ACU Australia Catholic University
Graduate Certificate in the Psychology of Risk
Unit 4
Lecturer
Dr Robert Long
Essay Topic
Examine a project or activity in the
light of Weick’s theories of
organisational sense making and
collective mindfulness.
Submitted By:
Philippa Curran
Student ID: S00174367
Word Count:
5964 words
Date Submitted:
4 December 2014
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Examine a project or activity in the light of Weick’s theories of organisational sense
making and collective mindfulness.
Introduction
Social networks give meaning to things1. Karl Weick’s socio-cultural evolution model of
organising was the first formal effort to adapt the concepts and propositions of evolution and
ecology to human organising. That is, organisations are socio-cultural systems that evolve in
responses to environmental changes, triggering alterations in the ecology of the organisation
(Everett 2002).
Weick in his review of the Bhopal disaster, suggested the practice of
organising affects the credibility of sensemaking, which in turn affects containment of and
recovery from the unexpected (Weick, 2010 p. 546). People satisfice, simplify, assume,
ignore, and deviate to make relationships more orderly, more predictable and more dependable
(Turner 1978).
Weick’s initial ideas on organising, sensmaking and mindfulness revolved around concepts
explored by Paget (1998) who argued mistakes, or actions that seemed right at the time, are
intrinsic features of error ridden work; Westrum’s (1982) contradictory concept of ego-centred
fallacy where role and position provide a comprehensive picture of events but in reality is
associated with loss of hazard recognition; Langer’s (1989) description of mindfulness and
awareness of discriminatory detail; Tsouka’s (2005) thoughts on simplification as the central
premise of organising; and Baron & Misovich (1993) who argued that complexity moves
people from perceptual knowing to category based knowing and the effects of labels,
stereotypes and schemas has on tradeoffs. These propositions are touched on further within
the body of this paper.
Following a brief description of sensmaking and its foundation for understanding how
mindfulness comes about, this paper also uses the experience of developing emergency
1 Insight SBS, 16 Sept 2014 (http://www.sbs.com.au/news/insight/tvepisode/memories)
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response plans to critique the organising, sensemaking and mindfulness processes employed
on a major Sydney construction project, the North West Rail Link, using the constructs
designed by Weick and his colleagues.
Stakeholder and casual loop mapping has been
included to illustrate the social arrangements, complex and tightly coupled nature of
construction projects. Outputs and reflections from the emergency planning process have also
been included.
Weick’s Theories on Organisational Sensemaking
Organisations are a complicated collective network of individuals each bringing unique skills,
perceptions and beliefs which at times results in a state of flux. Sensemaking helps people
deal with equivocality, the inherent streaming of experiences or changes that bring uncertainty
and ambiguity (differences, discrepancies, breakdowns, surprises, opportunities, interruptions)
and to restore normality (Weick, Sutcliffe & Obstfeld, 2005). When equivocailty is low,
organisations can rely on established ways of doing things and thinking about events (Miller,
2011).
Sensmaking helps to rationalise what people are doing, to give the experience a particular
shape, through generalising and institutionalising meaning and rules (Tsoukas & Chia 2002 p,
570). Steps in the sensemaking process include enactment and retention resulting in a cultural
schema, an abstracted pattern into or onto which information can be organised (Rice, 1980).
Schema also serves as an external frame of reference for action and perception (Weick 1979).
The looped process of sensemaking is illustrated in Figure 1. Something becomes an event
once is it brought into existence by enactment (thinking and acting). A disruption occurs, clues
are extracted, attention is paid, and the event becomes bracketed using training and life
experiences. Events are then labeled using language to provide a common currency for
communication, simplified and stabilised to bring about consequence.
As Klein (2006)
conveys, “data evokes frames and frames select and connect data”.
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Figure 1: The Relationship Among Enactment, Organising and Sensemaking.
Source: Weick, K.E., Sutcliffe, K.M.; & Obstfeld, D. (2005). Organising and the Process of Sensemaking. Organisational
Science, Vol.16. No.4 July-August 2005 p.139
Enactments are not apparent and can be influenced by the tendency for people to consider
options and select the most socially appropriate. Power affects control over clues, who talks
to who, notion of identity, criteria for plausibility, permitted actions and history (Weick,
Sutcliffe & Obstfeld, 2005 p.143). Mood and emotions have effect on response repertoire and
trajectory (Weick 2010 p. 545).
The seven key elements of Weick’s theory on sensemaking which affect the way people
interpret or sense or process new information include:
Element 1 - Identity Construction
Identity construction involves reflection of ones actions, knowing yourself or the
organisational image and identity, using core beliefs and filtering to construct a framework for
interpretation, or a narrative. Organisations weave into their operations the kinds of rituals
and stories that serve to orally transmit operational behavior, organisational culture and
collective responsibility (Meyer and Rowan, 1997). Identity construction, or context shapes
what is enacted and how it is interpreted.
