Butler & Gray/Reliability, Mindfulness, & IS
MIS Quarterly Vol. 30 No. 2, pp. 211-224/June 2006 211
ISSUES & OPINIONS
RELIABILITY, MINDFULNESS, AND INFORMATION SYSTEMS1
By: Brian S. Butler
Katz Graduate School of Business
University of Pittsburgh
Pittsburgh, PA 15260
Peter H. Gray
Katz Graduate School of Business
University of Pittsburgh
Pittsburgh, PA 15260
In a world where information technology is both important
and imperfect, organizations and individuals are faced with
the ongoing challenge of determining how to use complex,
fragile systems in dynamic contexts to achieve reliable out-
comes. While reliability is a central concern of information
systems practitioners at many levels, there has been limited
consideration in information systems scholarship of how firms
and individuals create, manage, and use technology to attain
reliability. We propose that examining how individuals and
organizations use information systems to reliably perform
work will increase both the richness and relevance of IS
research. Drawing from studies of individual and organiza-
tional cognition, we examine the concept of mindfulness as a
theoretical foundation for explaining efforts to achieve in-
dividual and organizational reliability in the face of complex
1Ron Weber was the accepting senior editor for this paper. Sid Huff and
Peter Seddon served as reviewers.
technologies and surprising environments. We then consider
a variety of implications of mindfulness theories of reliability
in the form of alternative interpretations of existing knowl-
edge and new directions for inquiry in the areas of IS opera-
tions, design, and management.
Keywords: Mindfulness, reliability, IS operations, IS
management, IS design, resilience
Software crashes. Hardware breaks. Networks become con-
gested. Viruses and worms bring down systems. Data gets
corrupted. Users, for better or worse, use information tech-
nologies in ways designers never imagined. Processes evolve.
Communication flows and coordination links are restructured.
Plans and strategies change, or they remain unchanged long
after the world has moved on. Even when functioning well,
information systems evolve in response to new problems and
environmental changes (Truex et al. 1999). Information
systems are fundamentally complex; system features and their
outcomes are often more emergent than planned (Orlikowski
1996). Despite this complexity, individuals, organizations,
and societies increasingly depend on information systems to
reliably provide core services and capabilities.
The paradox of relying on complex systems composed of
unreliable components for reliable outcomes is rarely
acknowledged in theoretical discussions of IS operations,
design, and management. IS research tends to assume a best-
case scenario regarding reliability of information systems,
focusing on techniques for achieving reliable performance by
building technically reliable information systems from struc-
tured combinations of components. While increasing
technical reliability is desirable, this focus fails to account for
Butler & Gray/Reliability, Mindfulness, & IS
212 MIS Quarterly Vol. 30 No. 2/June 2006
the reality that many important systems are not (and perhaps
cannot be) inherently reliable. Largely unaddressed are ques-
tions about how individuals and organizations achieve reliable
performance when working with unreliable systems. This
may be one reason why the IS literature often has an ethereal
flavor, seeming to be both correct and yet irrelevant to prac-
titioners who must make things work with real technologies,
users, and organizations (Benbasat and Zmud 1999).
Rather than assuming that individual and organizational
reliability are beyond the scope of IS research, the role of
information systems in undermining or realizing reliable
performance should be a central concern (Stewart 2003). We
seek to highlight how organizations achieve reliability when
working with fundamentally complex, fragile, and often
unreliable information systems. Central to our approach is the
premise that individual and organizational reliability arises
from both what work is done and how it is performed. The
preplanned routines that are the focus of most IS design
efforts are necessary, but insufficient, elements of reliable
performance. It is also necessary for systems and processes
to promote individual and collective mindfulness—a way of
working characterized by a focus on the present, attention to
operational detail, willingness to consider alternative per-
spectives, and an interest in investigating and understanding
failures (Langer 1989; Weick and Sutcliffe 2001; Weick et al.
1999). While these principles have been touched upon in the
IS literature, individual and collective mindfulness theories
provide a succinct and compelling lens for viewing key
aspects of reliability. Our goal is to highlight how applying
individual and collective mindfulness concepts in studies of
IS design, management, and use can contribute to the realiza-
tion of reliable work and performance outcomes in
IS Research and Reliability
Organizational reliability has been defined as the “capacity to
produce collective outcomes of a certain minimum quality
repeatedly” (Hannan and Freeman 1984, p. 153). Reliable
performance is not merely the attainment of a desired out-
come level, but also the ability to control variance in out-
comes (Deming 1982). Achieving reliable business perfor-
mance is a focus of many popular management programs
(e.g., Six Sigma, ISO 9000), which incorporate an underlying
rationale of cost control and customer satisfaction through
elimination of unwanted variance in attributes of products and
As businesses depend increasingly on information systems, it
becomes important that they be designed, used, and managed
to contribute to reliable aggregate performance—in spite of
imperfect technology (Sipior and Ward 1998), uncontrollable
user behaviors (Orlikowski 1996), and dynamic environments
(Mendelson and Pillai 1998). Although the role of information
systems in achieving organizational reliability has not been a
major theme in prior IS research,2 scholars have recognized
that technical reliability is a factor in successful systems and
have discussed techniques for enhancing the reliability of
information systems and services. Models of information
system quality, success, and IS service quality (e.g., DeLone
and McLean 1992, 2003; Jiang et al. 2002) have assessed
system reliability by measuring users’ perceptions of system
dependability—often with a single survey item—and have
demonstrated its association with outcomes such as user
satisfaction or use behavior. Conceptually, these studies
characterize system reliability as a desirable “good,” the
nature, source, and consequences of which are typically
unspecified. Consistent with this approach, Broadbent and
Weill (1999) include reliability as a feature of an effective IT
infrastructure, while leaving its antecedents unexamined.
