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A Mindful Governance model for ultra-safe organisations
Abstract
Mindful organising is a key integrating concept in resolving the organisational accident. Mindful organising is both the unique source of critical information about the normal operation, as well as the key recipient of intelligence about the operation, ensuring that operational actions are always informed by the most current, relevant information about potential risks no matter how remote. However, the mindful organising construct has never been operationalised as a practical and effective approach for complex ultra-safe systems. Within the Future Sky Safety programme the construct has been reworked to reinforce the idea that mindful organising is more than just a state of mind. It is about the gathering and flow of information to ensure awareness and appropriate action, both at the operational level and amongst middle management in ensuring improvements are effectively implemented. A novel model has been advanced which provides an organisational context for its implementation, based on the behavioural-economic principle that being well informed about an issue, having an effective and practical solution and being accountable, creates a compelling obligation to act in an appropriate manner. It is suggested how the operationalisation of this model could be supported through a set of generic prototype software applications. The potential applicability of this approach covers not only all sectors of aviation, but also all industries that carry a significant operational risk, including other transport modes, health and social care, emergency services and financial services.
... This would include but also extend beyond the kind of information currently circulated, in the spirit of Respectful Interaction. This is briefly described in McDonald et al. (2019). ...
... To address this, it is necessary to develop more powerful concepts of organisational governance that can show how those apparently spontaneous processes of mindful organising can be deliberately fostered and developed. This argument is taken forward in McDonald et al. (2019). ...
... However, this 'heedful interaction' has a different logic in the wider organisational context and we need to pay attention to the types of organisational processes that could support developing a more global 'collective mind'. This issue is taken up in a subsequent research (McDonald et al., 2019), in which a Mindful Governance model is presented and tested in two case studies. This subsequent research will address the theoretical and practical challenges in developing a viable concept of mindful governance. ...
Mindful organising highlights the commitment to recognise latent failures, deviances, and surprises that may foreshadow the development of larger unwanted events. This social process is fed by extensive real-time communication and interaction by front-line operators. Safety is therefore achieved through these human processes and relationships. But what should an organisation do in practice to be mindful? We explored this in the Maastricht Upper Area Control Centre (MUAC), an Air Traffic Control (ATC) organisation, which has reported for many years high-standards of safety (i.e. very low numbers of serious incidents). A single-case study approach was used to support the in-depth description and understanding of the phenomenon within its real-life context. The mindful organising principles have been followed to design the protocol for data collection and its multiple sources of information (semi-structured interviews, observations, workshop, documents, analysis of the current tools in use). Data triangulation and the use of a software for Qualitative Data Analysis (QDA) have supported the achievement of data reliability and validity. The results provide a picture of the current safety mindful organising in place, assessing the way safety procedures and processes are advanced, the extent to which weak signals are detected, recorded, and analysed, how the best practices/recommendations are implemented, and the overall quality of the information flow. The results of this study suggest improvements in the mindful organising construct from an organisational point of view. This paves the way for the definition of requirements to advance a model able to provide clearer guidance to any organisation wishing to sustain mindful organising.
... The safety mindfulness concept describes flows of information that support mindfulness about safety in an organisation and how such mindfulness impacts decisions and actions to mitigate risks both directly within operations as well as in the management of system improvement [20][21][22][23][24]. The flow of information and the sharing and transformation of knowledge that is grounded in operational constraints represent the core activity. ...
... Questionnaires and workshops are the means to acquire such metrics. Two software applications were designed [22,24]: (1) a social media app that allows operators to share and learn safety-related experiences in their work and (2) an improvement manager app that supports information transfer for change management. The safety mindfulness metrics and apps have not yet been applied in operations. ...
A safety management system (SMS) is the overall set of procedures, documentation, and knowledge systems as well as the processes using them, which are employed within an organisation to control and improve its safety performance. Safety management systems are often observed as being bureaucratic, distinct from actual operations, and being too much focused on the prevention of deviations from procedures rather than on the effective support of safety in the real operational context. The soft parts of advancing safety in organisations, such as the multitude of interrelations and the informal aspects in an organisation that influence safety, are often only considered to a limited extent. As a way forward, this paper presents two coupled approaches. Firstly, a generic tool for assessing the maturity of safety management of aviation organisations is presented, which accounts for recent insights in effectively incorporating human factors. This assessment tool provides insight into the strong and weak topics of an organisation’s SMS. Secondly, an overview is given of a range of approaches that aim to improve the safety of aviation organisations by strengthening relevant organisational processes and structures, with a focus on human factors. The relations of these approaches with SMS are discussed, and the links with topics of the SMS maturity assessment tool are highlighted.
... The concept of Mindful Governance of Operational Risk [17] was developed as a way of operationalising a conceptual approach to mindful organising put forward by Weick [39]. Weick's approach argued for a set of general dispositions of individuals and collectively of organisations (e.g., preoccupation with failure, reluctance to simplify, and sensitivity to operations). ...
... However, for "mindful organising" to occur, there needs to be an actual flow, transformation and management of information, not just the right mindset. Therefore, the development of the initial concept of Mindful Governance was accompanied by the development of practical tools for gathering narratives from operational staff and demonstrating methods for analysing complex patterns of operational data [17,48]. Subsequently, the development focus moved towards implementation of change and improvement following the assessment of risk [49,50]. ...
Three key challenges to a whole-system approach to process improvement in health systems are the complexity of socio-technical activity, the capacity to change purposefully, and the consequent capacity to proactively manage and govern the system. The literature on healthcare improvement demonstrates the persistence of these problems. In this project, the Access-Risk-Knowledge (ARK) Platform, which supports the implementation of improvement projects, was deployed across three healthcare organisations to address risk management for the prevention and control of healthcare-associated infections (HCAIs). In each organisation, quality and safety experts initiated an ARK project and participated in a follow-up survey and focus group. The platform was then evaluated against a set of fifteen needs related to complex system transformation. While the results highlighted concerns about the platform’s usability, feedback was generally positive regarding its effectiveness and potential value in supporting HCAI risk management. The ARK Platform addresses the majority of identified needs for system transformation; other needs were validated in the trial or are undergoing development. This trial provided a starting point for a knowledge-based solution to enhance organisational governance and develop shared knowledge through a Community of Practice that will contribute to sustaining and generalising that change.
... The goal of the Special Issue is to build on these attempts and fundamentally and holistically reappraise MO and its value to safety research and practice. The articles in the Special Issue take prior critiques seriously and, as a result, jointly develop a more holistic , systemic (Kudesia et al., 2019;McDonald et al., 2019), and socially embedded (Gracia et al., 2019;Vendelø and Rerup, 2019) conception of MO. Before discussing the contributions of the articles of the issue in Sections 2 and 3, we discuss how the authors understand MO and collective mindfulness as well as the refinements they offer to both. ...
... The broader conceptualization of MO that emerges from the rich qualitative data in two of the studies in this issue McDonald et al., 2019) offers a direction for future researchtesting alternative conceptualizations of MO. Can MO be reliably and validly measured, perhaps as a higher order construct, with respectful interaction, heedful interrelating, and mindful infrastructure as its components? ...
... The HRA describes mindful organizing or collective mindfulness (Sutcliffe et al., 2016) as the hallmark of high reliability organizations. As such, it has been extensively studied in the context of organizations doing dangerous work, such as aviation (e.g., Callari et al., 2019;McDonald et al., 2019;Oliver et al., 2019) and nuclear power plants (Gracia et al., 2020). Its development is based on case studies in which negative consequences followed errors potentially causing severe harm and damage (including the loss of lives). ...
