The functioning of highly reliable organizations depends on an understand ing of the decision making process, particularly in terms of the cognitive biases and shortcuts that affect decision makers. Although decision makers' choices are usually satisfactory in highly reliable organizations, flawed decision making in such organizations can lead to catastrophe. We illustrate some cognitive biases and their potential for creating error by references to decision situations in one highly reliable organization, an aircraft carrier. We then show how the Navy often avoids errors successfully, and suggest improvements at the inter face of the organization and the decision maker.
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