Random House, 1986). More recently Roberts discussed functional and dysfunctional linkages of systems of organizations, and Grabowski and Roberts examined systems in the marine industry. M. Grabowski and K.H. Roberts "Human and Organizational Errors in Large Scale Systems," IEEE Transactions on Systems, Man, and Cybernetics, 26 (1996): 2-16; K.H. Roberts, "Functional and Dysfunctional Organizational Linkages," in C.L. Cooper and D.M. Rousseau, eds., Trends in Organizational Behavior, Volume 1 (New York, NY: Wiley, 1994); K.H. Roberts and M. Grabowski, "Human Systems in the Marine Industry," in Marine Navigation and Piloting: Minding the Helm (Washington, D.C: National Academy Press, 1994). Rees describes the formation of nuclear power generation companies in the United States into a system of sorts after the Three Mile Island accident. See J. V. Rees, Hostages of Each Other (Chicago, IL: University of Chicago Press, 1994). Many writers, such as Vaughan, allude to systems of organizations but their primary focus is elsewhere. D. Vaughan, The Challenger Launch Decision (Chicago, IL: University of Chicago Press, 1996).
21. In fact, Perrow reports that only one study specifically examined systems of organizations. C. Perrow, Complex Organizations: A Critical Essay, 2nd edition (New York, NY: Random House, 1979); C. Perrow, Complex Organizations: A Critical Essay, 3rd edition (New York, NY: Random House, 1986). More recently Roberts discussed functional and dysfunctional linkages of systems of organizations, and Grabowski and Roberts examined systems in the marine industry. M. Grabowski and K.H. Roberts "Human and Organizational Errors in Large Scale Systems," IEEE Transactions on Systems, Man, and Cybernetics, 26 (1996): 2-16; K.H. Roberts, "Functional and Dysfunctional Organizational Linkages," in C.L. Cooper and D.M. Rousseau, eds., Trends in Organizational Behavior, Volume 1 (New York, NY: Wiley, 1994); K.H. Roberts and M. Grabowski, "Human Systems in the Marine Industry," in Marine Navigation and Piloting: Minding the Helm (Washington, D.C: National Academy Press, 1994). Rees describes the formation of nuclear power generation companies in the United States into a system of sorts after the Three Mile Island accident. See J. V. Rees, Hostages of Each Other (Chicago, IL: University of Chicago Press, 1994). Many writers, such as Vaughan, allude to systems of organizations but their primary focus is elsewhere. D. Vaughan, The Challenger Launch Decision (Chicago, IL: University of Chicago Press, 1996).
22. In fact, Perrow reports that only one study specifically examined systems of organizations. C. Perrow, Complex Organizations: A Critical Essay, 2nd edition (New York, NY: Random House, 1979); C. Perrow, Complex Organizations: A Critical Essay, 3rd edition (New York, NY: Random House, 1986). More recently Roberts discussed functional and dysfunctional linkages of systems of organizations, and Grabowski and Roberts examined systems in the marine industry. M. Grabowski and K.H. Roberts "Human and Organizational Errors in Large Scale Systems," IEEE Transactions on Systems, Man, and Cybernetics, 26 (1996): 2-16; K.H. Roberts, "Functional and Dysfunctional Organizational Linkages," in C.L. Cooper and D.M. Rousseau, eds., Trends in Organizational Behavior, Volume 1 (New York, NY: Wiley, 1994); K.H. Roberts and M. Grabowski, "Human Systems in the Marine Industry," in Marine Navigation and Piloting: Minding the Helm (Washington, D.C: National Academy Press, 1994). Rees describes the formation of nuclear power generation companies in the United States into a system of sorts after the Three Mile Island accident. See J. V. Rees, Hostages of Each Other (Chicago, IL: University of Chicago Press, 1994). Many writers, such as Vaughan, allude to systems of organizations but their primary focus is elsewhere. D. Vaughan, The Challenger Launch Decision (Chicago, IL: University of Chicago Press, 1996).
