Table 1 High reliability design in different organizational stages.

Local stage	Control stage	Open stage	Deep stage
Challenges to reliability within stage
Local variability and reinventing the wheelDenial/avoidance of vulnerability (“iron man” mentality; “shame and blame” approach to correction)Difficulty cooperating across boundaries	Tension between standardizing and innovatingComplacencyKnowledge in the rules v expertsCompetition driving down profit margins	Costs of experimentation: (performance declines while trying new things)Maintaining controls while learning new thingsUneven rates of progress regarding openness leading to culture wars	Complex interdependenciesLure of a quick fix pushes out fundamental improvements/changeMaintaining slack resources under cost pressures
Selected design elements for reliability within stage
SpecializeImproviseInnovateRevere expertise and craft knowledgeApprenticeships and mentoring	StandardizeFormalize rulesCentralizeRedundancyRisk analysis and planningTraining	Heedful inter‐relatingCross‐functional, cross‐hierarchy communicationMutual respectBenchmark	Reflection skillsSystems thinkingRoot cause analysisTolerate “worse‐before‐better” pattern of process improvementMaintain safety resources as safety improves