Article

The Self-Designing High-Reliability Organization: Aircraft Carrier Flight Operations at Sea

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Building on foundational studies of safety in environments such as aircraft carriers (Rochlin, LaPorte, & Roberts, 1987), high reliability organization (HRO) theory has had a major impact on the safety community. Weick has served a leader of the HRO movement, and his more recent work with Sutcliffe (2007) distilled much of what they had come to believe about organizational safety into principles of anticipation and commitment. ...
... Success in this model requires adaptation by groups, and not just individuals as in the resilient case. Amalberti considered (non-combat) naval aviation (Rochlin et al., 1987), fire fighting, and the oil industry to be operating along HRO lines. ...
... Sounding a chord similar to that voiced above by the scheduler, one operator assistant team leader likened his coordination with maintenance to a system of "checks and balances" to ensure that a vehicle had the necessary capabilities to safely and successfully complete its trip. This philosophy was similar to what Rochlin et al. (1987) identified as the redundancy in management and decision making found in aircraft carrier operations and what Patterson, Woods, Cook, and Render (2007) described as collaborative cross-checks in healthcare. ...
Thesis
Full-text available
This study applies principles of the emerging field of Resilience Engineering to examine the relationship between how well organizations can adapt to disruption and how effective that organization is at proactive safety management.
... Such systems occur in many contexts: in process industries, e.g., in desalination plants [1]; in transportation systems, e.g., electric traction motors on commuter trains [2]; in power generation, e.g., secondary-cooling pumping systems [3]; in distribution networks, e.g., electricity supply [4]; Larsen et al. (2017); in manufacturing e.g. soft drinks production [5]; in aerospace navigation systems [6]; and in oil and gas production infrastructure, e.g., in [7] and in the military [8]. Essentially, such systems are designed with additional capacity or redundancy [9] so that operation is resilient [10] to unit failure. ...
... μ 0.0397, 0.073, 0.1153, λ c 0.0114, 0.024, 0.0429, μ c 0.04427, 0.0737, 0. 10637 We solve our model's equations (13)-(17) numerically under the initial conditions P 0 (0) 1, P i (0) 0; i 1, 2, F, C at arbitrary values of α to obtain the system fuzzy availability at time t by relation (7) and represent it graphically as shown in Figure 2. Let μ c 0 in equations (13)- (17) and µ 0 in (15) and (16); then, solve them again under the same initial conditions to get the system fuzzy reliability at time t by relation (8) and graph it as Figure 3. Also, we can graph the fuzzy availability and reliability of our system at any instant value of time (take t 0.3) as shown in 6. Discussion e classical approach based on the probability theory became inappropriate for analyzing the system performance due to di erent types of errors or lack of su cient data. For this reason, we have presented a simple and faster algorithm for analyzing the performance of fuzzy repairable parallel warm standby k-out-of-n model in the presence of perfect switching and common-cause failure. ...
Article
Full-text available
In the real life, there exists limited information or uncertainty in knowledge about failure and repair rates which follow one of the standard distributions as exponential distribution and Weibull distribution with some parameters. We suppose that these parameters are fuzzy which allow one to specify a system design for a "worst-case scenario." In this paper, the fuzzy availability and the fuzzy reliability of a redundant repairable parallel k-out-of-n warm standby system with common-cause failure are evaluated. We assume that the failure time of each operating unit or warm standby unit follows Weibull distribution with two fuzzy parameters and the repair time of any failed unit follows exponential distribution with one fuzzy parameter. Each fuzzy parameter is represented by triangular membership function estimated from statistical data taken from random samples of each unit. Also, we give a numerical example for a fuzzy repairable parallel 3-out-of-5 warm standby system with two active and three warm standby units to get analytically and represent graphically the fuzzy availability and reliability function of this fuzzy system.
... The theory of "high reliability organizations" (HRO) was developed with the aim to understand which factors determine that complex, high-risk organizations, such as those in the aeronautics sector and the nuclear industry, are able to maintain high safety levels [26]. HRO are seen as organizations capable of maintaining an error-free performance for long periods of time [27]. ...
... These results reveal four key defining characteristics of safety culture in SNPPs: (a) the perception of safety as an essential condition to successfully operate the plant (safety scale); (b) the assessment of solid organizational preparation and proactiveness to address potential problems (scale of resilience planning); (c) the belief that the organization prioritizes safety against production aspects (BARS attention to safety); and (d) the perception of a high level of activity standardization and documentation (BARS formalization). These four attributes are features of high reliability organizations [26]. ...
Article
Full-text available
Featured Application: The description of safety culture traits within the Spanish nuclear power plants, both globally and at the particular level, can benefit the safe performance of facilities. Abstract: Safety culture is the result of values, attitudes, and perceptions of the members of an organization that prioritize safety over competing goals. Previous research has shown the impact that organizational aspects can have in safety performance. Under the prism of the theoretical approaches from the high reliability organizations theory (HROT), resilience engineering (RE), and conflicting objectives perspective, this study was aimed at describing the overall main safety culture traits of the Spanish nuclear power plants, as well as identifying particularities associated with sub-cultures. For this purpose, a statistical analysis of safety culture surveys and behavioral anchored rating scales (BARS), handed over to all the operating Spanish nuclear power plants, was carried out. Results reveal that safety is a recognized value that prevails over production, there is a high degree of standardization, power plants are better prepared to organize plans and strategies than to adapt and cope with the needs of a crisis, and there is a critical and fragmented perception about the processes of resources allocation. Findings also identify that sociodemographic aspects, such as work location and contractual relationship, seem to be shaping differentiated visions. Several safety implications linked to the results are discussed.
... High profile events in the 1980s including the explosion of the Chernobyl nuclear powerplant in 1986, the NASA Challenger space shuttle explosion the same year or the Piper Alpha explosion in 1988 provoked an increased attention which led to the development of several research traditions in psychology, cognitive engineering, sociology, management or political science, among other (Rasmussen, Batstone, 1989). Canonical texts were published in this period, introducing notions such as human error (Reason, 1990, Rasmussen, 1990, normal accidents (Perrow, 1984, Sagan, 1993, highreliability organisation (Roberts, 1987(Roberts, , 1993, culture of reliability (Weick, 1987, Westrum, 1993 or safety regulation regimes (Braithwaite, 1985, Rees, 1994. ...
... Tasks were never completely performed by isolated individuals, teams and organisational properties were also indicated as core feature of safe performances. Redundancy in teams for instance and flexible modes of operating were identified as sources of reliability (Roberts, Rochlin, La Porte, 1987). ...
... High-reliability organisations (such as air traffic control centres or nuclear power plants) operate in trying conditions filled with constant risks and potential for error, and in these environments one error could lead to catastrophic consequences. What makes HROs remarkable is that they manage to operate almost error-free and maintain consistently stable performance (Rochlin et al., 1987). Through analyses of how these organisations managed to achieve such high reliability, researchers found that HROs designed for safety on a systems level and had a very intricate understanding of their operations with highly mapped our procedures and protocols (Schulman, 2004). ...