23. In fact, Perrow reports that only one study specifically examined systems of organizations. C. Perrow, Complex Organizations: A Critical Essay, 2nd edition (New York, NY: Random House, 1979); C. Perrow, Complex Organizations: A Critical Essay, 3rd edition (New York, NY: Random House, 1986). More recently Roberts discussed functional and dysfunctional linkages of systems of organizations, and Grabowski and Roberts examined systems in the marine industry. M. Grabowski and K.H. Roberts "Human and Organizational Errors in Large Scale Systems," IEEE Transactions on Systems, Man, and Cybernetics, 26 (1996): 2-16; K.H. Roberts, "Functional and Dysfunctional Organizational Linkages," in C.L. Cooper and D.M. Rousseau, eds., Trends in Organizational Behavior, Volume 1 (New York, NY: Wiley, 1994); K.H. Roberts and M. Grabowski, "Human Systems in the Marine Industry," in Marine Navigation and Piloting: Minding the Helm (Washington, D.C: National Academy Press, 1994). Rees describes the formation of nuclear power generation companies in the United States into a system of sorts after the Three Mile Island accident. See J. V. Rees, Hostages of Each Other (Chicago, IL: University of Chicago Press, 1994). Many writers, such as Vaughan, allude to systems of organizations but their primary focus is elsewhere. D. Vaughan, The Challenger Launch Decision (Chicago, IL: University of Chicago Press, 1996).
24. In fact, Perrow reports that only one study specifically examined systems of organizations. C. Perrow, Complex Organizations: A Critical Essay, 2nd edition (New York, NY: Random House, 1979); C. Perrow, Complex Organizations: A Critical Essay, 3rd edition (New York, NY: Random House, 1986). More recently Roberts discussed functional and dysfunctional linkages of systems of organizations, and Grabowski and Roberts examined systems in the marine industry. M. Grabowski and K.H. Roberts "Human and Organizational Errors in Large Scale Systems," IEEE Transactions on Systems, Man, and Cybernetics, 26 (1996): 2-16; K.H. Roberts, "Functional and Dysfunctional Organizational Linkages," in C.L. Cooper and D.M. Rousseau, eds., Trends in Organizational Behavior, Volume 1 (New York, NY: Wiley, 1994); K.H. Roberts and M. Grabowski, "Human Systems in the Marine Industry," in Marine Navigation and Piloting: Minding the Helm (Washington, D.C: National Academy Press, 1994). Rees describes the formation of nuclear power generation companies in the United States into a system of sorts after the Three Mile Island accident. See J. V. Rees, Hostages of Each Other (Chicago, IL: University of Chicago Press, 1994). Many writers, such as Vaughan, allude to systems of organizations but their primary focus is elsewhere. D. Vaughan, The Challenger Launch Decision (Chicago, IL: University of Chicago Press, 1996).
25. See, for example, K.H. Roberts, S.K. Stout, and J.J. Halpern, "Decision Dynamics in Two High Reliability Organizations," Management Science, 40 (1994): 614-624; G I. Rochlin and A. von Meier "Nuclear Power Operations: A Cross Cultural Perspective," Annual Review of Energy and Environment, 19 (1994): 153-187; K.E. Weick "Organizational Culture as a Source of High Reliability," California Management Review, 29/2 (Winter 1987): 112-127.
26. See, for example, K.H. Roberts, S.K. Stout, and J.J. Halpern, "Decision Dynamics in Two High Reliability Organizations," Management Science, 40 (1994): 614-624; G I. Rochlin and A. von Meier "Nuclear Power Operations: A Cross Cultural Perspective," Annual Review of Energy and Environment, 19 (1994): 153-187; K.E. Weick "Organizational Culture as a Source of High Reliability," California Management Review, 29/2 (Winter 1987): 112-127.
27. See, for example, K.H. Roberts, S.K. Stout, and J.J. Halpern, "Decision Dynamics in Two High Reliability Organizations," Management Science, 40 (1994): 614-624; G I. Rochlin and A. von Meier "Nuclear Power Operations: A Cross Cultural Perspective," Annual Review of Energy and Environment, 19 (1994): 153-187; K.E. Weick "Organizational Culture as a Source of High Reliability," California Management Review, 29/2 (Winter 1987): 112-127.
28. D. Vaughan, "Autonomy, Interdependence, and Social Control: The Space Shuttle Challenger," Administrative Science Quarterly, 35 (1990): 225-257.
29. W.M. Evan, "The Organization Set: Toward a Theory of Interorganizational Relations," in J.D. Thompson, ed., Approaches to Organizational Design (Pittsburgh, PA: University of Pittsburgh Press, 1966), pp. 175-191; C. Perrow (1979), op. cit.; C. Perrow (1986), op. cit.
30. W.M. Evan, "The Organization Set: Toward a Theory of Interorganizational Relations," in J.D. Thompson, ed., Approaches to Organizational Design (Pittsburgh, PA: University of Pittsburgh Press, 1966), pp. 175-191; C. Perrow (1979), op. cit.; C. Perrow (1986), op. cit.