Errors may be a safety hazard, yet all organizations and managers have to deal with errors. Error management and high reliability are strategies for dealing with errors. While these strategies originate from different research approaches and have been well studied independently, they have not been directly compared in empirical studies. Based on a theoretical analysis of similarities and differences between these approaches, we developed a training based on each of them. For our High Reliability Approach (HRA) training, we deduced training principles based on the facets of safety organizing. For the Error Management Training (EMT) and the training in the error-avoidant control condition (EAT), we oriented on existing training studies. We trained university students (N = 359) in a relevant skill. Our study revealed that both EMT and HRA training led to better performance than EAT. Exploratory analyses revealed emotion control towards errors to be related to performance only in the EMT group. Our article suggests that in spite of similar effectiveness of EMT and HRA training, there may be differential processes in these two approaches.
... If deviation has become the new norm (and is informal), its predecessor must be discussed and transformed by all those involved in the real work. In this scenario, strengthened communication is the next step, as relevant information must circulate within the institution to ensure that operational actions align with the current knowledge of all workers involved [10,39,40]. Unlike the norms agreed upon by the collective in the past, self-checking was previously known only to the author. ...
This study investigated how a standard could become reality-based in a workplace where certain types of deviations are not permitted, such as a radiopharmaceutical production unit. Compliance with standards is necessary to ensure the safety of individuals who manufacture such substances as well as the security of patients receiving treatment. In this qualitative case study, an ergonomic analysis of work (also known as activity analysis) was performed, with noncompliance recorded in internal audits as a starting point: the lack of double-checking in radiopharmaceutical synthesis cassette assembly. Field observations and self-confrontation interviews with workers from a production unit were conducted to analyze the activities. Although a double-check did not occur, the radiopharmaceutical synthesis operator apparently developed another risk control strategy, focusing his attention to the equipment assembly details, which necessitated continuous control and verification actions to ensure that there were no problems at this stage of production. A multilevel approach was used to demonstrate how the safety and quality of production processes based on standard compliance only become effective and adherent to the activity after resolving various conflicts at work, including control systems (external and internal audits), work collectives, the contradiction of the activity itself, and the discussion of singular situations arising daily. This study contributes to the discussion on workplace safety considering standardization and advances the discussion on changing perspectives regarding rule compliance.
... The Access-Risk-Knowledge (ARK) software platform was developed around a socio-technical methodology for analysing complex risks and mitigating these through a managed process of change. The basic theoretical concept behind the ARK platform is the Mindful Risk Governance model of McDonald et al. (2019). The platform was deployed within three collaborating healthcare organisations. ...
Effective governance necessitates going beyond compliance with rules, regulations and procedures; particularly as adverse events are generally the result of a combination of human, organisational, technological, and economic factors. This study explores the use of socio-technical systems analysis (STSA) in an Artificial Intelligence (AI) platform called Access-Risk-Knowledge (ARK) to go beyond established accountability frameworks by linking evidence, outcomes, and accountability. The aim of the ARK-Virus project was to use the ARK Platform to support mindful risk governance of infection prevention and control (IPC) for healthcare organisations during the COVID-19 pandemic. ARK was deployed across three healthcare organisations: a fire and ambulance service, an outpatient dialysis unit, and a large acute hospital. Each organisation conducted an IPC case study, the three of which were then compiled into a synthesis project. A set of guidance principles for a pandemic preparedness strategy were proposed using the synthesis project findings. A Community of Practice (CoP) enabled the successful deployment of ARK, including intense interdisciplinary collaboration and was facilitated by practitioner-researchers in the implementing organisations. Data governance methods and tools supported a whole organisation and multi-organisation approach to risk. This first full implementation trial of the ARK platform deployed dedicated STSA within a semantically structured AI framework, demonstrating accountable risk management that addresses the complex antecedents of risk, links to evidence, and has the potential for managing the full cycle of risk mitigation and improvement.
... Until recently, most mindful organizing studies have been qualitative (Martínez-Córcoles & Vogus, 2020;Sutcliffe et al., 2016). In mindful organizing research in the ATC context, to our knowledge, only two qualitative case studies exist McDonald et al., 2019). The present study aims to contribute to an emerging body of quantitative research on mindful organizing (Gracia, Tomás, et al., 2020;Renecle et al., 2021;Renecle, Gracia, et al., 2020;Renecle, Tomás, et al., 2020) and its antecedents and outcomes, to empirically support the assumptions of mindful organizing theory and extend our understanding of conditions for safety and sustainable performance. ...
Mindful organizing is the collective capability of teams to anticipate, detect, and contain early signs of emerging problems, act proactively, and recover quickly if unexpected events and errors occur. The present study aimed to add to our currently limited understanding of antecedents of mindful organizing: empowering leadership, safety culture, and team safety climate. To do so, we tested a moderated mediation model using a sample of 73 Air Traffic Management company employees. The model evaluated whether safety climate mediates the relationship between empowering leadership and mindful organizing, and whether safety culture understanding as enacted value of safety moderates the effect of empowering leadership on team safety climate. The results showed that a strong safety climate was a significant predictor of mindful organizing. Moreover, empowering leadership influenced mindful organizing indirectly through its positive effect on the safety climate in a work unit. However, the moderating role of safety culture was not confirmed.
... Our model of trust incorporates existing theories of organisational trust [9,10], governance of risk [11], and data governance [12]. Drawing upon several decades of research, dialogue with collaborators, and the literature, three core dimensions of trust were identified: data governance, validation of evidence, and reciprocal obligation to act. ...
This paper proposes a framework for developing a trustworthy artificial intelligence (AI) supported knowledge management system (KMS) by integrating existing approaches to trustworthy AI, trust in data, and trust in organisations. We argue that improvement in three core dimensions (data governance, validation of evidence, and reciprocal obligation to act) will lead to the development of trust in the three domains of the data, the AI technology, and the organisation. The framework was informed by a case study implementing the Access-Risk-Knowledge (ARK) platform for mindful risk governance across three collaborating healthcare organisations. Subsequently, the framework was applied within each organisation with the aim of measuring trust to this point and generating objectives for future ARK platform development. The resulting discussion of ARK and the framework has implications for the development of KMSs, the development of trustworthy AI, and the management of risk and change in complex socio-technical systems.
... In particular, the use of the ASA framework (Schneider, 1987) as a conceptual foundation allowed us to disentangle the way specific culture features of a given organization may fuel, or conversely constrain, each one of the mindful organizing processes. As such, our CMO model enlarges the scarce existing knowledge on the importance of cultural assumptions and values in enhancing mindful organizing processes (e.g., McDonald et al., 2019). ...
The Covid-19 pandemic has involved nations world-wide in the necessity to manage and control the spread of infection, and challenged organizations to effectively counteract an unchartered medical crisis while preserving the safety of workers. While the pandemic and geopolitical turmoil caused by the war in Ukraine are recent examples of complex environments that require effective safety and crisis management, organizations may generally need to find ways to deal with the unexpected and reliably perform in the face of fluctuations. Mindful organizing (MO) is defined as the collective capability to detect discriminatory details about emerging issues and act swiftly in response to these details, thus allowing members to anticipate, and recover from, any errors or unexpected events that arise. Organizational culture refers to the mindset shared among members which orients their actions and thus qualifies as a relevant contextual factor that determines whether the specific forms of perceiving and acting entailed by MO may emerge in an organization. The present paper aimed to propose a conceptual model linking organizational culture, MO and organizational outcomes (i.e., safety, reliability, crisis management), and delineate arguments to address the match/mismatch between MO and culture types. Specifically, it is proposed that organizational culture determines the way an organization develops MO and the subsequent ability to handle unexpected events which might jeopardize organizational effectiveness and safety. Our contribution bridges the still disparate fields of MO and organizational culture, and provides scholars and practitioners with a complexity- and uncertainty-sensitive integrative framework in order to intervene on organizational outcomes.