In other work, IS scholars have examined the nature of
information system reliability problems. A first perspective
treats a lack of IS reliability as an agency problem. Software
errors (Austin 2001), data quality problems (Ba et al. 2001),
and system failures (Abdel-Hamid 1999) happen because IS
personnel focus on objectives other than reliability. From this
perspective, the solution is to realign incentive structures,
encouraging individuals to focus on creating reliable systems
(Ravichandran and Rai 1999). However, these studies have
little to say about what individuals or organizations actually
do differently to achieve this reliability.
Other work focuses on the application of structured routines
to reduce uncertainty and increase system quality (De and
Hsu 1986; Hardgrave et al. 2003). For stable environments
and technologies, structured designs and routine-driven
approaches can significantly improve system reliability (Kydd
1989). However, in the face of dynamic environments and
evolving systems, managers and developers often must adapt
or abandon structured approaches, thereby reducing (or elim-
inating) their reliability-related benefits. Some authors
advocate the use of more responsive development methods,
such as short-cycle development processes and shorter-term
2We found only 32 articles that dealt directly or indirectly with issues of
reliability when we manually examined articles published in MIS Quarterly,
Information Systems Research, and Journal of Management Information
Systems for the period 1999 through 2003 and searched the titles, abstracts,
and keywords of articles in these journals back to journal inception (or 1980,
in the case of MIS Quarterly), using the terms reliability, consistency,
unreliable, failure, inconsistency, resilience, error, trustworthy, untrust-
worthy, continuity, flexibility, and adaptiveness.
Butler & Gray/Reliability, Mindfulness, & IS
MIS Quarterly Vol. 30 No. 2/June 2006 213
Emergent systems composed of
Emergent systems composed of
Figure 1. Foundations of Information Systems Reliability
goals (e.g., Truex et al. 1999; van der Zee and de Jong 1999).
These approaches rely on faster problem detection and mid-
course adjustment of development trajectories to reduce
technological flaws and improve alignment of system and
organizational goals. Other scholars emphasize procedure s for
gathering and using information during development. They
suggest that reliable execution of IS development activities is
enhanced by intentionally seeking out conflicting information
(Salaway 1987), considering a wider range of ideas (Peffers
et al. 2003), and using risk-management techniques that shape
and direct managers’ attention (Lyytinen et al. 1998).
While existing work contributes to our understanding of
information system reliability, it leaves largely unexamined
questions of how system reliability translates into reliable
organizational performance. Although some have argued that
perfectly reliable information systems may actually hinder an
organization’s ability to perform reliably in dynamic environ-
ments (Hedberg and Jonson 1978), it is likely that reliable
systems will typically improve individuals’ and organizations’
ability to perform work reliably. However, analytic modeling
and anecdotal evidence suggests that it is not feasible to
expect development methods and operational procedures to
result in flawless information systems (Olson 2003; Westland
2000). Therefore, important questions remain about how
systems should be designed and used if individuals and
organizations are to achieve reliable performance in spite of
Beyond technical flaws, research highlighting the complex
interplay of practices, processes, and structures surrounding
information systems suggests that even technically reliable
systems may not result in consistent organizational outcomes.
Information technologies are interpreted differently by
various parties (Bloomfield and Coombs 1992; Gopal and
Prasad 2000), and applied differently across contexts. Their
appearance triggers change within organizations (Griffith
1999) which factors into the ongoing emergence of individ-
uals’ work practices and organizations’ structures (Orlikowski
and Barley 2001). This research underscores the interplay of
technology, potentially idiosyncratic behaviors, and context
(Orlikowski 1996), suggesting that even when based on the
best technology, information systems can introduce signifi-
cant complexity and variation. Thus, the challenge remains
for IS researchers to provide theories and models that help
organizations and individuals design, manage, and use infor-
mation systems to achieve reliable work from complex,
fragile systems composed of unreliable components.
Achieving Reliable Performance
Studies of human systems reveal two strategies for achieving
reliable performance: routine-based reliability and mindful-
ness-based reliability (Figure 1).
Management and IS research has typically focused on one of
these strategies at a time, ignoring their interdependence and
synergistic impacts. We review each approach below, and
identify their individual and cumulative benefits in achieving
reliability in the face of dynamic complexity.
A routine is a “relatively complex pattern of behavior…
functioning as a recognizable unit in a relatively automatic
fashion” (Winter 1986, p. 165). An activity is routinized
when a certain stimulus produces a fixed response that
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214 MIS Quarterly Vol. 30 No. 2/June 2006
involves a predefined pattern of choice from an established
set of options without searching for new possibilities (March
and Simon 1958). Routine-based reliability posits that
reliable performance can be achieved efficiently by creating
repeatable packages of decision rules and associated actions.
For individuals, this involves learning steps to be taken, often
to the point where executing the routine becomes automatic
(Langer and Piper 1987; Langer and Weinman 1981).
Organizationally, routine-based reliability involves the
creation and execution of standard operating and decision-
making procedures, which may be unique to the organization
or widely accepted across an industry (Spender 1989). One
goal of identifying and institutionalizing “best practices” is to
reduce variation in outcomes. At both the individual and
organizational levels, routines are powerful tools for
efficiently increasing outcome reliability.