Element 2 - Retrospection
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Retrospection uses previous knowledge, beliefs, reflections and interpretations generated
through historical connections to inherently contemplate past events or actions. Retrospection
may be used as the basis to formulate tradeoff and produce byproducts during enactment in
order to reduce complexity.
Element 3 - Enactive Sensible Environments
Enacting sensible environments involves the compilation of confirming evidence using it to
bring about a new scenario or belief, often unconsciously driven by cognitive dissonance via
its function in value judgments, decisions, and evaluations. Objects are inconsequential until
they are acted upon (Weick 1998, p.306).
Sensemaking also involves situational awareness, or the understanding of connections to
anticipate trajectory and to act effectively (Klein et al 2000). Sensmakers actively shape their
environments (Bloch 2013, p.99).
Element 4 - Social in Nature
Unconscious heuristics, biases, and beliefs affect sensemaking during interactions with others
and the surrounding social environment, with semiotics important for ongoing conversations
and categorising between people (Freyd, 1983). Shared knowledge among a group of people is
based on widely held beliefs and values, certain dynamics lead to the emergence of certain
knowledge. Heedful inter-relating (Weicks & Roberts, 1993) and respectful interactions
provide the platform for constructive social interaction, making tacit knowledge explicit and
public (Obstfeld 2004, p.138).
Element 5 - Ongoing Processes
The pace and speed of events (flow) lead to action, as a result of commitment and enactment.
Weick (1988, p.309) believed initial responses sets the tone and determines the trajectory of a
crisis.
Sensemaking often tries to create order by learning from enactment using a
retrospective view of an event.
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Organisational performance is subject to constraints or controls that supervise, regulate or
restrict the flow of activity. Constraints seek to suppress variability or keen it within certain
boundaries. Constraints are necessary for system stability but can limit flexibility, variability
and ability to achieve goals or provide for opportunities (Eurocontrol, 2014 p.16).
Element 6 - Extracted Clues
Recognition of clues is based on experience and is linked to propositions and expectations.
Propositions, or bracketing of clues, represent collective extrapolation from the “pool” of
cognitive premises and casual maps, transforming raw data elements into information.
Variations in cultural propositions occur due to the degree of cultural integration present in an
organisation, the life cycle stage of the organisation and the nature of decision making with
the organisations (Everett 2002).
The importance of extracted clues relates to their salience, enabling cognitive efforts to be
focused on the most significant clues.
Saliency can be impacted by attribution and
justification, itself becoming a constraint in sensmaking (Weick 2010, p547). Assumptions,
where associated with clues or not, may lead to expectations and self-fulfilling prophecy
(Maitlis, 2010).
Element 7 -Plausibility
Sensemaking is driven by plausibility rather than accuracy (Weick, Sutcliffe & Obstfeld, 2005
p.141). Plausibility taps into a sense of the current climate, checks for consistency with other
data, reduces equivocality, has an aura of accuracy, and offers a potentially exciting future
(Mills 2003 in Weick, Sutcliffe and Obstfeld (2005 p.141).
Mintzberg (1994, p.8) comments “we think in order to act, to be sure, but we also act in order
to think”. With sensemaking, cognitive processes become schema driven (concept driven
using awareness) rather than stimulus driven (alertness) (Weick 2010 p. 541). Sensemaking is
the interplay of action and interpretation rather than evaluation of choice.
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These ideas are in tension with traditional ideas in management, where accuracy often defines
characteristics of good managers.
Weick, Sutcliffe & Obstfeld (2005 p.2) exemplify
sensemaking using a study by Snook (2001) when describing friendly fire in Iraq that killed 26
people, noting “good people struggling to make sense rather than bad ones making poor
decisions”.
Organisational Mindfulness
Weick and his colleagues suggest unvarying performance cannot cope with the unexpected.
Organisations require the collective cognitive mindset to detect, the ability to step back,
understand and recover from surprises, developing a sense of collective empowerment.
Expectations create orderliness and predictability that is needed to organise, but may also
creates blind spots by overlooking clues that do not fit expectations, experiences or result in
negative consequences (Weick & Sutcliffe, 2001 p23). They may form the basis of deliberate
acts that constrain behavioural choices (Weick & Sutcliffe, 2001 p25). To counteract this,
organisations try to develop greater discrimination of detail and nuances, or mindfulness. The
components relating to Weick’s view of organisational mindfulness is shown in Figure 2 and
described in more detail below.
Figure 2: A Mindful Structure for High Reliability
Source: Weick, K.E., Sutcliffe, K.M., & Obstfeld, D. (1999). Organizing for High Reliability: Processes of Collective
Mindfulness. Research on Organizational Behaviour, Vol 1. Standford Jai Press, pp. 37.