... Our model of trust incorporates existing theories of organisational trust [9,10], governance of risk [11], and data governance [12]. Drawing upon several decades of research, dialogue with collaborators, and the literature, three core dimensions of trust were identified: data governance, validation of evidence, and reciprocal obligation to act. ...
This paper proposes a framework for developing a trustworthy artificial intelligence (AI) supported knowledge management system (KMS) by integrating existing approaches to trustworthy AI, trust in data, and trust in organisations. We argue that improvement in three core dimensions (data governance, validation of evidence, and reciprocal obligation to act) will lead to the development of trust in the three domains of the data, the AI technology, and the organisation. The framework was informed by a case study implementing the Access-Risk-Knowledge (ARK) platform for mindful risk governance across three collaborating healthcare organisations. Subsequently, the framework was applied within each organisation with the aim of measuring trust to this point and generating objectives for future ARK platform development. The resulting discussion of ARK and the framework has implications for the development of KMSs, the development of trustworthy AI, and the management of risk and change in complex socio-technical systems.
... The individual's way of doing things should be adaptable, based on contemporary conditions instead of orthodox structures. Additionally, organizations can be more reliable if they can be adaptable through their workforce collectively [38,39]. Further, the resilience of the workforce is pivotal and needs to be maintained and developed constantly while facing stressful scenarios for mindful organizing [11]. ...
This study aimed to assess the impact of workforce agility on private hospital nursing
staff’s safety behavior with the mediating role of mindful organizing. This study was cross-sectional.
A self-administered questionnaire was used to collect data from 369 nursing staff. The structural
equation modeling (SEM) technique was used to check the internal consistency, convergent validity,
discriminant validity, and hypotheses testing. For mediation analysis, the bootstrapping technique
was used. Our findings suggested that workforce agility is the possible predictor of mindful organizing,
as all of these dimensions have a positive impact on mindful organizing. Reference to
safety performance sub-dimensions, proactivity, adaptability, and resilience had a positive significant
impact on (a) safety compliance, and proactivity had a positive impact on (b) safety participation.
Further, mindful organizing was also found to be positively associated with safety performance.
Evidence for mediation between workforce agility and safety performance was also observed. Proactivity,
adaptability, and resilience can enhance safety performance for the nursing staff. Workforce
agility can also help the organization to attain mindful organizing, which will help them to achieve
operational excellence, whereas in the past, high-reliability organizations were mainly found practicing
mindful organizing. This study demonstrated the key impact of workforce agility and mindful
organizing on safety behaviors directly and indirectly.
... A study was conducted on the EHR in Canada. This study aimed to have the comparison between the perceptions among physicians on the utilization of EHR and with those who did not utilize it in the working environment [19]. In addition, 220 physicians participated in this study and The Unified Theory of Acceptance and Use of Technology (UTAUT) was apparently adopted for this purpose. ...
Paper based approach to clinical documentation such as handwritten notes among health care providers are cause of errors in medical field. Therefore, health record system needs to be replaced with electronic health record (EHR). Many health professionals in developing countries specifically in Iraq refuse to use the systems implemented for their benefits due to many reasons. Thus, the use of electronic services is important for successful electronic health implementations. Therefore, this study is intended to identify the main factors affecting the intention of use of the electronic health record in Iraq. Health professional staff who work in the main hospital in Dhi-Qar is chosen because this province is the first local province that implemented many electronic projects. The present study examined use of user acceptance of technology, based on the Technology Acceptance Model (TAM). Moreover, the quantitative method approach for data collection using survey from staff who work in the main hospital in Dhi-Qar. Data was analyzed using Structural Equation Modeling using AMOS. The results indicated significant relationship between Ease of Use, Usefulness, Usefulness, Attitude, and Intention of use of EHR. These finding have implementation for decision makers in Iraq government to improve future implementation of e-health services. Keywords: Electronic health Health Quantitative approach SEM TAM Workers This is an open access article under the CC BY-SA license.
... In order to understand and project how flows of information within an organization could foster not only enhanced collective awareness but also more effective management, a model of mindful governance of operational risk was developed and, in part, validated through two industrial case studies [18] [19]. ...
Aviation, health care and financial services are increasingly stretched due to aspects that pose deep enduring systemic threats to our societies, challenging our ability to respond with commensurate socio-technical solutions. It has been argued that complex systems like these are intractable, defying generalisable analysis that could support prediction and control, and hence are not amenable to compliance models of regulation. Instead it is argued here that this ability can be developed with applying governance to a knowledge system.The knowledge system needs to identify relevant system properties with leverage on operational risk. Big data analysis plus model-based reasoning, can identify generic socio-technical system characteristics. To make sense of the relations between system and outcome a complementary capability to model the functionality of producing the data is needed. Our socio-technical analysis model is based on the following principles: purposive human systems have outcomes and produce value; this involves at least a minimal sequence of activity with related dependencies; it is the reciprocal nature of social relations that makes that sequence possible, and the flow of knowledge and information enables these productive roles of people. A governance system is required to assure that this works. A governance system should generate a motivation, an “obligation to act” to use the knowledge directly within operations, to implement and validate solutions, and to manage risk across the system. This behaviour needs to be sustained in three cycles of governance: Operational, Improvement and Strategic. The operational feedback loop maintains its role to ensure close monitoring of the operational impact of the system change, maintaining a close link between strategic implementation and operational experience. Safety is not something distinct and separate from other aspects of system functionality, but it needs to be integrated into a new evidence-based governance of operational risk which is outlined in this paper.
Purpose
Sustainability is a pressing global issue that affects everyone on the planet. This study aims to provide a deeper understanding of the nuanced interplay between mindful organizing (MO), organizational learning capability (OLC), leadership commitment to sustainable development goals (SDGs) and sustainability performance, adopting the theoretical foundation of organizational learning.
Design/methodology/approach
The survey data from 728 middle management employees of exporting firms in Pakistan were collected at two points. The mediated moderation analysis was performed through structural equation modeling in AMOS 26.
Findings
The results indicate a positive relationship between MO and sustainability performance. The mediating effect of OLC highlights that firms that acquire, assimilate and apply knowledge and insights leverage their MO strategies to improve sustainability performance more effectively. Additionally, the leadership commitment to SDGs amplifies the positive effect of OLC on sustainability performance.
Practical implications
These results have important implications for managers and policymakers who seek to promote sustainability in organizations. The findings suggest that cultivating a mindful organizational culture and investing in learning capability enhance sustainability performance. Exporting firms should develop comprehensive learning programs that embed mindfulness and sustainability into the core of organizational culture. More interdisciplinary research is needed to integrate insights from environmental science, psychology, management and organizational behavior.
Originality/value
This research stands out for its integrative approach, practical relevance, empirical examination of important concepts and alignment with global sustainability goals. Exporting firms must understand how organizational learning capabilities and MO can be harnessed to achieve sustainable outcomes.
