High reliability organizations
Organizations that run dangerous technology for years without catastrophe, and how they do it.
Todd La Porte, Karlene Roberts, and Gene Rochlin, high reliability organization studies, University of California, Berkeley
1987 to 1988
Karl Weick and Kathleen Sutcliffe, Managing the Unexpected
2001; third edition 2015
The Berkeley research group of Todd La Porte, Karlene Roberts, and Gene Rochlin studied aircraft carrier flight decks, nuclear power plants, and air traffic control between 1987 and 1988, asking why some organizations operating hazardous technology almost never fail. Karl Weick and Kathleen Sutcliffe codified the findings in Managing the Unexpected, first published in 2001.
The finding the canvas uses is deference to expertise: in an anomaly, authority migrates to whoever has the relevant knowledge, regardless of rank, and returns afterward. That is the Deference Ladder, a candidate shape on the patterns page. Fukushima Daiichi in 2011 is the standard counterexample, where efficiency drift normalized weak signals until the reflex was gone.
Who is qualified to overrule the machine, and how would you prove it?
What would you show an auditor, and can the system produce it without being asked?
How does tacit judgment become reusable, and who owns the loop that has to close?