Routine-based reliability is commonly advocated in the IS
literature. Processes are often automated by embedding them
in computer systems in order to increase both reliability and
efficiency (Zuboff 1988). Software is a codification of human
knowledge (Conceição et al. 1998), and information systems
users are implicitly expected to defer to the technology,
allowing the embedded routines and standards to determine
what should be done next. The idea that standardizing
processes, automating routines, and embedding procedures in
information systems is the optimal strategy for reducing errors
and improving reliability is so well accepted that it is stated
as fact in many systems analysis and design texts (e.g.,
Dennis and Wixom 2003) and practitioner publications (e.g.,
Routine-based approaches to reliability are fundamentally
Taylorist (Morgan 1986). They posit that individual and
organizational reliability is best achieved by front-loading
human cognition. Procedures and processes are designed in
advance, usually by managers or analysts, and applied in the
moment by operators. Information systems are created and
training programs are prepared to lead users step-by-step
through the proper routine. Procedures, routines, training, and
systems are designed to decrease the need for creative human
involvement in the moment, in an effort to reduce errors,
unwanted variation, and waste.
While routines are important tools for creating reliable
performance, they are not without limitations. Routine-based
approaches depend on a match between situation and
response. Ideally, each stimulus triggers an appropriate
routine. However, there is evidence that both individual and
organizational perceptions are shaped by the routines and
systems that are in place (Langer 1989). Routines, plans, and
systems predispose us to see situations in particular ways.
Individuals and organizations are significantly less likely to
detect stimuli for which they are unprepared (Clarke 1993).
When faced with variation and complexity, such mispercep-
tions reduce individual and organization reliability. The
assumption that perception triggers appropriate responses
ignores the possibility that pre-learned responses can them-
selves color perception.
Moreover, routines achieve their purpose primarily when they
are reproduced faithfully and appropriately. It remains
unclear what happens when routines and systems are them-
selves emergent and composed of imperfect, evolving com-
ponents. Does process automation result in more reliable
outcomes when handling exceptions is a central part of the
process (Kraut et al. 1999)? How does formal training and
control interact with the processes by which work and system
use practices emerge (Galletta et al. 1995)? Routine-based
reliability implicitly assumes that systems and routines are
themselves rationally constructed, stable, repeatable, and
reliable. If this is untrue, as suggested by recent studies of
organizational rules, processes, and systems (Feldman and
Pentland 2003; March et al. 2000; Orlikowski 2000;
Repenning and Sterman 2002), rather than solving the
reliability problem, routines may aggravate it by adding
greater complexity and more unreliable components.
While routine-based approaches focus on reducing or
eliminating situated human cognition as the cause of errors,
mindfulness-based approaches focus on promoting highly
situated human cognition as the solution to individual and
organizational reliability problems (Weick and Sutcliffe
2001). A mindful response “to a particular situation is not an
attempt to make the best choice from among available options
but to create options” (Langer 1997, p. 114). Mindfulness-
based approaches hold that individuals’ and organizations’
ability to achieve reliable performance in changing environ-
ments depends on how they think: how they gather informa-
tion, how they perceive the world around them, and whether
they are able to change their perspective to reflect the situa-
tion at hand (Langer 1989). From this perspective, routines
are a double-edged sword. They are helpful when they pro-
vide options, but detrimental when they hinder detection of
changes in the task or environment. Whether describing
individuals or organizations, mindfulness-based approaches
posit that—more than just consistency of action—properly
situated cognition is ultimately the basis for reliable
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MIS Quarterly Vol. 30 No. 2/June 2006 215
At an individual level, mindfulness focuses on the ability to
continuously create and use new categories in perception and
interpretation of the world (Langer 1997, p. 4). In contrast,
mindless behavior involves routine use of preexisting catego-
rization schemes. Mindlessness is a state of reduced attention
resulting from premature commitment to beliefs that may not
accurately reflect the phenomena at hand (e.g., Chanowitz and
Langer 1980). It tends to lead to “mechanically employing
cognitively and emotionally rigid, rule-ba sed behaviors” (Fiol
and O’Connor 2003, p. 58).
For individuals, mindfulness involves (1) openness to novelty,
(2) alertness to dis tinction, (3) sensitivity to different contexts,
(4) awareness of multiple perspectives, and (5) orientation in
the present (Sternberg 2000 quoting from Langer 1997).
Sternberg (2000) describes these constituent parts of a mind-
ful cognitive style as being based on certain abilities. Open-
ness to novelty is the ability to reason about new kinds of
stimuli. Alertness to distinction involves an ability to com-
pare, contrast, and make judgments about how things are the
same or different. This is particularly important when indi-
viduals must define the nature of a problem they are facing;
greater alertness to distinction reduces the chances that one
will misdefine, or misdiagnose, a problem. Sensitivity to
context is an awareness of the characteristics of whatever
particular situation an individual faces, which is a precursor
to being able to notice when situational characteristics
change. People who are aware of multiple perspectives can
engage in dialectical thinking—that is, to see things from
different or opposing points of view. Finally, individuals who
are oriented to the present devote more of their attention to
their immediate situation (as opposed to contemplating future
possibilities or recalling past events). Together, these may go
beyond a set of capabilities or cognitive styles. Instead,
mindfulness may be “considered a disposition because it has
to do with how disposed people are to process information in
an alert, flexible way” (Perkins et al. 1993, p. 75).
