Managing the Unexpected: Sustained Performance in a Complex World, 3rd Edition

Chapter 5Principle 3: Sensitivity to Operations

“The actions made sense at the time.”¹

—Richard I. Cook and David D. Woods

The realities of unlimited interdependence get linked to limited concepts in real-time operations. These linkages do not occur simply at the bottom of the organizational pyramid, which we often call the front line. Instead, the front line we worry about, and that high reliability organizations (HROs) worry about, is located at all levels. Here are five examples of frontline operations:

1. During surgery, as unexpected bleeding occurs, the chief surgeon says to the rattled resident, “When there is bleeding put your finger on it; don't waste time hunting for the cauterizing instrument while the bleeding continues and the ...