82 4: Public Institutional Th eory
air traffi c controllers; local airport managers; commercial airline companies, in-
cluding pilots, fl ight attendants, and so forth; and airline manufacturers, airline
maintenance companies, and fuel suppliers.
Seventh, these systems are composed of a marvelous mix of governmen-
tal, nongovernmental, and commercial organizations, the very defi nition of
high-functioning public-private partnerships.
Eighth, when the systems are working properly, error reporting is encouraged
and not punished. Indeed, initiatives to identify fl aws in procedures and proto-
cols and thereby avoid failure are rewarded.
Ninth, ordinarily such systems are rather hierarchical, both within the system
and within the organization making up the system. But at times of peak load and
emergencies, one fi nds rule switching by which offi cials move away from hierar-
chy and procedures to seek the expertise or experience that might account for or
explain an anomaly and suggest possible nonroutine solutions. One thinks again
of the Apollo 13 space mission (LaPorte and Consolini 1991).
Th ese failure-free systems reveal how remarkably eff ective modern public and
private organizations can be if they have adequate resources and are well man-
aged. To be sure, failure-free systems are the subject of intense public scrutiny
because of the visibility of failures, however rare.
Th ere will be failures, and there will be accidents. Simple probability demon-
strates that this is so (Perrow 1999). But every day we all enjoy the modern mir-
acles of high-reliability systems. And, interestingly, when they fail, it is usually
because of human fallibility.
It is diffi cult to imagine modern life without high-reliability systems. When
they work perfectly, nothing appears to happen; in fact, everything happens
properly.
Low-Reliability Systems and Th eir Improvement
As envisioned by LaPorte, high-reliability systems are quite rare (Bourrier 2011).
Most systems or organizations simply do not exist in an environment where fail-
ure results in total catastrophe. As a result, trial and error is not only acceptable,
but is also perhaps the best way to cope with potential risk (Wildavsky 1988). It
is easy to understand how an unwillingness to take risks can paralyze an organi-
zation. Th e result is the paradox that in order to seek safety or improved eff ec-
tiveness, an organization must accept a certain level of risk—it must tolerate at
least some danger or mistakes. Th e trial and error process is needed because of
the inability to rationally make decisions in the face of limited information, time
constraints, and insuffi cient monetary and personnel resources. Consequently,
the literature surrounding this has given us familiar concepts of decisionmaking,
such as “muddling through” (Lindblom 1959, 1979) and incrementalism (Wil-
davsky 1984). Owing to the fact that most of our organizations and systems are
not high reliability, the literature has tended to focus on agencies and systems