While there are certainly dispositional aspects to mindfulness,
mindful cognition and behavior are also context-dependent
and can be promoted or inhibited in a variety of ways. The
composition of the immediate social context, a person’s back-
ground, ability, and relationships with others, and the nature
of available information all contribute in subtle ways to the
likelihood of mindful thinking. Some theorized antecedents
of individual mindfulness, such as thinking critically about
how things can be and are done (i.e., adopting a process
orientation; Langer 1989, p. 34) or being an outsider in a
group or organization (Langer 1989, p. 160), are consistent
with techniques that are central to information systems design,
development, and management. Other approaches to en-
hancing mindfulness, such as presentation of information as
conditional, models as nondeterministic, and data as highly
contextualized (Langer et al. 1989), or avoiding a strong goal
or outcome focus (Langer 1989, p. 34) present greater chal-
lenges for IS professionals. In the extreme, mindfulness
theory suggests that some staples of information systems
design, such as the transfer of routines between contexts, the
use of highly specific instructions, and the assumption that
information gathering necessarily leads to greater certainty,
can hinder mindfulness with significant detrimental
Individuals who are mindfully engaged in a task are both
motivated and able to explore a wider variety of perspectives.
They can also make more relevant and precise distinctions
about phenomena in their environments, enabling them to
adapt to shifts in those environments (Fiol and O’Connor
2003, p. 59). Individuals who mindfully process information
are more likely to be willing and able to apply it in new ways
and in alternative contexts (Chanowitz and Langer 1980;
Langer 1989). Because such individuals are more likely to
consider different perspectives (Langer et al. 1975), they are
apt to create innovative solutions to problems and alter their
actions to take advantage of changing environments (Langer
1989, pp. 199-201).
In contrast, individuals who focus on one perspective and a
single way of doing things are likely to encounter a variety of
problems. Mindless acceptance of information or data gives
rise to a perception of certainty that can create premature
commitment to a solution (Langer and Piper 1987). Mindless
learning of a routine in an effort to increase short-term effi-
ciency often comes at the expense of adaptability. This can
lead to overlearning, a condition in which individuals lose the
ability to critically evaluate, explain, and adapt their behavior
(Langer 1989, p. 20-21; Langer and Weinman 1981).
Mindless adoption of a role or routine can also undermine an
individual’s perception of self-confidence and competence in
dynamic contexts (Langer and Benevento 1978). This sug-
gests that efforts to promote IS use through the development
of routine or habit (Limayem et al. 2003) should be under-
taken with an awareness that this type of behavior may have
unexpected detrimental consequences.
Collective mindfulness is to individual mindfulness as
organizational learning is to individual learning: a theoretical
elaboration of cognitive concepts at the level of an organi-
zational entity. Drawing on studies of high-reliability organi-
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216 MIS Quarterly Vol. 30 No. 2/June 2006
zations and the individual mindfulness literature, researchers
have recently begun to develop the idea of mindfulness at
macro-levels of analysis, such as business unit, work group,
and organizations. Collective mindfulness3 is
a combination of ongoing scrutiny of existing expec-
tations, continuous refinement and differentiation of
expectations based on newer experiences, willing-
ness and capability to invent new expectations that
make sense of unprecedented events, a more
nuanced appreciation of context and ways to deal
with it, and identification of new dimensions of con-
text that improve foresight and current functioning
(Weick and Sutcliffe 2001, p. 42).
Like individual mindfulness, organizational mindfulness
focuses on an organization’s ability to perceive cues, interpret
them, and respond appropriately. Extreme examples of
collectively mindful organizations include hospitals that pro-
vide life-and-death services under tight resource constraints
(Kohn et al. 1999) and aircraft carriers that must coordinate
fuel, personnel, and explosives in complex, hostile environ-
ments (Weick and Roberts 1993). However, performance in
organizations as mundane as community swimming pools
(Knight 2004) and restaurants (Rose 2004) also relies on the
ability to remain collectively mindful.
Theorists specifically interested in organizational reliability
have highlighted (1) preoccupation with failure, (2) reluctance
to simplify, (3) attention to operations, (4) focus on resilience,
and (5) the migration of decisions to expertise as key aspects
of organizational mindfulness (Weick and Sutcliffe 2001;
Weick et al. 1999). A preoccupation with failure focuses the
organization on converting errors and failures into grounds for
improvement, often by treating all failures and near-failures
as indicators of the health of the overall system. For example,
aircraft carrier personnel are encouraged to report even small
problems, and significant organizational effort is expended to
review both failures and near misses (Weick and Sutcliffe
2001). Focusing on errors and failures helps avoid the over-
confidence, complacency, and inattention that can result when
employees believe success has become commonplace and
routine. Reluctance to simplify refers to a collective desire to
continually see problems from different perspectives. This
increases the organization’s chances of noticing and reacting
appropriately to small anomalies and errors and reduces the
likelihood of larger, disastrous failures. Sensitivity to
operations implies that some individuals in an organization
have developed an integrated overall picture of operations in
the moment. For example, studies of nuclear weapons sug-
gest that many problems arise not from a single failure, but
when small deviations in different operational areas combine
to create conditions that were never imagined in the plans and
designs (Sagan 1993). In these cases, considering general
polices and plans (i.e., what should be done) can mask
potential problems, while attending to the true nature of the
firm’s operations (i.e., what is actually done) improves the
likelihood that small errors can be detected before they
interact to produce large failures. A commitment to resilience
refers to a tendency to cope with dangers and problems as
they arise—through error detection and error containment—
and exists in contrast to a commitment to anticipation, which
focuses on planning. Weick et al. (1999) describe the fifth
and final component of collective mindfulness as the
migration of decisions to expertise resulting from the under-
specification of structures. This departure from hierarchical
decision structures permits problems to migrate to the experts
most capable of solving them. Collective mindfulness is asso-
ciated with cultures and structures that promote open discus-
sion of errors and mistakes (Weick and Roberts 1993) and
cross-job training and awareness (Hutchins 1995). It increases
organizations’ ability to achieve reliable performance in
dynamic, unstable environments (Weick et al. 1999).