Article
Mindful organising is a team level capability that allows teams in high-risk operations to anticipate when something is about to go wrong and quickly act to maintain the stability of the system. The present study aimed to add to our currently limited understanding of the team level conditions that are important for mindful organising to develop as well as broaden our understanding of the impact of mindful organising on individual safety behaviours. To do so, the authors test a multilevel mediation model using data collected from a sample of chemical workers. The model tested whether mindful organising mediates the relationship between team safety climate and individual in-role and extra-role safety behaviour. The findings showed that high levels of priority given to safety over other competing demands in a team is an important prerequisite for mindful organising to develop. The findings also showed that mindful organising leads to increased safety citizenship and compliance with safety protocol.
... Effective change emerges from the interrelated factors of the entire system in civil society (Lichtenstein & Plowman, 2009;Onyx & Leonard, 2011). Engaging this systems-knowledge and experience through learning, training, and encountering systems leadership is supplementary to existing systems approaches within U.S. armed forces' high reliability organizations (Rochlin et al., 1987), and thus provide the ability for leaders that engage in systems leadership to operate from that systems-thinking lens, enhancing the capability of wholesystem assessments in sense-making and decision-making during crises (Northouse, 2015;Uhl-Bien et al., 2007;Yukl, 2013). ...
Article
Full-text available
Scenarios that disrupt and jolt entire systems, such as the 2019 novel coronavirus (COVID-19) pandemic, place organizations, communities, and populations in volatile, uncertain, complex, and ambiguous (VUCA) environments that can affect all sectors of societies and can have disastrous effects ranging from high morbidity and mortality, political upheaval, and extensive economic damage that can last for weeks, months, or even years. Effective leaders are considered one of the most pivotal resources for organizations both in times of normalcy and crisis, yet international criticism has flared pertaining to national, state, local, corporate, and policy leadership in this COVID-19 environment of discontinuous change. We posit that these challenges arise as a result of historically rare allocation of sufficient resources to crisis and disaster preparedness. This paper explores the leadership challenges associated with highly chaotic environments and makes a theoretical argument that leadership effectiveness in these scenarios can best be realized through an advanced, comprehensive, and preparedness-based model of leadership development—Shock Leadership Development.
... Since its beginning, research on HROs, such as Rochlin et al. (1987), has been concerned with organizations' cultural characteristics that operate with high levels of safety and reliability (Sutcliffe, 2011). Several broad themes emerge. ...
Thesis
The safety culture of so-called high-reliability organizations (HROs) encompasses values, routines, and work processes that allow an organization to prevent mistakes and quickly bounce back if unexpected events occur. It is said to provide a model for improving organizational resilience in the offshore oil and gas industry, where small errors can grow into accidents with devastating environmental, social, and economic impacts. To date, such a transfer of successful practices is impeded by a lack of system perspective that would allow researchers and practitioners to fully understand the safety dynamics in HROs, adjust them to the unique setting of offshore oil and gas, plan safety interventions, and anticipate the direct and indirect effects of these interventions. In this dissertation, I have developed and rigorously tested a model of how safety interventions impact the interdependent aspects of the HROs’ characteristics, based on peer-reviewed research, an industry workshop, and a survey of offshore oil and gas practitioners. This approach combines the qualitative research methods of Thematic Analysis (TA) and Thematic Network (TN) with Fuzzy Cognitive Maps (FCMs) modeling and simulation, and Exploratory Modelling and Analysis (EMA). Furthermore, I developed a thematic proximity measure to determine the weights of the edges in the FCMs based on research texts, thus reducing the need for including subject matter experts in modeling studies. This work makes several contributions: on a theoretical level, it shows the inherent dynamics of HROs and points to several limitations in existing High Reliability Organizations Theory (HROT) as well as uncertainties regarding the efficacy of some ii safety interventions. On a practical level, it provides a tested and verified planning tool for the safety decision-makers that can also serve as the foundation of future safety culture training. Finally, it makes several contributions to the FCM methodology, namely a model architecture that combines knowledge from the literature with that of human experts, the introduction of thematic proximity coefficient, and the adaptation of model testing strategies from the literature on Systems Dynamics
... HROs ergreifen wirksame organisationale Maßnahmen, die es ihnen ermöglichen, sicher und zuverlässig zu operieren (u.a. Rochlin et al. 1987;Roberts 1990 Fünf wesentliche, miteinander zusammenhängende Prinzipien sind dafür maßgebend (siehe Abbildung 1) (Weick/ Sutcliffe 2016, 41 ff), die sich in zwei parallel verlaufende und wechselseitig beeinfussende Strategien gliedern (Wildavsky 1988, 77): 1) Antizipation, 2) Resilienz. ...
Article
Full-text available
Die Räumung des Schlossgartens in Stuttgart 2010 (Stuttgart 21), die Loveparade-Katastrophe in Duisburg 2010 oder der G20-Gipfel der Regierungs- und Staatschefs in Hamburg 2017 waren mit Risiken verbunden, die von der Polizeiführung bereits im Vorfeld der Gefahrensituation hätten erkannt werden können. Gab es womöglich erste alarmierende Anzeichen, die auf Gefährdungsmomente oder sich anbahnende gravierende Fehlleistungen hinwiesen? Hätten sie erkannt werden können und wären sie bei achtsamer Planung bzw. Organisation unterblieben? In komplexen Lagen, wie der Großveranstaltung Loveparade am 24. Juli 2010 in Duisburg, können auf Grund der gegebenen großen Menschenansammlung viele Unsicherheitsfaktoren auftreten, die zu unvorhersehbaren Situationen und letztlich katastrophalen Ereignissen führen. Angefangen in der dafür erforderlichen interorganisationalen Kooperation verschiedenster Stakeholder (Polizei, private Sicherheitsdienste, Veranstalter, Genehmigungsbehörden etc.) bis zur videogestützten Überwachung der dynamischen Personenmengen, vor allem an kritischen Punkten auf dem Veranstaltungsgelände. Für die Polizei als staatlichen Sicherheitsakteur ergeben sich daraus wachsende Herausforderungen hinsichtlich der Veranstaltungssicherheit und der Dynamik der Abläufe in einem komplexen Umfeld. Der praxisnahe Ansatz von High Reliability Organizations (HROs) (Weick/Sutcliffe 2016) könnte für die Untersuchung von komplexen und unerwarteten Einsatzlagen der Polizei nützlich sein. Diese neue Form des Organisierens bzw. Managens von komplexen Systemen basiert auf den fünf HRO-Prinzipien achtsamen Organisierens, die auf Fehler, Vereinfachung, Abläufe, Resilienz und Expertise aufbauen. Für die zivile Sicherheitsforschung bietet der organisationale Ansatz genügend Anknüpfungspunkte, damit die Polizei eine anhaltend zuverlässige Leistung zur Gefahrenabwehr erbringen kann und besser versteht, welche Rolle der Faktor Mensch für das Gelingen von Planungs- und Entscheidungsprozessen für den Einsatz spielt.
... A hierarchical, military-style structure with a clear line of command is in mind: the center gives the orders, and the subordinates execute. However, the "centralization thesis" is contradicted not only by the above-reported cases but also by several authors who have dealt with crisis management, who suggest decentralizing decision-making under emergency conditions (Boin & 't Hart 2010;Quarantelli, 1988;Roberts et al., 1994;Rochlin et al., 1987;'t Hart et al. 1993). ...