31. W.M. Evan, "The Organization Set: Toward a Theory of Interorganizational Relations," in J.D. Thompson, ed., Approaches to Organizational Design (Pittsburgh, PA: University of Pittsburgh Press, 1966), pp. 175-191; C. Perrow (1979), op. cit.; C. Perrow (1986), op. cit.
32. See P.M. Senge, The Fifth Dimension (New York, NY: Doubleday, 1990); A. Wishart, J.J. Elam, and D. Robey, "Redrawing the Portrait of a Learning Organization: Inside Knight Ridder, Inc.," Academy of Management Executive, 10/1 (1996).
33. See P.M. Senge, The Fifth Dimension (New York, NY: Doubleday, 1990); A. Wishart, J.J. Elam, and D. Robey, "Redrawing the Portrait of a Learning Organization: Inside Knight Ridder, Inc.," Academy of Management Executive, 10/1 (1996).
34. See, for example E. Tenner, Why Things Bite Back: Technology and the Revenge of Unintended Consequences (New York, NY: Knopf, 1996).
35. D. Vaughan (1990), op. cit.
36. D. Vaughan (1996), op. cit.
37. B.M. Turner, "The Organizational and Intraorganizational Development of Disasters," Administrative Science Quarterly, 21 (1976): 378-397; and B.M. Turner, Man Made Disasters (London: Wykeham Press, 1978).
38. B.M. Turner, "The Organizational and Intraorganizational Development of Disasters," Administrative Science Quarterly, 21 (1976): 378-397; and B.M. Turner, Man Made Disasters (London: Wykeham Press, 1978).
39. Turner (1978), op. cit., p. 51.
40. Turner (1976), op. cit., p. 391; P.P. Read, Ablaze: The Story of the Heroes and Victims of Chernobyl (New York, NY: Random House, 1993).
41. Turner (1976), op. cit., p. 391; P.P. Read, Ablaze: The Story of the Heroes and Victims of Chernobyl (New York, NY: Random House, 1993).
42. Perrow (1984), op. cit.; Sagan, op. cit.; Vaughan, op. cit.
43. Perrow (1984), op. cit.; Sagan, op. cit.; Vaughan, op. cit.
44. Perrow (1984), op. cit.; Sagan, op. cit.; Vaughan, op. cit.
45. Roberts (1993), op. cit.
46. See K.E. Weick and K.H. Roberts, "Collective Mind and Organizational Reliability: The Case of Flight Operations on an Aircraft Carrier Deck," Administrative Science Quarterly, 38 (1993): 357-381.
47. K.E. Weick, "The Vulnerable System: An Analysis of the Tenerife Air Disaster," Journal of Management, 16 (1990): 571-593.
48. Ibid.
49. Ibid.
50. Ibid.
51. See, as examples, K.H. Roberts, "Some Aspects of Organizational Culture and Strategies to Manage them in Reliability Enhancing Organizations," Journal of Managerial Issues, 5 (1993): 165-181; R.L. Klein, G.A. Bigley, and K.H. Roberts, "Organization Culture in High Reliability Organizations: An Extension," Human Relations, 48 (1995): 771-793.
52. See, as examples, K.H. Roberts, "Some Aspects of Organizational Culture and Strategies to Manage them in Reliability Enhancing Organizations," Journal of Managerial Issues, 5 (1993): 165-181; R.L. Klein, G.A. Bigley, and K.H. Roberts, "Organization Culture in High Reliability Organizations: An Extension," Human Relations, 48 (1995): 771-793.
53. M.R. Grabowski and K.H. Roberts, "Human and Organizational Error in Large Scale Systems," IEEE Transactions on Systems, Man and Cybernetics, 26/1 (1996): 1-16.
54. Weick, op. cit., p.24.
55. Ibid., p.32.
56. D. Miller, "The Architecture of Simplicity," Academy of Management Review, 18 (1993): 116-138.
57. See, for example, S.E. Bleeker, "The Virtual Organization," The Futurist, 28 (March/April 1994): 9-14; T. Peters, Thriving on Chaos (New York, NY: Knopf, 1987).
58. See, for example, S.E. Bleeker, "The Virtual Organization," The Futurist, 28 (March/April 1994): 9-14; T. Peters, Thriving on Chaos (New York, NY: Knopf, 1987).