Collective mindfulness is not simply the result of having
individually mindful personnel. In general, mindfulness
involves the ability to detect important aspects of the context
and take timely, appropriate action. However, more so than
with individuals, in organizations the processes of perception
are often separate from the processes of action. Front-line
employees are often most knowledgeable about the true state
of the organization’s systems and capabilities. For example,
sales people who interact regularly with customers are often
most aware of shifting needs and demand. Yet, these indi-
viduals rarely are capable of fundamentally changing the
direction or priorities of the organization. Collective mind-
fulness requires organizations to couple the ability to quickly
detect issues, problems, or opportunities with the power to
make organizationally significant decisions. This may be
accomplished by moving decision-making authority (Weick
and Roberts 1993; Weick et al. 1999), taking steps to increase
top management’s ability to perceive the important signals, or
creating an organizational environment that enables the
smooth interaction of perception and action (Grove 1996).
Regardless, achieving organizational mindfulness ultimately
relates as much to the distribution of decision-making rights
(i.e., power) as it does to the capabilities of any particular
3Although the following discussion refers primarily to organizations,
collective mindfulness can be a characteristic of any organizational unit or
Butler & Gray/Reliability, Mindfulness, & IS
MIS Quarterly Vol. 30 No. 2/June 2006 217
The concept of mindfulness offers a theoretical basis for
resolving the IS reliability dilemma. It provides a possible
basis for answering questions about how individuals and
organizations can hope to efficiently create information
systems, processes, and practices out of complex, fragile,
uncertain components in order to achieve reliable results.
How can organizational reliability be achieved in complex
environments by adding additional unreliable components?
If information systems and work practices are really the result
of emergent social processes involving negotiation of multiple
interests, why do formal systems development methodologies
based on structured design principles have any beneficial
effect? Mindfulness theories suggest the answer to these
questions lies in characteristics of the perspectives and work
practices that the systems and methodologies promote.
Whether intentional or not, methods, models, and systems that
encourage individuals and organizations to engage their work
mindfully are likely to result in more reliable outcomes.
Implications for Information Systems
Research and Practice
The assertion that reliable performance depends on both
routines and mindful behavior is of considerable importance
to many areas of IS research. In this section, we identify
several reliability-related issues within IS operations, manage-
ment, and design, and consider how individual and collective
mindfulness can be applied to both reinterpret existing
knowledge and provide a foundation for future studies that
engage this increasingly important problem.
Information Systems Operations
One managerial implication of collective mindfulness theory
is that reliable performance arises not from abstract plans or
strategies but rather from an ongoing focus on operations
(Weick and Sutcliffe 2001). If organizations are to achieve
reliable outcomes from real systems, it is paramount that they
have ways of organizing and managing IS operations. Yet,
aspects of IS operations are rarely considered in the IS
literature. When they are considered, the approaches taken
are largely atheoretical. Over the past three decades, far more
attention has been given to development of IS strategic plans
(Hartono et al. 2003) than to understanding the challenges of
IS operations. Individual and collective mindfulness provides
a foundation that both justifies and grounds research in IS
Structuring Information Systems Operations
to Handle Normal Accidents
How can (and should) the IS function be structured to provide
reliable systems and services? While some research focuses
on users’ evaluation of the IS function (e.g., Pitt et al. 1995),
there is little work, either normative or empirical, related to
the work practices, structures, or personnel arrangements that
make reliable IS operations possible. Given the extensive
body of research about system development teams, it is sur-
prising that no comparable body of work examines how firms
organize (or how they should organize) the operational
aspects of the IS function. For example, some organizations
create specialized units tasked with rapidly addressing system
failures—that is, to improve the reliability of fundamentally
unreliable technologies. These groups are already prevalent
in industries such as banking and utilities that have cultural
and regulatory emphases on reliability, and they are in-
creasingly common in other industries. Anecdotal evidence
suggests that response teams can differ widely in terms of
effectiveness, cost, and their ability to learn over time. Some
firms staff response groups with experienced IS professionals
able to repair failed systems themselves, while others assign
this role to teams of relative novices who focus on marshal-
ling the resources and knowledge necessary to address
failures as they arise. Other organizations take a different
approach to managing the “normal accidents” (Perrow 1984)
that occur when working with complex information systems.
Instead of creating specialized units, they handle system
failures through ad hoc mobilization of IS personnel.
Between specialized response teams and pure ad hoc crisis
resolution are a range of structures and practices for managing
day-to-day fire-fighting, failures, and catastrophes that arise
when working with complex information systems in dynamic
organizational settings. Organizational mindfulness theory
implies that, far from being incidental, it is these structures,
roles, and practices that underlie a firm’s ability to make
effective use of information technologies. However, the
existence of specialized crisis response groups presents an
interesting theoretical puzzle: if they are indeed viable
mechanisms for assuring a high level of reliability in IS
operations, how do they fit into mindfulness theory, which
argues that reliable collective outcomes are only possible
when a mindful approach permeates an organization? Addi-
tional research is needed to better understand how these
aspects of IS operations are, and should be, managed to
effectively balance the potentially competing needs for
efficiency and reliability.