Innovative approaches are needed for managing risk and system change in healthcare. This paper presents a case study of a project that took place over two years, taking a systems approach to managing the risk of healthcare acquired infection in an acute hospital setting, supported by an Access Risk Knowledge Platform which brings together Human Factors Ergonomics, Data Science, Data Governance and AI expertise. Evidence for change including meeting notes and use of the platform were studied. The work on the project focused on first systematically building a rich picture of the current situation from a transdisciplinary perspective. This allowed for understanding risk in context and developing a better capability to support enterprise risk management and accountability. From there a linking of operational and risk data took place which led to mapping of the risk pattern in the hospital.
Even if enhancing safety remains a key challenge in civil aviation, safety research has mainly focussed on front line operators, senior managers and safety managers. This paper aims to shed light on the middle managers, more specifically on the overall context that influences their contribution to safety in their daily operations, and the challenges they face. Over a two-year period, extensive field research was undertaken involving six sector organisations, and overall forty-three middle managers. Interviews were conducted to capture the participants’ views and experiences in embedding safety-related aspects in their daily activities and actions. A data-driven approach was used to support the emergence of recurring codes/themes that could describe the conditions the middle managers face in their organisations, and explain how the specific factors interplay and impact on their action. NVivo, with its tools, supported the entire research process (data storage, codification, both qualitatively and quantitatively descriptive analysis at code level, and explanatory analysis at codes-relationship level). Our results suggest a number of conditions/dimensions (internal and external to the organisation) that interplay to either support or hinder the middle managers’ contribution to safety. This contribution is translated in practices (i.e. strategies and actions that the middle managers apply to support safety-related outcomes) modulated by a certain ‘mindset’ that each middle manager possesses as a result of past experiences, background education and view on the role of a manager. These aspects are interrelated not only with the middle managers’ safety-related practices directly, but also with one another. To understand management contribution to safety, and what may promote or hinder it, one should adopt a systemic view combining individual, organisational, external aspects and their interrelations.
Aviation, health care and financial services are increasingly stretched due to aspects that pose deep enduring systemic threats to our societies, challenging our ability to respond with commensurate socio-technical solutions. It has been argued that complex systems like these are intractable, defying generalisable analysis that could support prediction and control, and hence are not amenable to compliance models of regulation. Instead it is argued here that this ability can be developed with applying governance to a knowledge system.The knowledge system needs to identify relevant system properties with leverage on operational risk. Big data analysis plus model-based reasoning, can identify generic socio-technical system characteristics. To make sense of the relations between system and outcome a complementary capability to model the functionality of producing the data is needed. Our socio-technical analysis model is based on the following principles: purposive human systems have outcomes and produce value; this involves at least a minimal sequence of activity with related dependencies; it is the reciprocal nature of social relations that makes that sequence possible, and the flow of knowledge and information enables these productive roles of people. A governance system is required to assure that this works. A governance system should generate a motivation, an “obligation to act” to use the knowledge directly within operations, to implement and validate solutions, and to manage risk across the system. This behaviour needs to be sustained in three cycles of governance: Operational, Improvement and Strategic. The operational feedback loop maintains its role to ensure close monitoring of the operational impact of the system change, maintaining a close link between strategic implementation and operational experience. Safety is not something distinct and separate from other aspects of system functionality, but it needs to be integrated into a new evidence-based governance of operational risk which is outlined in this paper.
Nothing has been more prolific over the past century than human/machine interaction. Automobiles, telephones, computers, manufacturing machines, robots, office equipment, machines large and small; all affect the very essence of our daily lives. However, this interaction has not always been efficient or easy and has at times turned fairly hazardous. Cognitive Systems Engineering (CSE) seeks to improve this situation by the careful study of human/machine interaction as the meaningful behavior of a unified system. Written by pioneers in the development of CSE, Joint Cognitive Systems: Foundations of Cognitive Systems Engineering offers a principled approach to studying human work with complex technology. The authors use a top-down, functional approach and emphasize a proactive (coping) perspective on work that overcomes the limitations of the structural human information processing view. They describe a conceptual framework for analysis with concrete theories and methods for joint system modeling that can be applied across the spectrum of single human/machine systems, social/technical systems, and whole organizations. The book explores both current and potential applications of CSE illustrated by examples. Understanding the complexities and functions of the human/machine interaction is critical to designing safe, highly functional, and efficient technological systems. This is a critical reference for students, designers, and engineers in a wide variety of disciplines.
Aviation today is seen as a very safe industry, yet recent accidents have shown that vulnerabilities still exist. The literature has often drawn attention to the role played by top managers/CEO in running their businesses profitably, and at the same time keeping them safe from threats. Research has also investigated the way people at the sharp-end of organisations are ‘mindful’ of the possible threats that can occur in their day-to-day activities, and how they can anticipate (most of) them. But what about the role played by middle managers in ensuring safety in every organisational operation? Even if researchers now agree that middle managers’ actions are a valuable asset for organisations and central to pursuing key organisational outcomes, very little is known about how middle managers take safety into account in their daily operations, and the challenges they face. This paper reports on the safety-related practices and challenges of middle managers of the civil aviation industry. Within the Future Sky Safety project, over a two-year research activity, 48 middle managers from a range of aviation organisations agreed to talk about the strategies and actions they put in place on a routine basis, to embed safety in the daily operations. Methodologically, semi-structured interviews were conducted and the qualitative content analysis (QCA) method was used to make sense of the raw material, through a data-driven coding frame. The findings of this research suggest that the practices middle managers identify as central in relation to their role in the management of safety can be grouped into three high-level categories: (1) making decisions, (2) influencing key stakeholders to get the job done, and (3) managing information. This research adds knowledge in relation to the middle managers’ role in the management of safety, in particular shedding light on the competency that middle managers from the civil aviation industry rely on to get the job done when it comes to contributing to safety.
We need teams in nearly every aspect of our lives (e.g., hospitals, schools, flight decks, nuclear power plants, oil rigs, the military, and corporate offices). Nearly a century of psychological science has uncovered extensive knowledge about team-related processes and outcomes. In this article, we draw from the reviews and articles of this special issue to identify 10 key reflections that have arisen in the team literature, briefly summarized here. Team researchers have developed many theories surrounding the multilayered aspects of teams, such that now we have a solid theoretical basis for teams. We have recognized that the collective is often stronger than the individual, initiating the shift from individual tasks to team tasks. All teams are not created equal, so it is important to consider the context to understand relevant team dynamics and outcomes, but sometimes teams performing in different contexts are more similar than not. It is critical to have teamwork-supportive organizational conditions and environments where psychological safety can flourish and be a mechanism to resolve conflicts, ensure safety, mitigate errors, learn, and improve performance. There are also helpful teamwork competencies that can increase effectiveness across teams or tasks that have been identified (e.g., coordination, communication, and adaptability). Even if a team is made up of experts, it can still fail if they do not know how to cooperate, coordinate, and communicate well together. To ensure the improvement and maintenance of effective team functioning, the organization must implement team development interventions and evaluate relevant team outcomes with robust diagnostic measurement. We conclude with 3 main directions for scientists to expand upon in the future: (a) address issues with technology to make further improvements in team assessment, (b) learn more about multiteam systems, and (c) bridge the gap between theory and practice. In summary, the science of teams has made substantial progress but still has plenty of room for advancement.
Algorithmic results of Machine Learning applications in a commercial aviation airline.
Scores for Unstable Approaches (UA) for individual flight operations of an undisclosed european airline are presented. A selection of features (predictors) have been modelled by logistic functions to target the UA variable (prediction). All possible combinations of such features have been processed over several thousands of flight operations.
Some combinations (true risk pattern signatures) got statistically significant parameters (significant beta values/odd ratios with large effects) by various Machine Learning algorithms performed in IBM SPSS 25 software between 2017 and 2018. SPSS syntax coding was preferred.
