‘High Consequence Decision Making’ began as a research project whose aim is to minimise the risk of catastrophic error. HCD draws on a wide range of existing knowledge in order to define and create an organisational culture, management systems, and training programs that can reduce this risk to a minimum.
HCD is founded on the lessons learned from examples of catastrophic decision making that have taken place in the past. These include the 1987 shooting down of Iran Air’s Flight 655 by the USS Vincennes. In response to this incident, the US Navy launched an 8 year research program into ‘Tactical Decision Making Under Stress’ (TADMUS) and developed a system of training to improve the team processes that led to the fateful decision to open fire on a civilian aircraft.
The 1994 friendly fire incident over Iraq, in which two Black Hawks carrying UN VIP’s were shot down in error, is another case rich in lessons for HCD. The Inquiry that followed was unable to pin the blame on any one set of individuals, neither the F-15 or the Black Hawk pilots, the AWACS crew who monitored the event as it unfolded, or the C2 component on the ground. Everyone performed their role in accordance with procedure and their training, the problem lay at a systemic level.
HCD also draws on positive examples, where organisations successfully cope with catastrophic risk on a day to day basis. Examples include air traffic control, nuclear power plants, emergency services, and intensive health care. The initial research into these ‘High Reliability Organisations’ (HRO’s) was done on aircraft carriers, which managed a drastic reduction in their accident rate by introducing a number of guiding principles. These generate a high performing organisational culture in a complex, technical environment where error is not an option.
Drawing on all these various elements, HCD seeks to minimise the possibility of catastrophic error by targeting the following areas –
• DESIRED ORGANISATIONAL CULTURE
• DECISION MAKING & RAPID DECISION MAKING
• TEAM PROCESSES (combat encounter)
• TEAM LEADER ROLE
• ERROR MANAGEMENT
• PROCESS GUARDIAN ROLE
(first written for Facebook in 2014)
for more on the relationship between ‘Avoiding Catastrophe’ and HCD, click here