Technical Support and Just-In-Time Mindfulness
Technical support is another aspect of IS operations that
individual and organizational mindfulness theories suggest is
Butler & Gray/Reliability, Mindfulness, & IS
218 MIS Quarterly Vol. 30 No. 2/June 2006
crucial. When IS users and procedures are assumed to be
reliable, technical support is seen as a cost arising from
inadequate user training or poor design. However, when
systems, users, and processes are seen as fragile, technical
support becomes an important part of how organizations
achieve reliable outcomes from unreliable systems, processes,
and practices. Faced with the need to balance efficient appli-
cation of routines under “normal” circumstances, and mindful
attention to abnormalities and alternative possibilities,
individuals must find a way to quickly transition between
these states. Work pressures favor routinized efficiency,
which makes it difficult for individuals to act in a mindful
fashion (Langer 1989). Interaction with technical support
personnel helps users momentarily transition to mindful
consideration of their situation. This shifts users’ focus from
the goal to the process, increases the salience of technical
details and specific actions, and forces them to consciously
attend to the current state of the system (as opposed to the
expected state). Much of the benefit of this type of technical
support may arise simply from interacting with someone who
is knowledgeable about the system, focused upon the imme-
diate problem, and unaware of the individual’s work goals
and expectations for the system. More than simple knowl-
edge transfer, some technical support interactions may be
micro-environments that promote the rapid and temporary
adoption of individually mindful thinking. This function of
technical support is unlikely to be well supported by “self-
help” solutions, such as manuals or knowledge-bases,
designed primarily to convey technical information.
From an organizational perspective, characterizing technical
support in terms of mindfulness raises questions about how
this aspect of IS operations should be managed. Mindful
groups and organizations are characterized by the movement
of problems and decisions to individuals with appropriate
expertise and knowledge (Weick and Roberts 1993). This
suggests that the escalation strategies, whether formal or
informal (Pentland 1992), by which problems are shifted from
users to technical support personnel are important not just for
the efficient operation of the IS function but for the reliable
operation of the IT-enabled organization as a whole.
The importance of focusing upon failure—and the general
unwillingness of most organizations to do so under normal
operating conditions—is anoth er aspect of mindfulness theory
that points to the technical support function as an important
part of an organization’s ability to achieve reliable perfor-
mance. This raises questions about how technical support
should be managed and how the link between technical
support personnel and the rest of the organization should be
handled. For example, if awareness of near-misses and
learning from failure is an important aspect in ongoing
reliable operations, what are the consequences of relying on
external service providers for technical support? Could it be
that organizations, in pursuit of cost reduction, are losing a
core aspect of their ability to function reliably over the long
term? At both an individual and organizational level,
mindfulness theories suggest that in spite of its mundane
nature, technical support may be a crucial aspect of an IT-
enabled organization’s ability to function reliably while using
critical, yet fragile technologies, systems, and procedures.
Business Continuity: Mindfully
Managing the Unexpected
Another aspect of IS operations that is of increasing interest
to managers concerned about reliability, and yet essentially
absent from IS literature, is business continuity and disaster
recovery. In spite of a series of high-profile disasters that
directly affected many organizations and business systems
(e.g., the World Trade Center bombings of 1993 and 2001,
and the widespread power failures in the northeast United
States and Canada in 2003), firms still vary widely in their
approaches to preparing for, and adapting in response to, such
unexpected events. Despite the crucial role that information
systems play in organizations and the high costs associated
with information systems failures (NIST 2002), IS research
provides little guidance for managers who must evaluate
investments in this area, craft policies, train personnel, and
adjust organizational structures to enhance business con-
tinuity. In this realm, firms are faced with the problem of
managing the unexpected—of ensuring that signs of failure
are detected quickly and handled early, before they become
costly disasters (Weick and Sutcliffe 2001).
Business continuity professionals recently have sought to
articulate how and why organizations should take special
steps to prepare for unexpected events (Barnes 2001; Doughty
2001). While some techniques developed by this practitioner
community derive from mainstream IS management methods,
many business continuity practices differ significantly in both
intent and form. Standard planning assumptions (that likely
future scenarios can be probabilistically anticipated and that
individuals can understand, or at least imagine, their potential
impact) often do not apply when considering large-scale
breakdowns of organizational processes and systems (Clarke
1993). Standard approaches to program evaluation and
financial justification also often fail to capture the importance
of business continuity and security efforts, leading to system-
atic under-investment in these activities (Doughty 2001).
Thus, while continuity planning often involves the develop-
ment of plans and specification of routines, business
continuity personnel are aware that the purpose of plans and
Butler & Gray/Reliability, Mindfulness, & IS
MIS Quarterly Vol. 30 No. 2/June 2006 219
routines is to create a context and culture in which individuals
and organizational units are better able to practice resilience
and reliability in the face of unexpected events (Hiles and
Barnes 1999). Because such cultures embody aspects of
mindfulness, including a focus on operations, a commitment
to resilience, and a willingness to openly consider past failure,
mindfulness theory may be important in descriptive and
normative research of these increasingly important capa-
bilities. For example, collective mindfulness theory’s
emphasis on operational practice mirrors the common busi-
ness continuity management recommendations that firms
seeking reliability must move beyond general, high-level
planning (e.g., Segars and Grover 1999) and regularly engage
in operationally focused simulations of specific failures and
disasters (Barnes 2001). Generally, the juxtaposition of
routine-based and mindfulness theories of organizational
reliability suggests that while standard planning techniques
and disaster handling routines may increase an organization’s
ability to perform reliably, the impact of these techniques is
affected by the degree to which they either enhance (media-
tion) or are enhanced by (moderation) collective mindfulness.
Information Systems Management
While IS operations focuses on running systems in such a way
that firms can achieve reliable outcomes, and IS design is
concerned with creating systems that promote mindful use
and work, IS management is focused on blending the avail-
able technologies, resources, and people so that a firm’s IS
investments reliably provide value. Whether at the level of a
particular development project or for the IS function as a
whole, the goal is not just to provide momentary business
value, but to do so consistently over time by reliably pro-
viding the capabilities that the firm needs to survive and grow
(Weill and Broadbent 2000).