Recent changes in the global construction industry coupled with rising challenges as a result of the dynamic nature of offshore operations have greatly underscored the need for stakeholders to evolve safety management systems that optimize safety during the execution of their construction project operations. As a result, the offshore industry has witnessed significant changes which currently place a greater premium on effective safety management, with organizations’ requiring to look across the whole project’s life cycle. To optimize safety during operations, formulating effective safety management systems becomes a crucial challenge faced by industry stakeholders. Utilising evidence from semi- structured interviews, this paper examines senior managers’ role in safety leadership in Nigerian offshore oil and gas projects. It concluded that leadership style is critical for the implementation of any effective safety management system utilised during offshore construction projects. The findings also facilitate an in-depth understanding of lessons learnt from offshore construction projects and will be useful for improving the overall safety management strategy of organisations in line with important factors usually considered by the global offshore oil and gas industry.
In this paper the findings are presented of a multinational study involving 27 companies that have adopted a ‘Zero Accident Vision’ (ZAV). ZAV is the ambition that all accidents are preventable, and this paper focuses on how companies implement ZAV through ZAV commitment, safety communication, safety culture and safety learning. Managers and workers took part in a survey (8,819 respondents), company interviews and national workshops in seven European countries. A common characteristic of all the companies was the high ZAV commitment of their managers and workers, which often were embedded in the companies’ business strategies. It is very likely that this commitment is the main driver for long-term safety improvements. This research supports the importance of safety communication for ZAV implementation, especially of: specific ZAV or safety promotion programmes, constant and updated communication on functional tools, and effective supervisor communication. Successful communication must ensure ‘relevant’ information to respective organisational levels (not a one-size fits-all strategy), and allow for ‘decentralised’ initiatives. This research also highlights the importance of safety culture for ZAV implementation, with ZAV companies having high survey scores on management safety priority, safety empowerment and safety justice. The results also support the importance of safety learning (incidents and good-practice) for ZAV implementation. Additional success factors were top management support and an ‘open atmosphere’, systematic communication and dialogue on incidents, and a focus on things that go right. We conclude that ZAV is the basis for inspiring and innovative approaches to improve safety, as an integrated part of doing business.
Consistent with the positive organizational scholarship (POS) focus on positively deviant performance, mindful organizing represents a set of social processes that underlie the near-flawless performance of high-reliability organizations (HROs). This chapter details the foundations of mindful organizing, reviews recent empirical developments, and proposes five potential directions for further theoretical and empirical development, each of which deepens its contribution and connection to POS. The first proposed direction is to conceptually and empirically link both Eastern and Western conceptions of individual mindfulness and mindful organizing. The second is to establish the affective foundations of mindful organizing, namely how emotion affects the relationships between mindful organizing and error-free performance, the discrete emotions that constitute mindful organizing, and how emotional narratives sustain mindful organizing. Third is to examine a broader range of outcomes of mindful organizing, including its effects on employees. Fourth is to better link mindful organizing to leader attributes and leadership processes. Last, the impact of mindful organizing also requires further construct validation, including differentiating it from related constructs and establishing its responsiveness to interventions.
In recent years, research on mindfulness has grown rapidly in organizational psychology and organizational behavior. Specifically, two bodies of research have emerged: One focuses on the intrapsychic processes of individual mind-fulness and the other on the social processes of collective mindfulness. In this review we provide a pioneering, cross-level review of mindfulness in organizations and find that mindfulness is neither mysterious nor mystical, but rather can be reliably and validly measured, linked to an array of individual and organizational outcomes, and induced through meditative and nonmeditative practices and processes at the individual and collective levels. Our analysis of the combined literatures further reveals that although each literature is impressive, there is a significant need for multilevel mindfulness research that simultaneously examines individual and collective mindfulness and broadens its conception of context. This research agenda provides a more robust understanding of the antecedents, processes, and consequences of individual and collective mindfulness as well as more definitive evidence maximizing mindfulness and its benefits in practice.
Within the aviation industry, the need for sustainable change is becoming more and more critical due to increasing commercial pressure, upcoming regulations and accelerating cycles of new technologies. But, whilst there is wide acceptance that change is necessary, the evidence is scant both in terms of empirical academic work and industrial-based case studies. Addressing the very real challenges industry has in implementing sustainable change was the key focus of the MAnaging System Change in Aviation (MASCA) project. MASCA was a three-year FP7 collaborative project funded by the European Union that finished in December 2013. The project was driven by the following four industry change initiatives:Case Study 1: Implementing Airport Collaborative Decision-Making (A-CDM).Case Study 2: The development and implementation of a comprehensive Safety Management System (SMS) in a major airline.Case Study 3: The development and implementation of a holistic performance management approach in a s ...
Organisational change is as likely to fail as to succeed. The core proposition of the approach outlined in this paper is that the functionality of a socio-technical system is a potential constraint on the way that it can change, and this is something that current theories do not address. Thus, some of the variance in the success rate of change could be due to the inherent properties of the system and/or the way in which these properties are understood. This paper explores this proposition through a high-level discussion of four aviation industry case studies. These include: the change of a small regional airport from a public body to a business concern; the introduction of Airport Collaborative Decision-Making (A-CDM) at a major international airport; the introduction of a new Safety Management System at a major airline; and the assessment of risk in advance of major change in a regional airline. A theory of the mechanisms of socio-technical systems is proposed based on the relation between the functional requirements of operational processes and the social relations that are necessary to support them. Cycles of knowledge and information mediate between these and provide opportunities for intervention. This theory is applied to the case studies through a system change and operational evaluation tool (SCOPE/Structured Enquiry). The theory provides a basis for supporting the change initiatives as well as a framework for evaluating their status and progress. The evaluation emphasises the following themes: understanding the functionality of the operational system, how this can be enhanced by management processes, the inclusiveness of social relations, trust, the transformative role of information and the development of knowledge.
The key objective of this paper was to report on one of the industrial-based change case studies of the MASCA project (MAnaging System Change in Aviation—EU FP7, 2010–2013
). This case study provides a systematic insight into one airport’s approach to their preparation for full implementation of Airport Collaborative Decision Making (A-CDM). An action-based methodological approach was applied over a 3-year period, and a particular focus of this paper is on the application of the MASCA system change and operational evaluation tool (SCOPE/Structured Enquiry). Key recommendations resulted in research-led interventions, such as the development of a Serious Game to facilitate co-ordination and communications. The paper also reports on future recommendations for the implementation of A-CDM, such as prioritising social relations and trust building amongst airport stakeholders as opposed to viewing A-CDM solely as an IT-led project. Recommendations and learning from this case study can also be disseminated to other airports who are about to embark on the preparation for full A-CDM implementation and compliance.
Organization studies have long focused on the problem of understanding the possibility of
pursuing effectiveness and resilience at the same time. An emerging perspective, reconciling mindfulness and routines, allows to address these contrasting goals: routines channel the exploratory nature of mindfulness, but they also support it by providing context to its enactment. Despite these results, available empirical evidence from mindful organizations has not helped understand how mindfulness can be supported by routines without losing its broader scope of attention. Moreover, an operational definition of mindfulness is still an open question. In this paper, we adopt an analytical framework allowing to break down routines into their sensing and reacting components. Using evidence from the flying practices of Tornado crews in the
Italian Air Force, we show that mindfulness concerns the parallel activation and re-combination of these components, allowing the rapid deployment of responses but also the continuous reassessment of the situation.