Article
Full-text available
Policies are continually subjected to turbulence and crises. Interest in policy robustness as a fundamental way to deal with what cannot be foreseen is increasing. Thus, there is a flourishing stream of literature suggesting that policies need to be designed to be agile and flexible. However, the associated characteristics remain undeveloped. This article fills this gap by drawing on lessons obtained from the unplanned behaviours that were adopted in the management of the COVID‐19 pandemic. Individual and organisational behaviours characterised by outside the box thinking, improvisation and fast learning yielded solutions to unexpected problems. In this article, some of these emblematic unplanned behaviours are assessed, and the research builds on the literature on policy robustness, crisis management, and organisational theory to identify three enabling conditions to design more robust policies: coordinated autonomy, training for unplanned responses, and political institutional capacity. This article is protected by copyright. All rights reserved.
... Rank and file members also have a role in shaping the safety culture. Organizations need to include real-world training environments to foster the skills needed by newer members of the group to more quickly adopt HRO facility (Rochlin, La Porte, & Roberts, 1987). ...
Thesis
Full-text available
In 2014 The commercial space company, Scaled Composites, suffered a catastrophic event during a test flight, killing one astronaut. Several recommendations for the Federal Aviation Administration, Office of Commercial Space Transportation emerged from the National Transportation Safety Board. One recommendation was the introduction of a safety management system (SMS) as a safety protocol and became the genesis of this research project. This study has two purposes. The first purpose is to investigate whether the attributes of safety management system theory (SMST) exist in commercial space organizations. The second purpose is to explore the characteristics of high reliability theory (HRT) to determine whether they occur in SMS organizations in the airline industry. The attributes of HRT exist in some high-risk organizations. An exploratory, sequential, mixed-method study was performed using grounded theory and the Delphi methodology. A survey, the Organizational Safety Attribute Awareness Survey, was developed, combining the SMS theory-based survey with the HRT questions used in this study. Two demographic questions were used to determine whether one’s role in the organization or the length of time in the industry impacted perceptions of SMS and HRT attributes. Structural modeling produced an acceptable SMS survey model. Independent t-test results between commercial space and airline participants show promising acceptance levels for three of the four SMST elements. Results showed that participants from the commercial space organization had higher mean values for the attributes of SMST. Further, results suggested similar outcomes with the characteristics of HRT in participants from the airline industry. The practical implications of this research are twofold. First, understanding the degree of organizational members’ awareness of SMS attributes will allow for the focused implementation of the program with resources targeted to areas that require more attention. Second, by highlighting the recognition of HRT in an SMS environment, current safety awareness may be enhanced and include additional safety tools aimed at increasing overall organizational safety.
... Cependant, les chercheurs traitant du concept de HRO (e.g. Rochlin, La Porte & Roberts, 1987;Roberts, 1990aRoberts, , 1990bWeick & Roberts, 1993) Le couplage fort entre éléments nécessite une forte coordination et des interactions nombreuses des acteurs pour assurer la fiabilité. Par ailleurs, un environnement incertain nécessite une complexité et une flexibilité suffisante pour pallier l'imprévu. ...
Conference Paper
Full-text available
De nombreuses organisations font face à des situations extrêmes dont les conséquences peuvent être catastrophiques à une échelle locale, voire à l'échelle de la société entière. Vu ces conséquences, ces organisations doivent chercher à assurer un haut degré de fiabilité dans leur fonctionnement et être résiliente. Si la littérature souligne l'importance du slack organisationnel pour assurer la fiabilité et la résilience, elle reste muette sur l'utilisation et la mobilisation concrète du slack ne pratique. Ce papier ambitionne donc d'étudier et d'analyser comment concrètement le slack se créé et se mobilise dans un contexte extrême et à un niveau intra-organisationnel pour assurer la résilience. Au travers d'une recherche de type ethnographique dans un service des urgences vitales français pendant 14 mois, nous identifions deux processus de création et de consommation de slack qui participent à la gestion des situations extrêmes. Nos résultats soulignent également le caractère dynamique de ces processus et leurs liens, notamment autour de points d'inflexion, qui permettent à l'organisation de se stabiliser ou de se diriger au contraire vers des situations de crise. Nous montrons enfin qu'à des processus organisés de production et de consommation de slack prévus par l'organisation (slack officiel), se mêlent des processus ad hoc, apparaissant dans les situations de travail et mis en place par les acteurs de terrain lors de la gestion de ces situations extrêmes (slack situationnel). Cette distinction entre slack officiel et slack situationnel nous permet d'articuler pratiques de slack, rôles du slack face aux perturbations, et rôles des acteurs par rapport au slack.
... given more discretion to achieve a goal may better support quality decision making compared to more proceduralized work environments in which rule-following is emphasized. This insight contradicts the intuition that human systems should be proceduralized through myriad standard operating procedures to improve quality and performance and supports other work that demonstrates the value of front-line discretion (Rochlin, Porte, & Roberts, 1987). In such a system, pressures to process a high quantity of travelers without the aim of increasing performance quality may result in more misses. ...
Article
Full-text available
Accountability is an ill-defined and underexplored concept in job design, particularly in highly proceduralized environments that must operate under both high throughput and high-security expectations. Using x-ray images from the Airport Scanner game, this paper investigates two mechanisms of accountability: an active condition, and a passive condition. Each group was shown a list of prohibited items, but different feedback was provided. The active group was asked to be vigilant for any possible threat, whereas the passive group was instructed to stick to the list. Data from 76 participants were collected. The active group took longer (+16%) to process fewer (-10%) x-ray images compared to the passive group. As a result, the active group accomplished fewer hits (-14%), but also fewer misses (-31%) compared to the other group. While the active group worked slower, they provided higher quality performance. We conclude that accountability mechanisms can reduce errors if applied appropriately.
... When it comes to the planning, scheduling, and implementation of activities, it has been widely demonstrated that fluidity is a factor of reliability. [48][49][50] Constant organizational adjustment helps keep the flow of activity fluid, making it possible to maintain safe conditions. 48 To be effective, a management system ought to foster fluidity in activities, rather than hindering it. ...
Article
Full-text available
Many initiatives intended to improve safety in nuclear facilities have used the concept of “safety culture,” which focuses on human and organizational factors and emphasizes the importance of the perceptions, interpretations, and behaviors of the individuals and groups within organizations. Particularly when it comes to risk management, it is widely believed that safety culture can be a used as a lever to strengthen a company’s overall structure and organization. But how is it possible to ensure that a new safety policy or organizational infrastructure really will promote safe and reliable operations without unforeseen and undesired cultural consequences? Once recommendations have been issued, how is it possible to assess the extent to which safety culture has (or has not) improved? This paper argues that using what we call a “cultural analysis framework” can be a powerful way to identify and understand cultural elements that have an impact on reliability and safety within organizations. We will use a case study of the introduction of a safety management system in a nuclear facility to present this original approach. Because safety culture is a highly complex topic that can be challenging to address directly, our cultural analysis framework approaches a system at three levels, which, when explored together, can help to develop a comprehensive understanding of the cultural aspects of safety in an organization. First, at the macro level this approach examines the cultural background of a system and how it is integrated into an existing organizational culture. Second, at the meso level it looks at the collective aspects of a given system within an organization. Third, at the micro level it investigates collective and social life (modes of socialization, relationships, trust, practice sharing), as well as the symbolic and identity-related aspects of a system. Based on the findings of our study, this paper concludes that a socio-comprehensive approach to safety can be an effective means to identify “reasonable” actions to be taken in any organization seeking to improve risk management.