Mindfulness and Management of Information
Across a variety of technologies, industries, and organiza-
tions, it is noted that a large proportion of systems develop-
ment projects fail to provide any workable system (Abe et al.
1979; Standish Group 1995; van Genuchten 1991). Drawing
implicitly on routine-based approaches to reliability, re-
searchers have proposed a variety of control structures,
methodologies, and planning schemes to address this problem
(Lyytinen et al. 1998; Peffers et al. 2003; Ravichandran and
Rai 1999; Segars and Grover 1999). Formal controls,
reviews, and governance structures have been proposed as a
way of ensuring that new systems will meet users’ and
organizations’ needs (De and Hsu 1986). Structured analysis
of problem areas, with extensive documentation of require-
ments, is expected to increase system quality (Dennis and
Wixom 2003). However, in spite of the range of formal
techniques available, managers of development projects
continue to supplement them with ad hoc, informal activities
(Kirsch 1997; Kirsch et al. 2002). Likewise, while many soft-
ware development methodologies are available, organizations
often fail to use them in the way their advocates propose
would be necessary to achieve reliable project outcomes.
Technologies that embed structured methodologies have not
achieved widespread acceptance (Fichman and Kemerer
1993), and when used at all they are often significantly
modified (Orlikowski 1993). Similarly, relatively few firms
achieve the level of structure and rigor that is advocated by
software engineering experts as a basis for producing
technically robust systems (King 2003).
While it may be that most developers and firms are simply
blind to the advantages of formal development and project
management methodologies, mindfulness theories suggest
another possibility. Experienced developers and managers
may implicitly recognize the value, and difficulty, of main-
taining a mindful approach when performing complex tasks
in dynamic environments. This recognition would lead them
to avoid the use of techniques that hinder or discourage
mindful behaviors and perspectives in favor of those that
promote them. Recent work with project managers suggests
that techniques which help managers notice emerging
problems and rapidly mobilize necessary personnel to resolve
them are key to managing project risk (Lyytinen et al. 1998).
Thus, it is not the anticipation of generalized risks that leads
to reliable outcomes, but rather managerial and team mind-
fulness with its attention to operational details (so that issues
will be detected quickly) and flexible structure (so that issues
will quickly find their way to the those who have the expertise
needed to resolve them) (Weick and Roberts 1993; Weick and
Recent interest in agile development methods (Cusumano et
al. 2003) also reflects a desire for techniques that promote
mindfulness. While formal analysis and design methods have
many significant benefits, at their core they rely on cognitive
commitment and assumptions of stable requirements, abstract
characterizations of work settings, and design/use dualism
(Kakola and Koota 1999). Any methodology that works on
this basis runs the risk of promoting premature cognitive
commitment on the individual level (e.g., Chanowitz and
Langer 1980) and failure to consider emerging issues at the
organizational level due to an over-reliance on abstraction
(Weick and Sutcliffe 2001). In contrast, the principles under-
Butler & Gray/Reliability, Mindfulness, & IS
220 MIS Quarterly Vol. 30 No. 2/June 2006
lying agile development techniques such as eXtreme
programming (e.g., Beck 2000) may be desirable because they
promote mindfulness. Discarding formal requirements and
specifications entirely in favor of intimate user involvement
and ultra-fast cycling of operational systems focuses
developers on the details of what is needed and what exists,
rather than the abstractions of what is expected or promised.
Pair programming, where two individuals work together on a
single workstation, forces developers to consider problems
from multiple perspectives. Open access to code, in which
developers are allowed to make changes wherever necessary,
allows for easy migration of problems, expertise, and
solutions. Each of these techniques serves to increase individ-
ual or collective mindfulness. While the exact nature of the
tradeoffs between formal and agile development methodo-
logies remains unclear, mindfulness theory provides an
avenue for explaining how the latter can contribute to the
production of reliable information systems, and, perhaps, why
developers’ departures from structured methodologies may
actually benefit their projects.
Mindfulness theories also have a variety of implications for
the practice of designing information systems. First, de-
signing reliable systems is more than a software engineering
problem. If users contribute to, or undermine, a system’s
reliability, then designing reliable systems requires the
development of technologies that promote mindful user
behavior. Second, information systems embed and affect
work practices. As a result, they can change an organiza-
tion’s ability to develop and maintain mindful approaches to
its work and environment. Whether at the individual, unit, or
organizational level, mindfulness theory raises questions
about the principles and consequences of how systems are
Designing for Mindful Use
Technical views of system reliability focus on reliability as a
characteristic of a technology object resulting from a well-
executed design and development process. High-quality,
technically reliable software can be achieved when competent
IS professionals follow appropriate development method-
ologies (e.g., Ravichandran and Rai 1999). Yet because of
declining marginal returns to software testing (Westland
2000) and limits on programmers’ abilities to predict future
behavior of inherently complex systems (Donat and Chalk
2003), technical system reliability is unlikely to be fully
achieved. Even when they are able to create software that is
relatively high-quality, organizations routinely fall short of
ensuring adequate data quality (Olson 2003). Therefore,
while it remains important for designers to strive to create
systems that are free from hardware, software, and data flaws,
technical reliability is not sufficie nt. A complete characteriza-
tion of systems design must also consider how systems can be
designed to help users achieve reliable outcomes in spite of
the failures, glitches, and errors they will encounter.
A focus of the IS design literature is to develop systems that
fit with minimal effort into users’ work routines. Systems are
designed to enhance ease-of-use (e.g., Venkatesh et al.
