Organizational culture as a source of high reliability.
As organizations and their technologies have become more complex, they have also become susceptible to accidents that result from unforeseen consequences of misunderstood interventions. Organizations in which reliability is a more pressing issue than efficiency often have unique problems in learning and understanding, which, if unresolved, affect their performance adversely. One unique problem is that a major learning strategy, trial and error, is not available to them because errors cannot be contained. Because of this limitation, systems potentially know least about those very events that can be most damaging because they can propagate widely and rapidly. The article explores an unconventional means by which organizations achieve error-free performance despite limited use of trial and error. If the issue of accidents is posed this way, then there should be fewer accidents when there is a better match between system complexity and human complexity. Substitutes for trial and error come in the form of imagination, vicarious experiences, stories, simulations and other symbolic representations of technology and its effects.