... This approach also offers grounds for adaptability through the spontaneous redirection of activities and decisions to the persons with the adequate expertise (Roberts, Stout and Halpern, 1994). However, these structural choices imply the constitution of redundancies in expertise and other kinds of resources (Rochlin, LaPorte and Roberts, 1987;Klein et al., 2006). ...
... HROs ergreifen wirksame organisationale Maßnahmen, die es ihnen ermöglichen, sicher und zuverlässig zu operieren (u.a. Rochlin et al. 1987;Roberts 1990 Fünf wesentliche, miteinander zusammenhängende Prinzipien sind dafür maßgebend (siehe Abbildung 1) (Weick/ Sutcliffe 2016, 41 ff), die sich in zwei parallel verlaufende und wechselseitig beeinfussende Strategien gliedern (Wildavsky 1988, 77): 1) Antizipation, 2) Resilienz. ...
Article
Full-text available
Die Räumung des Schlossgartens in Stuttgart 2010 (Stuttgart 21), die Loveparade-Katastrophe in Duisburg 2010 oder der G20-Gipfel der Regierungs- und Staatschefs in Hamburg 2017 waren mit Risiken verbunden, die von der Polizeiführung bereits im Vorfeld der Gefahrensituation hätten erkannt werden können. Gab es womöglich erste alarmierende Anzeichen, die auf Gefährdungsmomente oder sich anbahnende gravierende Fehlleistungen hinwiesen? Hätten sie erkannt werden können und wären sie bei achtsamer Planung bzw. Organisation unterblieben? In komplexen Lagen, wie der Großveranstaltung Loveparade am 24. Juli 2010 in Duisburg, können auf Grund der gegebenen großen Menschenansammlung viele Unsicherheitsfaktoren auftreten, die zu unvorhersehbaren Situationen und letztlich katastrophalen Ereignissen führen. Angefangen in der dafür erforderlichen interorganisationalen Kooperation verschiedenster Stakeholder (Polizei, private Sicherheitsdienste, Veranstalter, Genehmigungsbehörden etc.) bis zur videogestützten Überwachung der dynamischen Personenmengen, vor allem an kritischen Punkten auf dem Veranstaltungsgelände. Für die Polizei als staatlichen Sicherheitsakteur ergeben sich daraus wachsende Herausforderungen hinsichtlich der Veranstaltungssicherheit und der Dynamik der Abläufe in einem komplexen Umfeld. Der praxisnahe Ansatz von High Reliability Organizations (HROs) (Weick/Sutcliffe 2016) könnte für die Untersuchung von komplexen und unerwarteten Einsatzlagen der Polizei nützlich sein. Diese neue Form des Organisierens bzw. Managens von komplexen Systemen basiert auf den fünf HRO-Prinzipien achtsamen Organisierens, die auf Fehler, Vereinfachung, Abläufe, Resilienz und Expertise aufbauen. Für die zivile Sicherheitsforschung bietet der organisationale Ansatz genügend Anknüpfungspunkte, damit die Polizei eine anhaltend zuverlässige Leistung zur Gefahrenabwehr erbringen kann und besser versteht, welche Rolle der Faktor Mensch für das Gelingen von Planungs- und Entscheidungsprozessen für den Einsatz spielt.
... Palabras clave: Organización consciente Atención plena colectiva Seguridad para elevar críticas Clima de participación Satisfacción laboral Propensión al abandono Modern organizations are operating in increasingly volatile, uncertain, complex, and ambiguous environments and their success in these environments becomes contingent on their ability to effectively adapt to, and recover from, unexpected events and demands (Bartscht, 2015;Weick & Sutcliffe, 2015). Researchers have identified a set of organizations called high-reliability organizations (HROs) that manage to operate almost error-free under trying conditions rife with unexpected events (Rochlin, 1993;Rochlin et al., 1987;Weick et al., 1999). Scholars and practitioners have thus turned to HROs (such as air traffic control centers and nuclear power plants) to extrapolate lessons about how these organizations manage to hardly ever have unwanted, unanticipated, and unexplainable variance in their performance (Hollnagel, 1993). ...
Article
Full-text available
Mindful organizing (also known as collective mindfulness) is a collective capability that allows teams to anticipate and swiftly recover from unexpected events. This collective capability is especially relevant in high-risk environments where reliability in performance is of utmost importance. In this paper, we build on current mindful organizing theory by showing how two front-line communication and participatory conditions (perceived safety for upward dissent and climate for employee engagement) interact to predict mindful organizing. We shed light on the controversy around mindful organizing’s effect on team’s subjective experience at work by showing that it leads to greater team job satisfaction and thus lowers individual turnover intentions. These relationships were tested using a time-lagged design with two data- collection points using a sample of 47 teams within the nuclear power industry.
... Of course, although widely acclaimed, the reception of the book by scholars was, sometimes from its first publication, and then subsequently, divided between those who challenged (e.g. Rochlin, La Porte, Roberts, 1987;Wynne, 1988;La Porte & Consolini, 1991;Pinch, 1991;Turner, 1992;Bierly & Spender, 1995;Weick, 1995;Bourrier, 1999), extended (Starbuck & Milliken, 1988a;Sagan, 1993;Vaughan, 1996;Snook, 2000;Evan & Manion, 2002;Downer, 2011) or simply rejected (Hirschhorn, 1985;Hopkins, 1999Hopkins, , 2001Mayer, 2003) its rationale. ...
Book
Pourquoi alors que depuis trente ans s’est élaborée une recherche dans le domaine de la sécurité industrielle, des accidents continuent à survenir ? Doit-on repenser de manière critique l’héritage des approches actuellement disponibles dans le domaine de la sécurité ? Comment entrer dans cette problématique en prenant le recul nécessaire face à sa très grande complexité ?
... The findings also highlight how interactions within the WDS lead, over time, to the construction of a culture focused on the importance of the mission and the priority of managing the unplanned flow of patients whose condition constitutes a life-threatening emergency. This importance of mission -widely documented in the literature (Boin and Schulman, 2008;La Porte and Consolini, 1991;Roberts, 1990;Rochlin et al., 1987) -reveals that beyond the discussion of practices within these WDS, it is the set of values and behaviors that are disseminated there (especially to newcomers) that are at the core of the unit's identity. ...
Article
From the beginning, studies on reliability and safety have highlighted the crucial role of organizational culture. However, culture, context and groups of individuals are highly intertwined, making the culture difficult to manipulate and steer. Like Hopkins (2019), this study considers that taking only a “hearts and minds” approach to safety is ineffective without appropriate organizational structures. An interesting research avenue is therefore to understand the relationship between organizational structure and culture over time. This research took the form of an ethnographic study carried out in a French critical care unit to examine how structural spaces – in the form of “work debate spaces” – can connect safe medical practices and organizational culture. The study shed light on two types of work debate spaces: formal and informal spaces. These inter-related work debate spaces enable a more refined approach to understanding the relationship between structure and culture.