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Weick emphasises the key to making sense of risk in the workplace, is focusing on active
distinction making and differentiation (Weick & Putman 2006 p.286). This construct expands
on Ellen Langer’s work in the 1980s on individual mindfulness (Thornton & McEntee 1995,
p.252) with Weick’s five principles for organisational operation and mindfulness, along with
potential tradeoffs and byproducts, are summarised as follows:
Preoccupation with Failure
Mindfulness requires continuous attention to detail in order to detect small discrepancies
which could be symptoms of larger problems in a system, as exemplified by the Bhopal
disaster (Weick, 2010) and Challenger disasters (Vaughan, 1990). It involves awareness of
warning signals (mis-specification, mis-estimation or mis-understandings) and treating their
causes with strong responses. Doubt and differences may not be of one persons making,
organisiations should be hesitate to label until the moment is seen with clarity. Wariness
expressed as active continuous revisiting and revision of assumptions rather than hesitant
action (Weick, Sutcliffe & Obstfeld 1999, p38).
Snowden & Boone (2007) note complex systems involve a large number of interacting
elements that are typically highly dynamic and constantly changing with changing conditions.
Complex systems have cause and effect relationships that are non linear and can produce
disproportionally large effects. (Acknoff 1999, p.4).
Clues to unfolding failure may include changes such as supervision, delegation without follow
up, lack of questioning, missed steps in a procedures, workers with differing approaches, staff
spread thin, distraction by project pressures.
Organisational tradeoffs may include weak signals treated with weak responses, persistent
signals that may become less predictable and controllable, plus difficulties in interpreting the
application of signals to wider environment if processes occur in organisational silos.
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Positive byproducts of preoccupation with failure may include trust and intuition, learning
from debriefs on events, and feeling safe to report. Negative by-products include automaticity,
compliance, complacency and normalising the unexpected.
Deference to Expertise
Deference to expertise (not experts) in mindful organisations allows decision making to
migrate to those with the assembly knowledge, experience, learning and intuition, rather than
in accordance with hierarchy. It de-couples hierarchy and links problem solvers with the
situation, loosens up structure and people pay more attention to inputs of the moment
(Eurocontrol, 2014).
These organisations demonstrate flexibility simultaneously with
orderliness (Weick, Sutcliffe & Obstfeld 1999, p.48), by practicing heedful interrelating to
decipher information about an event (Weick & Sutcliffe, 2001, p.78).
Deference to expertise marries problems more quickly with experience, expertise, credibility
and understands the limits of knowledge.
It leads to a reduction of tight coupling and
containment of problems early in their development.
Tradeoffs include the possibility to discount an individual’s impression of a situation for
expertise, and the requirement to defer to an “on the scene” person.
Negative by-products include the potential for confirmation bias and problem labeling, the
hierarchy misinformed by information with holding and uncertainty absorption. Positives
include organisational learnings that come about when people ask for help and increased trust.
Sensitivity to Operations
Mindful organisations learn from mistakes, pay less attention to plans and more attention to
emergent outcomes that are set in motion by enactment. They are sensitive to interconnected
operations and flow, and understanding the messiness of systems. Frontline workers have a
cognitive map to integrate solutions to changing environments (Endersly 1997, p.270). Weick
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Sutcliffe & Obstfeld (1999, p.44) go further to state that integration and extrapolation are also
required for situational awareness and this uses all five mindfulness processes to make sense
or to reconstruct to make sense of present operations.
Mindful organisations see interconnections and comprehend complexity in the moment,
enabling them to make adjustments to loosen tightly coupled dependencies. Operational
sensitivity requires information sharing between teams, procedures may not cover these
interpersonal interactions. Weick (2001, p.60) comments that engineers typically place
higher value on information that is measurable and lower value on more experiential learning
of the workforce.
Tradeoffs associated with sensitivity to operations includes a focus on frontline risk managers,
speaking up, impacts on budgets by ensuring redundancy, and sometimes the need for instant
action.
Positive byproducts for organisations include continual updating and conversations, increased
trust and creditability, interaction and shared understanding of complex processes. However it
may be hard to develop big picture if sensitivity is based at operational level, bottlenecks may
coupled with continual updating and information exchange. Production pressure and overload
may result in multiple demands and misinterpretation. Mindless acts become automatic, and
where command and control is present, it reduces organisational sensitivity and induces
blindspots (Weick and Sutcliffe, 2001).
Commitment to Resilience
Mindful organisations develop processes to recover from setbacks, through improvisation,
elasticity and adaptability. These organisations absorb strain, bounce back and learn from
events using bricolage2, the capability to recombine actions in the repertoire into novel
2 People combine fragments of old routines with novel actions into a unique response to deal with a unique input.
Skilled bricolage occurs when knowledge of resources, careful observation, trust in ones intuition, listening,
confidence combine to develop solutions to unique problems (Weick, 2001 )
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combinations. Mindful organisations are also able to simultaneously believe and doubt their
past experience (Weick 1979, p.217), by adjusting to the present situation and apply lessons
learned. This requires training, learning and varied experience, a willingness to question and
the use of respectful interaction to assess and exchange information.
