Photo courtesy of Drake Goodman via Flickr.

Photo courtesy of Drake Goodman via Flickr.

I’ve become a great student of “high reliability systems” over the past couple of years.  That is, systems that are designed to minimize the probability of failure to the absolute lowest possible level and that feature repeatable procedures so that success can be replicated.  The commercial airline system is a great example of a high reliability system.  In spite of incredible complexity, large volume of traffic, fallible flying machines, and the ever present specter of human error – commercial flights are, statistically, an incredibly safe way to travel.

In the wake of the terrible recent Asiana Airlines crash in San Francisco, where remarkably most passengers survived, I’ve observed another aspect of this high reliability system at work.  Whenever a crash or an “incident” occurs, the FAA and the NTSB step in and do a detailed analysis of the accident to determine the cause or error, publish those results, and consider what changes to the entire system might be implemented to prevent such instances from occurring in the future.

Recently, my leadership team with Eagle County Schools conducted a similar exercise, considering both recent and historical organizational failures. Also considered were the possible causes of these organizational “crashes.”  In many cases, the causes were multiple, fed and built off each other, or cascaded when early warning signs weren’t noticed or were ignored.

Going forward, we will work to develop some organizational and behavioral protocols for our leadership team to prevent such occurrences in the future.  The following are an early list of where we are headed:

  • Make complex decisions in teams.
  • Always consult available empirical data before making a key decision.
  • Consider micro and macro political considerations to actions.  What coalitions will form in favor, and against, what we are trying to do?
  • Understand adaptive versus technical change and treat them accordingly (see Heifetz & Linsky).
  • The way actions look and are perceived matters.
  • In adversarial situations, act with productive paranoia (see Collins and Hansen).

This was a valuable frame to consider our organization through.  We easily could have spent hours vetting recent and historical “crashes,” determining possible causes, and prescribing organizational solutions.  I’d encourage giving it a try in your school, district, or organization.  Let me know how things turn out!