... These people are engaged in a constant stream of conversation and verification on several different channels. The landing process is thus continuously evaluated from many different perspectives that allow one to identify any deviations or problems (Rochlin et al. 1987). ...
... Rochlin, and Karlene Roberts (Rochlin et al., 1998). In addition, Donald Schön and Chris Argyris developed the concept of single-loop and double-loop learning and offered explanations on how these translate into different models of organisational learning systems (Argyris & Schön, 1978). ...
Thesis
The global mining industry, including Ghana, continues to be associated with relatively high rates of unwanted events despite the implementation of various incidents reduction interventions. Learning from incidents has been regarded as a vital means of preventing incidents and improving organisational safety. Past incidents can provide valuable lessons on how to prevent future incidents. However, it has been identified that incidents continue to occur because organisations failed to learn from their own experiences and that of others. Although many scholarly works exist which discuss why organisations fail to learn from accidents, most of the research remains conceptual/theoretical in nature with only a few empirical studies. Evaluating current incident investigation practices and capturing the perspectives of practitioner-investigators is necessary to improve learning from incidents opportunities. This research addresses these knowledge gap by evaluating how investigations are undertaken in the Ghanaian mining industry.
... Currently, the aircraft movement afloat mainly relied on manually operated towing tractor with extra personnel to ensure the safety of parking route. However, the aircraft parking operation is usually manpower intensive and time-consuming evolution with low reliability, which creates a more hazard situation for the already congested deck environment leading to mishaps [3]. erefore, it is imperative to introduce an autonomous path planner that can speed up the aircraft parking operations with major improvements in safety and reduction in total manpower. ...
Article
Full-text available
To improve the safety and effectiveness of autonomous towing aircraft aboard the carrier deck, this study proposes a velocity-restricted path planner algorithm named as kinodynamic safety optimal rapidly exploring random tree (KS-RRT∗) to plan a near time-optimal path. First, a speed map is introduced to assign different maximum allowable velocity for the sampling points in the workspace, and the traverse time is calculated along the kinodynamic connection of two sampling points. Then the near time-optimal path in the tree-structured search map can be obtained by the rewiring procedures, instead of a distance-optimal path in the original RRT∗ algorithm. In order to enhance the planner’s performance, goal biasing scheme and fast collision checking technique are adopted in the algorithm. Since the sampling-based methods are sensitive to their parameters, simulation experiments are first conducted to determine the optimal input settings for the specific problem. The effectiveness of the proposed algorithm is validated in several common aircraft parking scenarios. Comparing with standard RRT∗ and human heuristic driving, KS-RRT∗ demonstrates a higher success rate, as well as shorter computation and trajectory time. In conclusion, KS-RRT∗ algorithm is suitable to generate a near time-optimal safe path for autonomous high density parking in semistructured environment.
... 96,128,130 In contrast to the pessimistic approach in Perrow's Normal Accident Theory, which tends to position accidents as normal and unpredictable events in complex socio-technical systems, HRT argues that high reliability organisations can function safely despite inherent hazards embedded in complex systems, with a particular role for learning from past failures. [131][132][133] At the heart of this focus on organisational learning are event analysis techniques such as RCA. In the context of healthcare, the practice of RCA is meant to facilitate the formation of ad hoc natural networks of multi-disciplinary staff to investigate unanticipated safety incidents. ...
Thesis
Full-text available
Improving risk controls following root cause analysis of serious incidents in healthcare- Mohammad Farhad Peerally Background Root cause analysis (RCA) is widely used following healthcare serious incidents, but does not necessarily lead to robust risk controls. This research aimed to examine current practices and to inform an understanding of what good looks like in formulating and implementing risk controls to improve patient safety. Methods First, I undertook a content analysis of 126 RCA reports over a three-year period from an acute NHS trust, with the goals of characterising (i)the contributory factors identified in investigations and (ii)the risk controls proposed in the action plans. Second, I conducted a narrative review of the academic literature on improving risk control practices in safety-critical industries, including but not limited to healthcare. Finally, I undertook a qualitative study involving 52 semi-structured interviews with expert stakeholders in post-incident management, analysed using the framework method. Results: Content analysis of serious incident investigation reports identified the preoccupation of RCAs with identifying proximate errors at the sharp end of care, neglecting wider contexts and structures. Most (74%) risk controls proposed could be characterised as weak and were poorly aligned with identified contributory factors. Together, the narrative review and the findings of the interview study suggested eleven features essential to addressing these problems: systems-based investigations; a participatory approach, skilled and independent investigators; clear and shared language; including patients’ views; allocating time and space to risk control formulation; adding structure to risk control formulation; sustainable risk controls mapped to identified problems; purposeful implementation and better tracking of risk controls; a collaborative approach to quality assurance and improved organisational learning. Discussion and conclusion: RCAs as currently conducted, and the action plans that arise from them, are often flawed. The eleven features identified will be important in improving risk control formulation and implementation. To operationalise these features, there is a need for: professional and independent investigations, risk controls based on a sound theory of change, and improved cultures and structures for organisational learning.
... In general, this study examines the gold-standard organizational change management theories that the AFMS leveraged as the basis, or groundwork, to creating a high reliability culture necessary for maturing as a "high reliability organization" (HRO). [6][7][8][9] An HRO is comprised of culture, standardized processes/standard work and the associated training, and specially designed systems. Specifically, this study analyzes the methodical basis and implementation of HRO practices and principles across the AFMS: ...
Technical Report
Full-text available
The Air Force Medical Services AFMS health system is a global enterprise tasked with caring for thousands of Service members and their families. In an effort to improve its ability to effectively accomplish its mission, the AFMS has launched out on a high reliability-driven journey, named Trusted Care that aims to improve safety, reliability, and resilience by enhancing the culture of front line staff, intermediate leaders, senior leaders, and others in delivery of preventative medicine and healthcare. In the study we 1 describe the AFMS approach to achieving high reliability and 2 present preliminary findings from survey data obtained from AFMS personnel that participated in the Trusted Care implementation process. Descriptive analysis of that data suggests that, although the majority of respondents supported and utilized some of the available Trusted Care tools and resources e.g., Huddles and CPI Management Boards, internet-based tools e.g., social media were not as well embraced to date. In support of achieving high reliability, a majority of stakeholders reported that they are actively engaged in the change management approach and feel comfortable and secure elevating concerns suggesting that the Trusted Care approach has instituted steps necessary to creating a psychologically safe culture across the AFMS. Furthermore, there was acceptance and application of the change management approaches with stakeholder feedback suggesting that recommendations at the front line are being acted upon and implemented. The net outcome of these findings indicate that, although the AFMS is maturing as a high reliability culture, there areas that require continued attention and improvement in the Trusted Care approach.
... High Reliability Organizations (HROs) such as 14 CFR Part 121 commercial airlines and commercial space licensees in the United States operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures [1][2][3][4][5][6][7][8] but still face occasional challenges with controlling unanticipated safety risks and safety events such as the in-flight break up of scaled composite space ship two and uncontained engine failure of Southwest flight 1380 [9][10][11][12][13][14][15] . HROs tend to quickly return to a state of normalcy after non-normal safety events that degrade operational capabilities, and they demonstrate a culture of high reliability and operational safety [ 7-9 , 11,16-18 ,]. ...