2003)—that is, to reduce the cognitive effort required to
perform a task. Cognitive fit arguments (e.g., Vessey and
Galletta 1991) also stress the benefits of providing an
interface and capabilities that are consistent with a user’s
cognitive frame. Expectation confirmation theory (e.g.,
Bhattacherjee 2001) implies that meeting users’ expectations
for a system is an important part of encouraging use. Well-
designed systems are thought to engender user trust and
confidence and enhance usability by providing interfaces and
capabilities that are easy to use and conform to users’
preferred perspectives and expectations.
When considered from a mindfulness perspective, these same
characteristics may have negative implications. While soft-
ware that is easy to use increases users’ efficiency, it also
increases their vulnerability to change or failure because it
makes task execution more automatic (Langer 1989).
Conscious, mindful effort is required to build and evolve the
kind of detailed understanding that underlies users’ ability to
detect failures, diagnose problems, and respond appropriately
to changes. Similarly, systems that provide results tailored to
one perspective, and avoid revealing alternative perspectives,
increase efficiency at the expense of reliability and effective-
ness (e.g., Markus et al. 2002) by discouraging mindfulness.
Finally, and perhaps most fundamentally, information systems
that present information as unequivocal facts, analysis results
as unambiguous, or system-provided “advice” as certain, run
the risk of hindering individuals’ ability to produce reliable
outcomes. For example, spreadsheets often contain errors
(Galletta et al. 1996), yet individuals routinely accept the
results of spreadsheet calculations uncritically. Grammar and
spell-checking agents embedded in word processors are
subject to similar problems, with novice users accepting
flawed recommendations and expert users missing errors that
they assumed the agents would catch (Galletta et al. 2005).
Users’ willingness to uncritically accept software-generated
results demonstrates how easy it is for systems to promote
routinized, mindless use that can ultimately undermine
reliable performance. Providing both explanations and
Butler & Gray/Reliability, Mindfulness, & IS
MIS Quarterly Vol. 30 No. 2/June 2006 221
answers, supporting the consideration of multiple perspectives
(Markus et al. 2002), and enabling what-if scenario analysis
are thus examples of design features that enhance individual
Designing to Enhance Collective Mindfulness
Beyond promoting or hindering individuals’ mindful use of
information systems, how systems are designed can also
affect collective mindfulness. Organizations that operate in
dynamic and unpredictable environments are particularly
vulnerable to systems that promote efficient, routinized
behavior by reducing the involvement of humans in day-to-
day activities (Weick and Sutcliffe 2001). Information
systems designed to automate tasks or aggregate data, such as
ERP systems, reduce the labor involved in handling
transactions within and between organizations but may under-
mine organizational mindfulness by masking unexpected
variation. Routines that are embedded in software restrict and
channel users’ choices (Kogut and Zander 1992). Process
automation can therefore have the undesirable effect of
increasing efficiency while lowering satisfaction and quality
of work (Kraut et al. 1999) Further, by aggregating data, such
systems encourage an abstract conceptualization of work
processes that makes maintaining collective mindfulness more
difficult. Finally, and perhaps most counterintuitively, mind-
fulness theory suggests that in the extreme, reliable perfor-
mance may actually be enhanced by systems that, as a result
of inadequacies and errors, encourage individuals to seek out
multiple information sources and critically evaluate the data
upon which they rely (Hedberg and Jonson 1978). Mind-
fulness theories do not imply that automation, routines, or
technically reliable systems are undesirable. However, they
do remind us that while it may seem costly, situated and
active human cognition ultimately underlies an organization’s
ability to handle the unexpected situations that inevitably arise
in modern IT-based business environments.
Recent commentaries have noted that while information
technology has become more complex, componentized, and
fragile, and its use has become more situated, diverse, and
central, our models of technology have remained largely
unchanged (Orlikowski and Iacono 2001). Other commen-
tators suggest that IS scholars have consistently avoided
engaging the nature of the technologies that we study
(Benbasat and Zmud 2003). Our response is to agree with the
premises but challenge the conclusions of these arguments.
Information technologies, and the ways in which they are
applied, have become much more “problematic” (Orlikowski
and Iacono 2001). Partially because of this, IS scholars have
tended away from theorizing about actual technologies.
While some respond to this with calls to reengage the
technology artifact and reclaim our competitive advantage of
understanding information systems, we contend that a profit-
able direction for IS research is to provide theories and
methods that help practitioners apply technologies and
manage systems that are, at best, fragile and complex, and, at
worst, unknowable and unpredictable, in ways that increase
individuals’, teams’, and organizations’ ability to work
reliably and efficiently. The examples we provide of real-
world conundrums in information systems design, develop-
ment, and management all demonstrate that mindfulness is a
useful lens for illuminating under-researched aspects of
phenomena that are central to the management and use of
information systems in organizations. Rather than trying to
generalize the situated, systematize the problematic, or
simplify the complex, IS practitioners need conceptual tools
that help them mindfully manage, so that they can support the
efforts of others to survive and thrive in complex, dynamic
The authors would like to thank Patrick Bateman for his
assistance and Carol Saunders, Kathleen Sutcliffe, and the
two reviewers for their invaluable insight and advice in
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About the Authors
Brian Butler is an associate professor in the Katz Graduate School
of Business at the University of Pittsburgh. His research interests
include the dynamics of electronic communities and other tech-
nology supported groups, the politics of technology implementation
in organizations, and the impact of electronic commerce on inter-
Peter Gray is an assistant professor in the Katz Graduate School of
Business at the University of Pittsburgh, where he teaches courses
in systems analysis and design and knowledge management systems.
He has a background in electronic commerce and online information
services, and has worked in a variety of information technology and
management consulting positions. He conducts research in the areas
of knowledge management and knowledge management systems,
knowledge sourcing, social technologies, communities of practice,
and individual models of IT-mediated learning.