The purpose of this paper is organizing mindfully for relevant process research on strategic change. This essay arises from an increasing concern that our understanding of strategic change is not delivering meaningful, relevant and true process wisdom that allows researchers to enrich their academic discourse and practitioners to effectively realize strategic change imposed by hostile business markets. Our goal is to challenge
fundamental assumptions of our field’s dominant discourse in performing research and generating theories for strategic change under real contexts, and redirect attention to a mindful organizing perspective to understand process elements of strategic change that really matter.
Senior managers can have a strong influence on organisational safety. But little is known about which of their personal attributes support their impact on safety. In this paper, we introduce the concept of 'safety intelligence' as related to senior managers' ability to develop and enact safety policies and explore possible characteristics related to it in two studies. Study 1 (N = 76) involved direct reports to chief executive officers (CEOs) of European air traffic management (ATM) organisations, who completed a short questionnaire asking about characteristics and behaviours that are ideal for a CEO's influence on safety. Study 2 involved senior ATM managers (N = 9) in various positions in interviews concerning their day-to-day work on safety. Both studies indicated six attributes of senior managers as relevant for their safety intelligence, particularly, social competence and safety knowledge, followed by motivation, problem-solving, personality and interpersonal leadership skills. These results have recently been applied in guidance for safety management practices in a White Paper published by EUROCONTROL.
Every day the hypothesis about safe operation materialised in procedures and standards is tested by actual flight operations. FOREC helps to understand both the adequacy of standards and procedures and situations where shortfalls may appear. This is done via collecting the stories pilots tell about their safety events and how they signify their experience against resilience concepts. Analysis can then show patterns that might be weak signals for impending problems. FOREC goes beyond simple counts of failures and errors, it reduces the interpretative layers between the operation and company management by allowing managers to read the pilots' stories in their context, and thereby understand the successes of flight operational resilience.
Research on organizational safety and reliability largely has emphasized system-level structures and processes neglecting the more micro-level, social processes necessary to enact organizational safety. In this qualitative study we remedy this gap by exploring these processes in the context of wildland fire management. In particular, using interview data gathered from 28 individuals involved in wildland firefighting, we explore the validity of the idea that a deterrent to organizational safety is an inability to redirect ongoing actions once they are underway. The findings suggest four major themes. First, individuals and groups redirect ongoing action as a result of re-evaluating that action. Second, noticing early warning signs, while necessary, is not sufficient to drive change. Third, two social processes — giving voice to concerns and actively seeking alternative perspectives — appear to be key drivers of re-evaluation. Fourth, the process of redirecting action is moderated by two social factors: institutional pressures and self-interest. We discuss the implications of these patterns for organization theory and for future research.
Ray, Baker, and Plowman's (2011) study of organizational mindfulness highlights latent tensions in the mindfulness literature and promising avenues for future research. Their study provides a springboard for reconciling the literature by differentiating organizational mindfulness from mindful organizing, establishing where organizational mindfulness and mindful organizing are most important, and clarifying how and when each construct can be most fruitfully deployed in research and practice. Clearer theorizing leads to a set of research questions that seek to integrate multiple conceptions of individual and organizational mindfulness, establish their individual and organizational antecedents, explore the consequences for individuals and organizations, and in so doing, further increase the relevance of organizational mindfulness for business schools.
Consistent with the positive organizational scholarship (POS) focus on positively deviant performance, mindful organizing represents a set of social processes that underlie the near-flawless performance of high-reliability organizations (HROs). This chapter details the foundations of mindful organizing, reviews recent empirical developments, and proposes five potential directions for further theoretical and empirical development, each of which deepens its contribution and connection to POS. The first proposed direction is to conceptually and empirically link both Eastern and Western conceptions of individual mindfulness and mindful organizing. The second is to establish the affective foundations of mindful organizing, namely how emotion affects the relationships between mindful organizing and error-free performance, the discrete emotions that constitute mindful organizing, and how emotional narratives sustain mindful organizing. Third is to examine a broader range of outcomes of mindful organizing, including its effects on employees. Fourth is to better link mindful organizing to leader attributes and leadership processes. Last, the impact of mindful organizing also requires further construct validation, including differentiating it from related constructs and establishing its responsiveness to interventions.
Organizations have difficulty learning from rare and unusual events because of their inability to interpret these events. Because organizations develop habitual ways of interpreting events---often top down---they can easily miss the novelty of rare and unusual events, which prevents them from experiencing events “richly.” We propose a multilevel, multistaged model of organizational interpretation that highlights the important, but generally unacknowledged, role middle managers can play in helping organizations experience rare and unusual events richly. Our model accounts for the effect of cognitive biases and hierarchical context on organizational interpretation. Because of their proximity to the interpretations of both strategic and front-line managers, middle managers can encourage divergence in interpretations of managers across hierarchical levels during early stages of the interpretation process and can blend and synthesize the divergent interpretations of managers during later stages. In this way middle managers contribute to a dynamic process of organizational interpretation in which multiple filters from throughout the organization help frame and enrich interpretations of rare and unusual events, which enables organizational learning.
This paper presents a theoretical model of situation awareness based on its role in dynamic human decision making in a variety of domains. Situation awareness is presented as a predominant concern in system operation, based on a descriptive view of decision making. The relationship between situation awareness and numerous individual and environmental factors is explored. Among these factors, attention and working memory are presented as critical factors limiting operators from acquiring and interpreting information from the environment to form situation awareness, and mental models and goal-directed behavior are hypothesized as important mechanisms for overcoming these limits. The impact of design features, workload, stress, system complexity, and automation on operator situation awareness is addressed, and a taxonomy of errors in situation awareness is introduced, based on the model presented. The model is used to generate design implications for enhancing operator situation awareness and future directions for situation awareness research.
For Resilience Engineering, 'failure' is the result of the adaptations necessary to cope with the complexity of the real world, rather than a breakdown or malfunction. The performance of individuals and organizations must continually adjust to current conditions and, because resources and time are finite, such adjustments are always approximate. This definitive new book explores this groundbreaking new development in safety and risk management, where 'success' is based on the ability of organizations, groups and individuals to anticipate the changing shape of risk before failures and harm occur. Featuring contributions from many of the worlds leading figures in the fields of human factors and safety, Resilience Engineering: Concepts and Precepts provides thought-provoking insights into system safety as an aggregate of its various components, subsystems, software, organizations, human behaviours, and the way in which they interact. The book provides an introduction to Resilience Engineering of systems, covering both the theoretical and practical aspects. It is written for those responsible for system safety on managerial or operational levels alike, including safety managers and engineers (line and maintenance), security experts, risk and safety consultants, human factors professionals and accident investigators.
Mindful organising highlights the commitment to recognise latent failures, deviances, and surprises that may foreshadow the development of larger unwanted events. This social process is fed by extensive real-time communication and interaction by front-line operators. Safety is therefore achieved through these human processes and relationships. But what should an organisation do in practice to be mindful? We explored this in the Maastricht Upper Area Control Centre (MUAC), an Air Traffic Control (ATC) organisation, which has reported for many years high-standards of safety (i.e. very low numbers of serious incidents). A single-case study approach was used to support the in-depth description and understanding of the phenomenon within its real-life context. The mindful organising principles have been followed to design the protocol for data collection and its multiple sources of information (semi-structured interviews, observations, workshop, documents, analysis of the current tools in use). Data triangulation and the use of a software for Qualitative Data Analysis (QDA) have supported the achievement of data reliability and validity. The results provide a picture of the current safety mindful organising in place, assessing the way safety procedures and processes are advanced, the extent to which weak signals are detected, recorded, and analysed, how the best practices/recommendations are implemented, and the overall quality of the information flow. The results of this study suggest improvements in the mindful organising construct from an organisational point of view. This paves the way for the definition of requirements to advance a model able to provide clearer guidance to any organisation wishing to sustain mindful organising.