Article
Full-text available
There seems to be a paucity in extant literature that assesses the relationship between Safety Management Systems (SMS) and High Reliability Theory (HRT) behavior process of Mindful Organizing (MO) among aerospace organizations. There could be benefits for organizational safety by exploring this relationship in high-reliability organizations (HROs) like the aerospace industry. Using a modified Safety Organizing Scale (SOS) by Vogus and Sutcliffe (2007) and a validated SMS scale, the relationship between SMS and MO was measured. The perceptions of a cross-section of respondents from commercial airlines with SMS and commercial space licensees without SMS in the United States (U.S) was assessed. A four-factor model of MO had acceptable fit. A model showing the relationship between SMS and MO had good fit and showed a high significant strength of relationship (r = .82, p =.000) with a big effect size. There were also significant differences in mean responses among management personnel and non-management personnel on the MO factor “sensitivity to operations” and the result suggests managers were better at identifying personnel with skills and knowledge to ensure safer task accomplishment than non-management personnel. The study results suggest that the SMS requirements for commercial airlines in the U.S. can enrich the identification and understanding of MO factors and it may be beneficial for the commercial space industry to formally adopt SMS. Future research studies may include direct comparisons in multiple aerospace organizations using a larger sample size to determine the overall understanding of MO factors and how it affects SMS.
Article
Full-text available
Zusammenfassung Die Debatte um die Integration von autonomen Systemen in Streitkräfte wird oftmals auf einer (militär-)strategischen Ebene geführt. Die technisch-operativen Aspekte werden außerhalb des Fachpublikums häufig nur am Rande erwähnt. Der Beitrag analysiert die Integration von U(C)AVs in den operativen Flugzeugträgerbetrieb am Beispiel der X‑47B. Die Studie zeigt, dass es keine fundamentalen Probleme bei der Integration gibt, U(C)AVs in einem Fünf-Jahres-Horizont zur neuen maritimen Realität gehören und die Gefahr eines Rüstungswettlaufs in Bezug auf autonome Waffensysteme steigen wird.
Article
Full-text available
Safety at work is an important factor in the successful operation of an enterprise. In practice, it is quite difficult to achieve safety at work, but there exist all necessary conditions for this. The article considers the role of the systematic management of an enterprise, which helps to ensure safety at all stages of the production life cycle. In the paper, we discuss the system of organizational culture that supports the management system, the concept of safety culture and how it can be implemented. Also in this study, we discuss the history of systematic safety management drawing on the experience of mining enterprises in the Irkutsk Region. The article contains practical research and calculated data on the evaluation of safety culture at such enterprises as Angasolsky Crushed Stone Plant, Pereval Quarry, and the stone-cutting production of Baikalquartzsamotsvety OJSC. The article concludes with a discussion of how to achieve high safety culture at these enterprises taking into account the regulatory environment that can encourage the development of the systematic safety culture management without this being a burden for organizations.
Article
Full-text available
The COVID-19 crisis has created a physical environment where neonatologists and neonatal staff face exposure to an easily transmissible, potentially fatal infection in the course of their duties. Leaders cannot reject an assignment, such as a resuscitation of a newborn, because of risk. As in military operations, safety and capability cannot be separated from neonatal operations. Leadership models developed in stable environments do not fully translate to dynamic, uncertain situations where the leader and subordinates personally face threats, the type of environment from which the High Reliability Organization (HRO) emerged. Short, negative feedback, sometimes called an error, denotes the boundary of performance, knowledge, and operations. Error corrects heuristic bias.There must be a shift from the increasingly abstract, academic, and normative representation of HRO leadership to its original, more pragmatic frame that iteratively supports engagement. The purpose of this paper is to present HRO as leadership principles, bridging the gap between abstract theory and practice by bringing attention to HRO as a scientifically supported pragmatic leadership stance.
Article
History has taught us that quite disastrous events with much human loss, injuries and asset damage could have been prevented or at least mitigated, if top management had recognized early warning signals in some form as urgent and had decided to take timely preventative measures. It turns out to be a rather common phenomenon in various sectors of life and some process industry examples are presented. The problem is further analyzed from a leadership point of view, from organizational structure and culture aspect, and what modern technology developments can help to improve the situation. Research in the latter directions is encouraged.
Chapter
Knowledge-based clinical decision making is one of the most challenging activities of physicians. Clinical Practice Guidelines are commonly recognized as a useful tool to help physicians in such activities by encoding the indications provided by evidence-based medicine. Computer-based approaches can provide useful facilities to put guidelines into practice and to support physicians in decision-making. Specifically, GLARE (GuideLine Acquisition, Representation and Execution) is a domain-independent prototypical tool providing advanced Artificial Intelligence techniques to support medical decision making, including what-if analysis, temporal reasoning, and decision theory analysis. The paper describes such facilities considering a real-world running example and focusing on the treatment of therapeutic decisions.
Article
Understanding the reliability of hazardous organizations and their protective systems is central to understanding the risk they produce. Work on “high reliability organization” has done much to illuminate the conditions in which social organization becomes reliable in highly demanding conditions. But risk depends just as much on how relying entities do their relying as it does on the reliability of the entities they rely on. Patterns of relying are often opaque in sociotechnical systems, and processes of relying and being relied on are mutually influencing in complex ways, so the relationship between relying and risk may not be at all obvious. This study was an attempt to study relying as a social practice, in particular analyzing how it had ecological validity in a social organization—how practice was responsive to the conditions in which it took place. This involved observational fieldwork and inductive, qualitative analysis on an offshore oil and gas production platform that was nearing the end of its design life and undergoing refurbishment. The analysis produced four main categories of ecological validity: responsiveness to formal organization, responsiveness to situational contingency, responsiveness to information asymmetry, and responsiveness to sociomateriality. This ecological validity of relying practice should be a primary focus of risk identification, assessing how relying can become mismatched to reliability in certain ways, both when relying practice is responsive to circumstances and when it is not.
Chapter
Vor dem Hintergrund einer systemtheoretischen Betrachtungsweise werden im Kap. 4 drei hybride Schlüsselkonzepte für das Lernen in Organisation, das organisationale Lernen vorgestellt. Nur in einem gemeinsamen systemtheoretischenSystemkomponente Bezugsrahmen aus akteurszentrierten und organisationstheoretischen Ansätzen – organisationales Lernen, SystemdenkenSystemdenken und achtsames Organisieren – können soziale Prozesse innerhalb der Organisation der Polizei ganzheitlich erklärt und die vielfältigen sozialpsychologischen Aspekte mitberücksichtigt werden. Dadurch sollen Rückschlüsse auf organisationsorientierte Lernanstrengungen und Entwicklungen der Polizei gezogen werden, die als Organisation ein soziales Gebilde der Denk- und Interaktionsweisen ihrer Mitglieder ist. Dieser Schritt scheint zweckdienlich, wenn man sozialisierte Denk- und Verhaltensweisen innerhalb der Polizeiorganisation verändern will, präziser: Konkrete Strukturen und Abläufe in einem Gesamtzusammenhang zum Besseren wandeln möchte, muss man sie zunächst verstehen und erfassen. Die Herausforderung besteht heute darin, dass die Denk- und Interaktionsmuster zwischen Menschen, Strukturen und ProzessenKybernetik von über Jahre gewachsenen Organisationen im Allgemeinen und im Speziellen bei der Polizei kaum erkennbar sind und im Verborgenen ablaufen. Das wiegt umso schwerer, wenn man bedenkt, dass sie die Voraussetzungen für Abwehrreaktionen und LernhemmnisseLernhemmnis sein können, die notwendige Wandlungsprozesse erschweren. Die Schlüsselkonzepte werden dabei auf das vorherrschende Managementsystem der Polizei und ihre Denk- und Interaktionsweisen übertragenGesamtsystem, wobei der praxisorientierte Fokus auf unterschiedlicheEinschleifen-Lernen polizeiliche Handlungspraxen dabei im VordergrundSystemdenken der Auseinandersetzung steht.
