Managing the Unexpected (Weick and Sutcliff) Summary
1) Hallmarks of High Reliability Organization (HRO) Mindfulness
a) Preoccupation with failure
i) HROs treat any lapse as a symptom that something is wrong with the system, something that could have severe consequences if separate small errors happen to coincide at one awful moment (like Bhopal)
ii) HROs encourage reporting of errors, they elaborate near misses for what can be learned and they are wary of the potential liabilities of success, including complacency, temptations to reduce margins of safety, and the drift into automatic processing.
b) Reluctance to simplify interpretations
i) HROs take deliberate steps to create more complete (less simple) and nuanced pictures. They simplify less and see more.
ii) Homogeneity in culture and outlook can be good in an organization, but it can lead to everyone seeing the same warning signals and being blind to the same unexpected warnings.
c) Sensitivity to operations
i) Unexpected events usually originate in what psychologist James Reason calls "latent failures."
(1) Latent failures are "loopholes in the system’s defenses, barriers, and safeguards whose potential existed for some time prior to the onset of the accident sequence, though usually without any bad effect.
(2) Loopholes consist of imperfections in features such as supervision, reporting of defects, engineered safety procedures, safety training, briefings, certification, and hazard identification.
ii) Often, latent failures are only discovered after an accident, but that need not be the case. Normal operations may reveal deficiencies that are "free lessons" that signal the development of unexpected events, if you look carefully enough and take the time to explore why unexpected results occur when they occur. These lessons are only visible if there is frequent assessment of the overall safety health of the organization.
iii) HROS are aware of the close tie between sensitivity to operations and sensitivity to relationships.
(1) If information is withheld out of fear, ignorance, or indifference, you cannot develop a good big picture of the operations.
(2) Anomalies need to be noticed while they are still tractable and can still be isolated.
d) Commitment to resilience
i) HROs develop capabilities to detect, contain, and bounce back from the inevitable errors that are part of an indeterminate world.
ii) The signature of an HRO is not that it is error free, but that errors do not disable it.
iii) Resilience demands deep knowledge of the technology, the system, one's coworkers, one's self, and the raw materials. HROs put a premium on experts: personnel with deep experience, skills of recombination, and training.
iv) Research suggests that the most effective fire commanders are those with rich fantasy lives who can mentally simulate potential lines of attack.
e) Deference to expertise
i) Decisions are made on the front line, and authority migrates to the people with the most expertise, regardless of their rank.
ii) HROs distinguish between normal times (decisions from the top), high tempo times (migrate around the organization to the expertise), and emergencies (predefined emergency structure kicks in) and clearly signal in which mode they are operating.
iii) Stonewalling does not manage the unexpected.
2) The Unexpected
a) Managing the unexpected is about
i) alertness,
ii) sense-making,
iii) updating, and
iv) staying in motion
3) Varieties of Surprise
a) Five forms of surprise and the unexpected
i) Bolt from the blue: no expectation, no prior model of the event, no hint that it was coming
ii) Issue expected, but the direction of the expectation is wrong (Fatigued crews often work better together than fresh crews because they have already worked out coordination and rhythms)
iii) Something is expected to happen and the order of events expected, but time of its occurrence is off (happens earlier or later than expected)
(1) clues were probably evident, but might have been dismissed for something else
iv) Expected duration of event wrong: may lead to other adverse consequences if action not taken because event was thought to be minor or normal.
v) Problem is expected but amplitude is not
b) Surprise starts with an expectation. Having expectations means you look for evidence that confirms them, postponing your realization that something unexpected is developing.
c) Being slow to recognize a developing problem
i) may leave you with fewer options for resolving it
ii) effectiveness/efficiency may decline,
iii) system vulnerable to further collapse, and
iv) Safety/Reputation/Production are now on the line.
4) Dynamics of Surprise
a) When something unexpected happens, it is an unpleasant experience. Part of managing the unexpected involves anticipating these feelings of unpleasantness and taking steps to minimize their impact.
i) When the unexpected happens, people pay closer attention to information related to the disconfirmed expectation and try to make sense of it. This is called "tunnel vision."
ii) Tunnel vision can lead to ignoring other, important information
iii) People often try to preserve the original expectation by explaining away the disconfirmation
b) People in HROs worry a lot about the temptation to normalize unexpected events.
i) Less fear of a false alarm than of missing something significant that could escalate.
5) Feelings of surprise
a) Perceptions of the unexpected are fleeting
b) Engenders surprise, agitation, puzzlement, anxiety, unsettledness, frustration, startlement
i) Aviators call these feelings "leemers;" the feeling that something is not quite right, but you cannot put your finger on what it is
c) Trust those feelings; resist the temptation to normalize the surprise.
i) In the brief interval between surprise and normalization lies one of the few opportunities to discover what you do not know. This is a rare moment where you can significantly improve your understanding.
(1) If you wait too long, normalizing will take over and you will be convinced there is nothing to learn.