Since the 1990ies, organizations from different sectors have been operating in increasingly dynamic socio-economic environments characterized by unexpected events and instability. Organizations tend to adjust to dynamic environments by change initiatives promoting permanent reorganization. Such change initiatives often induce unintended effects, e.g. an erosion of trust, the violation of ‘psychological contracts’ in employees’ eyes or a decrease in organizational effectiveness. This book explores and analyzes whether such unintended effects can be anticipated or constructively dealt with by mindful change. The latter refers to the concept of organizational mindfulness that originally is linked to risk and safety research, e.g. in respect to ‘High Reliability Organizations’. In this book, organizational mindfulness is re-conceptualized addressing organizational change in the perspective of organizational sustainability. Moreover, it is explored how institutions foster or restrict organizations’ capability of organizational mindfulness in change processes.
The idea that an organizational workforce as a collective can have the attribute of being ‘collectively mindful’ points towards a readiness to respond through stable cognitive processes and variability in actions which are needed to maintain system functioning and manage system fluctuations when the unexpected happens. This paper reviews recent theory and research on the concepts of Organizational Mindfulness and Mindful Organizing with a view to imparting understanding on how the collective workforce plays a key role in the management of the unexpected by using the five principles of organizational collective mindfulness. Suggestions for strategically enhancing these organizational mindfulness concepts are discussed to enable enhancement of an organizational resilience safety culture.
This introductory chapter highlights concepts covered in the subsequent chapters in this book. The first section of the book gives a bird's-eye view of the teamwork literature. It describes factors that influence team performance, in terms of overall effectiveness, contextual efficiency, and intrateam synchronicity. It gives a general summary of teams in terms of psychological dynamics and greater societal significance. Having set a comprehensive framework through which to understand teams, the second section of the book focuses on antecedents of team effectiveness. The third section of the book takes a finer-grained look at dynamics within teams: core processes, emerging states, and mediators. Each of the authors describes, in detail, different psychological forces that both affect and stem from team interaction. The fourth section explores methods of managing and assessing teams, and the final section offers a perspective on the future of teamwork research.
Managers’ strong commitment to safety is a key element of a successful safety management, culture and climate. Several studies have approached managers’ commitment from the employees’ point of view, but research approaching commitment from the managers’ viewpoint is scarce. This qualitative study aims to identify the organisational factors that hinder or promote managers’ commitment to safety and to suggest organisational measures that can be applied to support managers’ commitment to safety. A total of 49 managers in five industrial organisations were interviewed. In addition, a workshop for the safety professionals of the participating companies was organised to review the interview results and to suggest organisational measures to support managers’ commitment to safety.
The managers identified role overload, production demands, overly formal safety procedures, external safety goals, workforce attitudes and managers’ attitudes as the most common factors hindering their commitment to safety. On the other hand, the factors that promote managers’ commitment to safety are increasing managers’ safety awareness, influencing managers’ safety attitudes, recognising managers’ safety commitment, emphasising managers’ safety responsibilities, developing adequate organisational safety procedures, superiors’ encouragement and support, benchmarking others’ safety activities, understanding the economic effects of safety, and safety improvement. The suggested organisational measures to support managers’ commitment to safety include inspirational and participative management training; appropriate safety objectives; peer, superior and top management support; campaigns and competitions; employee safety training; and simplified safety procedures and reporting. The study expands on previous studies on supervisors’ safety engagement and suggests practical organisational measures to promote managers’ commitment to safety.
The increasingly complex and volatile nature of organizational environments and technologies exposes many organizations to unexpected, unpredictable, and uncertain vulnerabilities. A growing stream of organization theory proposes that the capability to adapt flexibly in real time results from organizing processes that foster collective mindfulness. Collective mindfulness encompasses rich awareness of discriminatory detail coupled with wise action that enables organizations to more quickly sense and manage complex, ill-structured contingencies. In this chapter, we review the literature on collective mindfulness, particularly, the organizing processes through which mindfulness is achieved. We begin by examining its conceptual origin in research on high reliability organizations, review some recent empirical research, and explore how mindful organizing integrates Western and Eastern conceptions. We end by proposing avenues for future research.
Economic globalization places increased competitive pressure on economic organizations. The latter more often respond to unpredictable socio-economic environments by change initiatives of permanent reorganization. However, permanent change can induce unintended and often detrimental effects in respect to organizational effectiveness, the quality of work and to social integration at organizational level. It is argued that the concept of organizational mindfulness – originally developed related to ‘high-reliability organizations’ – can facilitate mindful and sustainable change. In this chapter, this concept is re-conceptualized with regard to organizational change. Organizational mindfulness is viewed as an organizational capacity of action to anticipate and to constructively deal with unintended effects of permanent reorganization. Moreover, organizational mindfulness intends to uncover unnoticed innovation potentials in organizational change. Organizational mindfulness is comprised of an infrastructure of dialogue and organizational routines, and six core principles facilitating mindful change. The latter is assumed to contribute to the regeneration of economic organizations’ social-resource base, thereby promoting social sustainability at organizational level.
High Reliability Organizations (HROs) have been treated as exotic outliers in mainstream organizational theory because of their unique potentials for catastrophic consequences and interactively complex technology. We argue that HROs are more central to the mainstream because they provide a unique window into organizational effectiveness under trying conditions. HROs enact a distinctive though not unique set of cognitive processes directed at proxies for failure, tendencies to simplify, sensitivity to operations, capabilities for resilience, and temptations to overstructure the system. Taken together these processes induce a state of collective mindfulness that creates a rich awareness of discriminatory detail and facilitates the discovery and correction of errors capable of escalation into catastrophe. Though distinctive, these processes are not unique since they are a dormant infrastructure for process improvement in all organizations. Analysis of HROs suggests that inertia is not indigenous to organizing, that routines are effective because of their variation, that learning may be a byproduct of mindfulness, and that garbage cans may be safer than hierarchies.
Many 21st century operations are characterised by teams of workers dealing with significant risks and complex technology, in competitive, commercially-driven environments. Informed managers in such sectors have realised the necessity of understanding the human dimension to their operations if they hope to improve production and safety performance. While organisational safety culture is a key determinant of workplace safety, it is also essential to focus on the non-technical skills of the system operators based at the 'sharp end' of the organisation. These skills are the cognitive and social skills required for efficient and safe operations, often termed Crew Resource Management (CRM) skills. In industries such as civil aviation, it has long been appreciated that the majority of accidents could have been prevented if better non-technical skills had been demonstrated by personnel operating and maintaining the system. As a result, the aviation industry has pioneered the development of CRM training. Many other organisations are now introducing non-technical skills training, most notably within the healthcare sector. Safety at the Sharp End is a general guide to the theory and practice of non-technical skills for safety. It covers the identification, training and evaluation of non-technical skills and has been written for use by individuals who are studying or training these skills on CRM and other safety or human factors courses. The material is also suitable for undergraduate and post-experience students studying human factors or industrial safety programmes. © Rhona Flin, Paul O'Connor and Margaret Crichton 2008. All rights reserved.