Article
In an era when unprecedented events are occurring with increasing frequency, public management theory is challenged to consider whether it is possible to better prepare agencies to respond to situations previously neither expected, nor even seriously imagined. In this paper, we consider the case of the 2016 Chimney Tops 2 wildfire that contributed to the destruction of neighborhoods in and around Gatlinburg, TN. We argue this case illuminates a critical gap in extant organizational theory concerning the factors that impede sensemaking processes, which are fundamental to models of high reliability organizations during unprecedented events. Specifically, based on insights from this case considered through an institutional lens, we theorize that the nature of unprecedented events undermines an adaptive response through both structural and cultural/institutional processes. Structurally, we demonstrate how public agencies evolve to the contingencies of their normal task environment, which we should anticipate will be maladapted to the task demands of an unprecedented event. However, we theorize the greater challenge lies in the processes by which these structural features of the agency, over time, create, and reinforce a dominant institutional logic which can delay and weaken sensemaking processes, even when discrepant environmental cues are present. We conclude with a discussion of remedies that may facilitate earlier recognition, and thus more effective agency response, when the unprecedented is occurring.
Article
Full-text available
Stopping work when work becomes unsafe is universally considered to be a positive safety behaviour. Safety interventions aimed at building the capability to stop unsafe work have focussed on assertiveness training and creating authority to stop work policies. A recent focus group-based study found that these interventions do not necessarily capture the most common factors influencing stop work decisions, and found that stop-work decisions can be enacted in different forms. Inspired by this work, we used an ethnographic study in a water utility provider to understand how decisions to stop work were made, and how they were influenced by procedures. In this organisation, crews frequently made decisions to stop work, usually by handing over the job to another crew. The decisions were easy to make if they could be framed as finding the best way to complete the job. Operators did not view decisions framed this way as safety related decisions. Procedures could cause crews to consider stopping work, but were unlikely to actually lead to a decision to stop work. If a crew considered it impossible to comply with a procedure, the crew who would pick up the cancelled job would likely encounter the same situation. As such, stopping work for procedural requirements was not perceived as improving safety. These findings challenge the idea that stop-work decisions are best supported through procedures, assertiveness training, and authority to stop work policies. As an alternative, the results suggest that organisations can influence workers to stop work by providing alternative methods for them to complete a job which crews themselves can arrange.
Article
High-reliability organizations facilitate the reliable accomplishment of high-risk goals while avoiding catastrophe. Our paper evaluates natural gas utilities in the United States against the features of high-reliability organization (HRO) theory. We ask: 1) How is high-reliability organizational theory applicable to natural gas infrastructure? And 2) How might natural gas hazards be reconsidered using HRO models of industrial organization? We conclude that natural gas organizations are not high reliability but might be in a period of transition toward becoming HROs. Our conclusions are cautionary, noting that the expanded use of this energy source poses substantial environmental and societal risks under present organizational circumstances.
Article
In this article, the author – who served as special adviser to UNSCOM’s executive chair and spokesperson for UNSCOM for nearly four years – focuses on the way in which UNSCOM’s organization and culture evolved to adapt to its mission to destroy, remove, and render harmless Iraq’s weapons of mass destruction and its long-range missiles.
Thesis
Prior research in strategic human resource management has consistently shown a positive relationship between high performance human resource (HPHR) practices and organizational performance. However, this research has left the cognitive and behavioral mechanisms underlying this relationship both largely unexplored. I argue that the mechanisms previously proposed (employee skills, commitment, and effort) are necessary and sufficient only when one makes overly restrictive assumptions about employees (effort averse), work (routine and decomposable), and organizational performance (equal to the sum of individual performances). When these assumptions are relaxed, collective sensemaking and coordination become equally critical sources of high performance. In theorizing the HPHR practice---organizational performance relationship I assert that HPHR practices are sensegiving structures by which managers attempt to influence employee sensemaking and behavior. HPHR practices specifically define both the employment relationship and work practice. In defining the employment relationship, HPHR practices signal a strong and long-term investment in employees that engenders employee commitment and discretionary effort. HPHR practices also define expectations for how employees are to carry out their work and to the extent these practice signal an interpersonally safe work climate, they increases the richness of interactions, the system-awareness of action, and the mindfulness of ongoing processes. I empirically test my hypotheses by surveying registered nurses and nurse managers in 99 acute-care hospital nursing units. In analyzing these data I found that HPHR practices are positively associated with respectful interaction, but not with commitment. The cognitive mechanisms were also positively associated with their corresponding behavioral mechanisms and the behavioral mechanisms influenced performance, but not entirely as predicted. Discretionary effort was positively associated with quality of care while mindful organizing was not. Mindful organizing, however, was associated with significantly lower levels of errors and falls, while discretionary effort actually increased medication errors and patient falls. This suggests that in dynamic and interdependent knowledge work, discretionary effort may actually compromise performance when it distracts employees from their core tasks. In sum, my study demonstrates a much more nuanced relationship between HPHR practices and performance than anticipated by the prior literature that depends on the work setting studied and the performance measure examined.
Book
Full-text available
Inside Hazardous Technological Systems explores the applications, opportunities and challenges of applying qualitative methodologies to critical questions of organizational research and practice in the field of safety science. This book provides a broad exploration of the practices and methods of doing research, conducting fieldwork, and developing theory of hazardous technological systems, drawing on a range of different approaches and traditions. These span from critical accounts of applying interpretive and social research methods in organisational settings, to explorations of the opportunities and importance of integrating qualitative and quantitative methods, to practical reflections on the challenges associated with negotiating access to research sites and building theory from data. Recognizing methodological issues that cut across the fields of safety, risk and accident analysis, it provides academics, researchers, students, and professionals with a broad-ranging and expert guide to research strategies and histories, considerations of particular research methods, as well as reflections on the challenges and opportunities for integrating and combining methods and looking to new empirical domains.