(2) If you put too much energy/effort into it, you may get tunnel vision and lose situational awareness, allowing something else to happen.
ii) People in HROs try to freeze and stretch out their unexpected moments in order to learn more from them (think after action reviews, post watch debriefs)
6) The Idea of Mindfulness
b) It pays to be aware of your expectations
i) Expectations act like an invisible hand that guides you toward soothing perceptions that confirm your hunches, and away from more troublesome ones that do not.
ii) People in HROs try to weaken the grip of the invisible hand of expectations so they can see more, make better sense of what they see, and remain more attuned to their current situation.
iii) They do this by
(1) preoccupation with mistakes
(2) reluctance to simplify operations
(3) commitment to resilience
(4) deference to authority
c) Mindfulness: process encourages people to be self-conscious about the validity of their beliefs and to question them, reaffirm them, update them, replace them, and learn from all these activities
d) Mindfulness: the combination of
i) ongoing scrutiny of existing expectations
ii) continuous refinement and differentiation of expectations based on newer experiences
iii) willingness and capability to invent new expectations that make sense of unprecedented events
iv) a more nuanced appreciation of context and ways to deal with it
v) identification of new dimensions of context that improve foresight and current functioning
e) Mindfulness is essentially a preoccupation with updating (not planning). It is grounded on the understanding that knowledge and ignorance grow together. Mindful people accept this reality.
i) Mindfulness and updating counteract many of the blind spots that occur when people rely too heavily on expectations. These same blind spots conceal the early stages of eventual disruptions
ii) The power of mindfulness is that it redirects attention
(1) from the expected to the irrelevant
(2) from the pleasant to the unpleasant
(3) from the more certain to the less certain
(4) from the confirming to disconfirming
(5) from the explicit to the implicit
(6) from the factual to the probable,
(7) from the consensual to the contested
7) The Capability for Mindfulness
f) When people update their understanding of what is happening, they rework the ways they label and categorize what they see.
i) re-examine discarded information
ii) monitor how categories affect expectations
(1) categories help people gain control of their world, predict what will happen, and plan actions
(2) crucial tools that prevent people from having to reinvent everything they do because each situation and person would be unique
(3) also crude tools because they edit everything people see, especially if people remain fixated on the same dimensions of old categories (troublesome or introverted people vs. the contributions they can make)
(4) Must be mindful of the relationship between categories and expectations. Each helps define the other. Must continually reevaluate categories in light of the ability to help manage expectations, being willing to differentiate expectations, update them, replace/discard them.
(5) Believing is seeing. You tend to see only what you expect to see. You see what you what you have the labels to see (Eskimo have 6 words for "snow," expert skiers do not have as many, but have more than people who do not ski), what you have the skills to manage. Everything else is a blur. In that blur lies the developing unexpected event that can bite you and undermine your best intentions
iii) remove dated distinctions
3) Mindfulness on Aircraft Carriers
a) People on carriers are preoccupied with failure
i) small failures are treated as signs of larger problems
(1) everything is graded, always trying to improve performance
(2) near misses debriefed within the hour
b) People on carriers are reluctant to simplify
i) take nothing for granted
ii) planes not launched until multiple, redundant inspections are performed and reported
c) People on carriers maintain continuous sensitivity to operations
i) CO and down exchange continuous communications during flight ops about the status of the activity
ii) entire ship attuned to launching/recovering aircraft
d) People on carriers have a commitment to resilience
i) crews know the importance of routines and predictable behavior as well as doing what they are told
ii) they also know that surprises are inevitable, with surprise comes the necessity to improvise, adapt, think on your feet, and contain and bounce back from he unexpected events
iii) resilience is improved by deep knowledge of technologies, people, and capabilities
e) People on carriers maintain deference to expertise
f) No one on a carrier completely understands its operations and daily workings with certainty
g) No one knows enough to design the perfect, automatic control system or plans/rules/routines/stable categories for correct, error-free performance in a dynamic environment
h) Instead, designers who want to hold complex, dynamic systems together have to organize in ways that evoke mindful work.
i) People have to find it easy and natural and rewarding to adopt a mental style of functioning whereby they build into their job description the responsibility to engage in continuous learning and ongoing refinement and updating of emergent expectations
8) Sensemaking is the process of finding and using information for a purpose.
a) A narrative process whereby individuals and groups reflect upon and interpret phenomena, and construct meaning from this enactment (Brown, 2000)
b) Who is a sensemaker?
i) Actually, everyone is a sensemaker. We all get information and use it in our work.
c) Sensemaking is a big part of the work life of a nuclear operator. They spend much of their time making sense of plant conditions, logs, Reactor Plant Manuals, tours of the propulsion plant, audits and surveillances (of programs and watch standers), evaluating performance of members of their division and watch team, reviewing maintenance and material history records, evaluating training. They may have the most demanding sensemaking requirements of any group in the U.S. Navy.
d) When Sensemaking Collapses
i) Individuals’ sense of what they are encountering is challenged
ii) When this happens, there is a tendency to revert to routine behaviors
iii) Individuals’ sense of who they are is challenged
iv) When this happens, there is a tendency to react defensively, not to believe indications, to protect self-image and sense of identity
e) When Sensemaking Collapses
i) Tenerife KLM/Pan Am Air Disaster (Weick, 1990)
ii) Union Carbide’s Bhopal Plant (Shrivastava, 1987)
iii) Three Mile Island (Perrow, 1981)
iv) Mann Gulch Disaster (Weick, 1995)
f) Sensemaking - Learning from Crises
i) To survive, individuals/organizations must develop their/its capacity to interpret ambiguous events to construct meaning and establish direction.
ii) Individuals/organizations are meaning systems.
iii) Individuals need to build, maintain and apply more complex cognitive maps so that a wider range of potential responses are developed and practiced.
4) Summary
a) Mindfulness might be easier to develop in groups rather than one person at a time.
i) Individuals prefer to dwell on success, keep it simple, follow routines, avoid trouble, and equate expertise with rank. All these preferences run contrary to mindfulness.
b) If you update and differentiate the labels you impose on the world, the unexpected will be spotted earlier and dealt with more fully
c) Reliability is a dynamic event and gets compromised by distraction and ignorance. Mindfulness is about staying attuned to what is happening and about a deepening grasp of what those events mean.