# Working in Practice But Not in Theory: Theoretical Challenges of "High-Reliability Organizations"

*La Porte · Safety & Error, Complexity & Systems · Journal of Public Administration Research and Theory · 1991 · Open access*

The paper that named and set the agenda for the high reliability organizations (HRO) research programme, and the standing counterweight to Perrow's normal accident theory (already in this corpus). Drawing on the Berkeley group's field research inside three organisations held to a failure-free standard — the FAA's air traffic control system, US Navy nuclear aircraft carrier flight operations, and Pacific Gas and Electric's grid including Diablo Canyon — La Porte and Consolini pose the puzzle their title captures: some organisations running highly hazardous, tightly coupled, interactively complex technologies achieve reliability far higher than organisation theory says should be possible, and they do it precisely because trial-and-error learning is foreclosed to them, since the cost of a major failure exceeds the value of any lesson it would teach. The paper's distinctive contribution is not a claim that these systems are safe by luck but a structural account of how they are made reliable, organised around three theoretical surprises. First, decision-making: HROs cannot rely on the incremental, learn-by-doing model that dominates organisation theory, because some errors are too punishing to be allowed even once; instead they run a hybrid of calculative, SOP-bound routine and judgemental, professional improvisation, extending programmed decision as far as knowledge allows while staying alert to the surprises that can cascade into system failure. Second, and most influentially, authority migrates with tempo: the same personnel move fluidly between a routine bureaucratic mode (hierarchical, rank-based, feedback-suppressing), a high-tempo mode in which formal rank defers to functional skill and a lower-ranking specialist can direct a superior, and a scripted emergency mode of preprogrammed collegial response. This nested, tempo-dependent authority structure — in which hierarchy is real but suspends itself under load so that the person closest to the problem decides — is the paper's most cited idea and a direct empirical anchor for later work on speaking up, deference to expertise over rank, and the sharp end. Third, the authors show that the existing literatures on interdependence, networks, and structural complexity cannot yet describe what they observed, and decline to force a resolution, presenting the HRO phenomena as anomalous data rather than a finished theory. The four HRO conditions later distilled by others — leadership prioritisation of safety, redundancy, a decentralised culture of reliability, and continuous training — trace substantially to this work and its companion Berkeley studies. Read against Perrow, it frames the central dispute in safety science: whether human agency (culture, design, training, migrating authority) can compensate for the structural pressures of complexity and tight coupling, or whether serious accidents remain, in Perrow's sense, normal.

- **This page:** https://explore.psychsafety.com/n/laporte-consolini-1991/
- **View the source paper:** https://polisci.berkeley.edu/sites/default/files/people/u3825/LaPorte-WorkinginPracticebutNotinTheory.pdf
- **Interactive map:** https://explore.psychsafety.com/?mode=papers&node=laporte-consolini-1991

## Connected concepts (14)

- [Behind Human Error: Cognitive Systems, Computers, and Hindsight](https://explore.psychsafety.com/n/woods-et-al-1994.md) (paper)
- [Normal Accidents: Living with High-Risk Technologies](https://explore.psychsafety.com/n/perrow-1984.md) (paper)
- [Organizing for High Reliability: Processes of Collective Mindfulness](https://explore.psychsafety.com/n/weick-sutcliffe-obstfeld-1999.md) (paper)
- [Human Error: Models and Management](https://explore.psychsafety.com/n/reason-2000.md) (paper)
- [Collective Mind in Organizations: Heedful Interrelating on Flight Decks](https://explore.psychsafety.com/n/weick-roberts-1993.md) (paper)
- [Efficiency vs Resilience](https://explore.psychsafety.com/n/efficiency-vs-resilience.md)
- [Lessons from Everest: The Interaction of Cognitive Bias, Psychological Safety, and System Complexity](https://explore.psychsafety.com/n/roberto-2002.md) (paper)
- [Variation in Hospital Mortality Associated with Inpatient Surgery](https://explore.psychsafety.com/n/ghaferi-birkmeyer-dimick-2009.md) (paper)
- [Normal Accidents](https://explore.psychsafety.com/n/normal-accidents.md)
- [Redundancy, Layoffs & PS](https://explore.psychsafety.com/n/psychological-safety-redundancy-and-layoffs.md)
- [Resilience Engineering](https://explore.psychsafety.com/n/psychological-safety-resilience-engineering.md)
- [Safety I & Safety II](https://explore.psychsafety.com/n/psychological-safety-73-safety-i-safety-ii.md)
- [Sharp & Blunt End](https://explore.psychsafety.com/n/the-sharp-end-blunt-end-of-education.md)
- [WAI vs WAD](https://explore.psychsafety.com/n/psychological-safety-work-as-imagined-vs-work-as-done.md)