Article
Purpose Since Weick’s (1993) seminal Mann Gulch paper articulated a collapse of sensemaking, scholars have repeatedly investigated sensemaking downstream of enactment. Motivated by another wildland firefighting tragedy, the tragic loss of 19 firefighters in Arizona in 2013, this study aims to look at enactment itself and reveals that the endogenous creation and re-creation of the wildland fire caused a fatal feedback loop of “trigger traps” leading to perpetual enactment that short-circuited sensemaking. Wildland fires can have unpredictable consequences, which triggers in individual sensemakers a fatal and continuous return to the beginning of the sensemaking process. Design/methodology/approach This paper’s approach is a case study based on a textual analysis of sources investigating the 2013 Yarnell Hill fire. The authors also carefully compared the Yarnell Hill and Mann Gulch disasters in search of breakdowns in sensemaking that could help us understand why we continue to lose firefighters in the line of duty. Findings The simultaneously volatile and complex environment at Yarnell illustrates sensemaking antecedents to the study of enactment. The findings suggest ways that organizations – those fighting wildfire or those fighting a global pandemic – can avoid getting trapped in the early stages of enactment and can retain resilience in their sensemaking. Originality/value This paper introduces the concept of “trigger traps” to help explain the fatal feedback loop of repeated environmental triggers in the early stages of sensemaking in volatile environments.
Article
Full-text available
Objective This paper reviews recent articles related to human trust in automation to guide research and design for increasingly capable automation in complex work environments. Background Two recent trends—the development of increasingly capable automation and the flattening of organizational hierarchies—suggest a reframing of trust in automation is needed. Method Many publications related to human trust and human–automation interaction were integrated in this narrative literature review. Results Much research has focused on calibrating human trust to promote appropriate reliance on automation. This approach neglects relational aspects of increasingly capable automation and system-level outcomes, such as cooperation and resilience. To address these limitations, we adopt a relational framing of trust based on the decision situation, semiotics, interaction sequence, and strategy. This relational framework stresses that the goal is not to maximize trust, or to even calibrate trust, but to support a process of trusting through automation responsivity. Conclusion This framing clarifies why future work on trust in automation should consider not just individual characteristics and how automation influences people, but also how people can influence automation and how interdependent interactions affect trusting automation. In these new technological and organizational contexts that shift human operators to co-operators of automation, automation responsivity and the ability to resolve conflicting goals may be more relevant than reliability and reliance for advancing system design. Application A conceptual model comprising four concepts—situation, semiotics, strategy, and sequence—can guide future trust research and design for automation responsivity and more resilient human–automation systems.
Article
Improving safety culture and safety performance is a constant concern for companies operating in high-risk environments. For almost two decades, IDOCAL (the Research Institute of Personnel Psychology, Organizational Development and Quality of Working Life) has been contributing to advancing our understanding of these important concepts through theoretical development and empirical research. The objective of this article is to synthesize these contributions. Some of the most prominent are (1) the development of a framework for the evaluation of safety culture and its correlates based on the AMIGO model, (2) the establishment of the empowering leadership model as a valuable concept in safety leadership, and (3) the establishment of a three-dimensional safety performance model. In addition, the researchers within IDOCAL have made great progress in understanding the main predictors of safety performance, including empowering leadership and safety culture. Within this paper, IDOCAL's plans to advance this line of research in the coming years, by extending it from the nuclear power sector to other high-risk industries, are also outlined.
Chapter
Full-text available
Global crises that jolt entire systems, such as the COVID-19 pandemic, can place groups, organizations, and communities in volatile, uncertain, complex, and ambiguous (VUCA) environments that affect all sectors of society, having potentially disastrous effects including high morbidity and mortality rates, political upheaval, and extensive disruption of entire economic systems, causing damage that can last for years. Effective leadership is a pivotal organizational commodity in times of normalcy, and it becomes increasingly critical during crises and the subsequent environments of discontinuous change. There has been a consistent level of international criticism regarding national, state, local, and corporate leadership during the COVID-19 crisis. This chapter explores the leadership challenges associated with highly chaotic environments and introduces an advanced model of leadership—Shock Leadership—and a leadership development framework necessary for higher leader reliability and effectiveness in disasters and other crises that create disruptive and discontinuous change.
Article
Digital twins are virtual representations of subsystems within a system of systems. They can be utilized to model and predict performance and condition degradation throughout a system's life cycle. Condition based maintenance, or the performance of system maintenance based on the subsystem states, is often facilitated by the implementation of digital twins. An open challenge is selecting the subsystems that require digital twins. We establish a generic process for determining a set of priority-based system components requiring digital twin development for condition based maintenance purposes. The priority set, which we term the “triage” set, represents the set of components that when monitored through a digital twin lead to the greatest increase in total system reliability and simultaneously represent the minimal cost set of components for implementing a digital twin. While we focus our process on an unmanned underwater vehicle (UUV), where we frame the design problem as a multiobjective optimization problem utilizing experimentally determined data and metrics from the model of a real UUV system, the process is generic enough that it could be utilized by any system looking at cost and reliability estimates for leveraging digital twin technology.
Article
Studying safety from a broad (or multilevel) perspective in daily operations is a challenging prospect. The aim of this article, with the help of a case study, is to contribute to its development. In the introduction, broad (multilevel) safety research is introduced. This introduction indicates main authors who have produced in the past thirty to forty years a strong background against which one can build an idea of this challenge. It requires to decipher in real life situations the interactions between technology, task, structure, culture, strategy and environment of high-risk systems. An additional interest is, following the insights gained from the literature, to investigate the importance of strategic decision making in such broad (multilevel) safety approach. A first section discusses methodological issues linked to ethnographic research, and presents the methodology followed. The second section provides a narrative of the case study which combines a historical view of the plant, a description of some of the salient problems of working practices in a production department, an explanation of these problems through an organisational and managerial perspective, a description of the complex patterns of interactions between people in the plant and a strategic analysis of the situation. The last section discusses the interest of a broad (multilevel) research agenda explicitly incorporating the importance, influence and centrality of powerful decision makers, without simplifying the complexity of this issue.
Article
Full-text available
This article presents a discourse on the incorporation of organizational factors into probabilistic risk assessment (PRA)/probabilistic safety assessment (PSA), a topic of debate since the 1980s that has spurred discussions among industry, regulatory agencies, and the research community. The main contributions of this article include (1) identifying the four key open questions associated with this topic; (2) framing ongoing debates by considering differing perspectives around each question; (3) offering a categorical review of existing studies on this topic to justify the selection of each question and to analyze the challenges related to each perspective; and (4) highlighting the directions of research required to reach a final resolution for each question. The four key questions are: (I) How significant is the contribution of organizational factors to accidents and incidents? (II) How critical, with respect to improving risk assessment, is the explicit incorporation of organizational factors into PRA? (III) What theoretical bases are needed for explicit incorporation of organizational factors into PRA? (IV) What methodological bases are needed for the explicit incorporation of organizational factors into PRA? Questions I and II mainly analyze PRA literature from the nuclear domain. For Questions III and IV, a broader review and categorization is conducted of those existing cross‐disciplinary studies that have evaluated the effects of organizational factors on safety (not solely PRA‐based) to shed more light on future research needs.
Article
On the surface this is a paper about the Navy. More fundamentally, however, it is about language and the role it plays in generating and maintaining organization. The author explored some ways in which one particular organization (the U.S. Navy) uses language that is unique to that organization. There are words, symbols and modes of discourse that characterize this organization and which are unintelligible outside the organization. The thesis is that every organization, task/activity and social group has its own language (lexicon, sign system, mode of discourse). The facts of linguistic differentiation are apparent, but the determinants of, reasons for, and functions of this fact remain obscure.