In this paper, we propose that performance under uncertainty and ambiguity is enabled by a two-pronged set of practices enacted by leaders and frontline workers. These contextualized practices fuel performance by enabling teams and organizations to both discern, interpret and make sense of important discrepancies as situations unfold (what we refer to as anomalizing), and to develop a richer understanding of a situation (what we call proactive leader sensemaking). Together, these situation-specific practices contextualize engagement and promote capabilities to contingently tailor actions to unfolding conditions. We test our hypotheses using data gathered from a sample of wildland firefighters and find strong support for our theorizing. We also identify a set of additional group and situational conditions that provide a more nuanced understanding of factors that contribute to reliable performance under dynamic uncertainty. Together, the findings provide quantitative evidence for the micro-foundations of effective performance in uncertain contexts.
Senior managers’ safety commitment is emphasised in the safety literature as a crucial influence on organisational safety. Yet there is little understanding of the characteristics that underpin their ability to engage in behaviours that demonstrate safety commitment. This study investigates the contribution of problem-solving, social competence and safety knowledge to such behaviours. Senior managers (N = 60) from European and North American air traffic management organisations participated in interviews consisting of open questions designed to trigger safety knowledge and descriptions of behaviours that demonstrate safety commitment as well as scenarios designed to trigger problem-solving and social competence. Reliable scores were generated through systematic scoring procedures involving two independent coders. The results indicated that problem-solving, namely the number of issues and information sources considered when understanding problems and generating ideas to solve a problem were positively related to demonstrations of safety commitment. The ability to perceive others was also found to correlate with safety commitment, whereas safety knowledge was not associated with behaviours that demonstrate safety commitment. It is proposed that training and guidance designed for senior managers should focus on their problem-solving abilities and perception of others in order to support them in demonstrating safety commitment.
Safety has traditionally been defined as a condition where the number of adverse outcomes was as low as possible (Safety-I). From a Safety-I perspective, the purpose of safety management is to make sure that the number of accidents and incidents is kept as low as possible, or as low as is reasonably practicable. This means that safety management must start from the manifestations of the absence of safety and that - paradoxically - safety is measured by counting the number of cases where it fails rather than by the number of cases where it succeeds. This unavoidably leads to a reactive approach based on responding to what goes wrong or what is identified as a risk - as something that could go wrong.
Focusing on what goes right, rather than on what goes wrong, changes the definition of safety from ‘avoiding that something goes wrong’ to ‘ensuring that everything goes right’. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. From a Safety-II perspective, the purpose of safety management is to ensure that as much as possible goes right, in the sense that everyday work achieves its objectives. This means that safety is managed by what it achieves (successes, things that go right), and that likewise it is measured by counting the number of cases where things go right. In order to do this, safety management cannot only be reactive, it must also be proactive. But it must be proactive with regard to how actions succeed, to everyday acceptable performance, rather than with regard to how they can fail, as traditional risk analysis does.
This book analyses and explains the principles behind both approaches and uses this to consider the past and future of safety management practices. The analysis makes use of common examples and cases from domains such as aviation, nuclear power production, process management and health care. The final chapters explain the theoretical and practical consequences of the new perspective on the level of day-to-day operations as well as on the level of strategic management (safety culture).
An enriched view of mindfulness, jointly informed by Eastern and Western thinking, suggests that attentional processes in organizing have been underspecified. Respecification of attention in the context of classical views of mindfulness results in a perspective that features diminished dependence on concepts, increased focus on sources of distraction, and greater reliance on acts with meditative properties. Enriched mindfulness reveals the reality of impermanence and the necessity for continuous organizing to produce wise action.
The concept of collective mind is developed to explain organizational performance in situations requiring nearly continuous operational reliability. Collective mind is conceptualized as a pattern of heedful interrelations of actions in a social system. Actors in the system construct their actions (contributions), understanding that the system consists of connected actions by themselves and others (representation), and interrelate their actions within the system (subordination). Ongoing variation in the heed with which individual contributions, representations, and subordinations are interrelated influences comprehension of unfolding events and the incidence of errors. As heedful interrelating and mindful comprehension increase, organizational errors decrease. Flight operations on aircraft carriers exemplify the constructs presented. Implications for organization theory and practice are drawn.
Academic and professional disciplines, such as organisation and management theory, psychology, sociology and engineering, have, for years, grappled with the multidisciplinary issues of safety and accident prevention. However, these ideas are just beginning to enrich research on safety in medicine. This article examines a domain of research on system safety - the High Reliability Organization (HRO) paradigm. HROs operate in hazardous conditions, but have fewer than their fair share of adverse events. HROs are committed to safety at the highest level and adopt a special approach to its pursuit. The attributes and operating dynamics of the best HROs provide a template on which to better understand how safe and reliable performance can be achieved under trying conditions, and this may be useful to researchers and caregivers who seek to improve safety and reliability in health care.
"Reliability" has become a watchword in the business community. Increasingly, it refers to anticipation and resilience organizations' ability to plan for, absorb, and rebound from shocks. Across many sectors and cases, the approach to improving reliability in primary technical systems has been remarkably similar. Stakeholders assume that improved reliability lies in better design and technology. This book speaks to the severe limits of formal design and technology relative to operational skills, experience, and knowledge. The debate over the vulnerability of critical infrastructures has far too often neglected the managerial dimension of public security and business continuity. High Reliability Management is the first book about the people who manage for high reliability, namely, those professionals who provide critical services continuously and safely, even during peak demand times or periods of stress. The text draws on one of the most intensive studies of a critical infrastructure within a high reliability framework. This longitudinal analysis examines the California electrical gridone of the largest, most complex, and economically important in the world. From this research comes a new perspective on strategic balances in society, and practical advice to researchers and professionals who confront reliability daily. Visit highreligabilitymanagement.org.
This paper presents an approach to the description and analysis of complex Man-Machine Systems (MMSs) called Cognitive Systems Engineering (CSE). In contrast to traditional approaches to the study of man-machine systems which mainly operate on the physical and physiological level, CSE operates on the level of cognitive functions. Instead of viewing an MMS as decomposable by mechanistic principles, CSE introduces the concept of a cognitive system: an adaptive system which functions using knowledge about itself and the environment in the planning and modification of actions. Operators are generally acknowledged to use a model of the system (machine) with which they work. Similarly, the machine has an image of the operator. The designer of an MMS must recognize this, and strive to obtain a match between the machine's image and the user characteristics on a cognitive level, rather than just on the level of physical functions. This article gives a presentation of what cognitive systems are, and of how CSE can contribute to the design of an MMS, from cognitive task analysis to final evaluation.
Case study research by definition is well suited to the study of IS implementation, especially when context is important. Furthermore, its products are highly relevant and therefore they appeal to IS practitioners, an audience for which the IS literature has been critiqued of ignoring. While the value of single case research is methodologically viable in the study of critical cases, the multiple case study approach is believed to be more appropriate to the study of typical cases of IS implementations. However, the IS literature provides little guidance on strategies for case study selection, particularly for multiple case studies. More important, is the need to provide the rational for case selection that relates these suggested strategies to the particular objectives of the case research inquiry. The purpose of this study is to fill this gap by providing a review of strategies for single and multiple case study selection in the context of systems implementation. Furthermore, the application of these guidelines in a multiple case study of strategic decision making of enterprise systems implementations will be illustrated.
Risk Prediction & Risk Intelligence in Aviation - the next generation of aviation risk concepts from PROSPERO FP7 Project
- D Baranzini
- M Zanin
Baranzini, D., Zanin, M., 2015. Risk Prediction & Risk Intelligence in Aviation -the next
generation of aviation risk concepts from PROSPERO FP7 Project. In: ESREL 2015 -25th European Safety and Reliability Conference.