The Industrial Revolution has powered most of the world’s successful economies for the past three hundred years. So it’s only natural that the management paradigms from high-volume, low-error manufacturing have come to dominate business organizational practices. In a manufacturing environment, you are trying to eliminate variation, and most management approaches have been designed with this in mind. It really is a sign of excellence when a company manages to produce a million doses of penicillin or ten thousand identical automobiles with no errors.

I’d go so far as to say that insisting on high standards without psychological safety is a recipe for failure—and not the good kind. People are more likely to mess up (even for things they know how to do well) when they’re stressed. Similarly, when you have a question about how to do something but don’t feel able to ask someone, you’re at risk of running headlong into a basic failure. Also, when people encounter intelligent failures, they need to feel safe enough to tell other people about them. These useful failures are no longer “intelligent” when they happen a second time.

The problem with Perrow’s idea that organizations could not safely function with interactive complexity and tight coupling was that so many such organizations did in fact function without mishap for years, even decades. Nuclear power plants operated without incident nearly all the time. So did air traffic control systems, nuclear aircraft carriers, and a host of other inherently risky operations. A small group of researchers led by Karlene Roberts at the University of California, Berkeley, set out to study how they did it. What they discovered was more behavioral than technical. The term high reliability organization, or HRO, captures the essence of the theory. HROs are reliably safe because of how they make everyone in them feel accountable to one another for practices that consistently catch and correct

deviations to prevent major harm. Vigilance is one word for it. But it’s more than that. To me the most interesting part of HRO research is the observation that rather than downplaying failure, people in HROs are obsessed with failure. My colleagues Karl Weick, Kathie Sutcliffe, and David Obstfeld wrote a seminal paper highlighting the culture of HROs as preoccupied with failure, reluctant to simplify, acutely sensitive to ongoing operations (quick to detect subtle unexpected changes), committed to resilience (catching and correcting error,

rather than expecting error-free operations), and valuing expertise over rank. In other words, HROs are weird places. Rather than holding back to see what the boss is thinking, people there don’t hesitate to speak up immediately. A frontline associate, to avert a crisis, can tell the CEO what to do. Failure is clearly seen as an ever-present risk that can nonetheless be consistently averted.

Boston University professor Anita Tucker and I studied nurses carrying out the dozens of tasks that occupied them throughout long hospital shifts. Taking detailed notes, complete with time stamps, to document the work of these dedicated caregivers at nine hospitals, Anita observed that nurses confronted “process failures” surprisingly often—almost one an hour. A process failure was anything that disrupted a nurse’s ability to complete a task, such as an unexpected supply shortage in bed linens or medications. The nurses were acutely aware of these frustrating daily hurdles. Their jobs were hard enough! On average nurses were working an extra (unpaid) forty-five minutes simply to tie up loose ends before leaving the hospital.

What Wiseman noticed that day can be seen as a vital element of TPS: a deeply ingrained belief that problem-solving is a team sport. Failures are opportunities for improvement. Competent professionals are expected to successfully execute most of their tasks, so successes are not seen as worthy of colleagues’ valuable time. Hence the “puzzled” look on Mr. Cho’s face. Puzzlement occurred because an expected behavior (share your problems so we can work on them together) didn’t happen, while an unexpected one (bragging) did. What I love most about this story is that Wiseman’s boasting would not have raised an eyebrow in 99 percent of work environments I’ve studied. We are socialized to share accomplishments and good news in front of the boss. Nothing puzzling about it! The most impressive result of TPS in my view is that the system normalizes failure—bad news, requests for help, and problems alike. It creates a community of scientists. Not incidentally, the essence of failing well is thinking like a scientist.