Resilience links to understanding organisational complexity, as these organisations are able to
see threats via improvisation and imagination, and create requisite variety3 to loosen coupling.
Perrow (1984) infers the need for decentralisation and centralisation at different times and
situations.
In order to change deep structures and underlying problems, double loop learning features in
mindful organisations, with rethinking of cultural, organisational and political viewpoints,
using imagination, skillful inquiry, and by challenging assumptions and mindfulness, in
contract to mindless fixing of problems with single loop linear cause and effect thinking
(Milner 1994).
Tradeoffs associated with resilience include the development of general resources and
capabilities to deal with unexpected events, and recognising that following and event, the
addition of new rules that may reduce flexibility.
Negative by-products of practicing resilience may include the system becoming stretched,
fatigue, violations and subsequent reverting to old habits, whereas positive byproducts include
imagination and improvisation, thinking on one’s feet, continuous learning and refinement of
expectations.
Reluctance to Simplify
Mindfulness reminds an organisation of being hesitant to live by generalisations and generic
categories, and to pay closer attention to the here and now (Weick & Putman, p.285). To
register differences between present situations and past experiences more fully, people
3 Requiste variety involves specialisation and sensitivity to a variety of inputs (Weick, 2001, p.95).
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become wary of labels and routines inherited from the past. These significance of differences
may be easy to spot with hindsight but hard to see at the time.
Weick views each slice of the Swiss Cheese Incident Model4 as an opportunity to stop an
event progressing to a brutal audit, in contrast to the common place notion that alignment of
the ‘holes” in the cheese produces an event. A more recent discussion on managing the
unexpected using the concepts of volatility and organisational fragility has been presented by
Taleb (2012). Based on the concepts of ecosystems and evolution, Taleb describes the need
for disruption to cause change. Antifragile organisations use these shocks positively to “fuel”
improvement. They learn from mistakes and need stressors to reduce blind spots. Fragility
can be underestimated with complexity and increasing size of organisations.
Detail and context permits more differentiation and worldviews, diversity of opinion,
difference in expectations enable people to grasp variation and see specific change.
Organisations can take note of the detail of complexity and rearrange process to avoid
invariant sequences.
Reluctance to simplify, complexity and tight coupling require organisational communication
processes that curb bull headnedness, hubris, headstrong acts and self importance (Perrin
1995), and rather, develop mutual respect, continuous negotiation, re-accomplishment of trust
with simultaneous cultivation of credibility and deference (Weick, Sutcliffe & Obstfeld 1999,
p.43).
Tradeoffs include the need to simply to allow for focus on key issues, the use of ratings to
simplify complex information into a number (risk ratings), trust in procedures, valuing of
opinions, along with the process of checking rather than assuming.
Byproducts of simplification include the loss of detection of nuances in the interest of coordination and organising, use of the wrong systems for prediction, misjudging the intensity of
4 Reason (1990, 1997) http://www.aviation.unsw.edu.au/about/articles/swisscheese.html
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single elements by summed into an overall complexity rating, labeling and confirmation bias,
habitual simplification rather than deliberate choice, and overconfidence following success.
Appendix A contains a flow chart that attempts to summarise the key interactions described
above and by Weick & Sutcliffe (2001) with respect to mindfulness, anticipation and
containment. When these Weick’s principles are practiced, tendencies such as confirmation of
hunches, tunnel vision, misestimating and misunderstanding complexity of an event, blaming
others, discounting worst case scenarios and underestimating the rate of change are weakened
(Weick & Sutcliffe, 2008).
Characteristics of the Construction Industry
A recent RMIT Study (2014, p.23) described the construction industry as a demanding project
based work environment with high proportion of migrant workers and a male dominated
workforce (88%).
Lacuone (2005) studied maleness in the construction industry noting
hegemonic masculinity, contests of physical strength, and one-up manship. Long work hours
and poor work-life balance are experienced.
This industry operates on a multilevel system of contracting and subcontracting, where often
subcontractors have the least influence on decision making. Wadick (2010, p.26) describes a
subcontractor culture of independence and individual resourcefulness, which in turn
diminishes the importance of interdependence and consideration for others. Understandably,
subcontractors are required to complete work as quickly as possible, focusing on their own
interests.
Construction projects themselves are sub-systems of a company’s larger portfolio of work
(Blismas et al 2004, p.43) as each project delivered through a temporary organisational
structure. Work is highly decentralized and local managers exercise discretion on how to
implement company policies and procedures.
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Senior management often are overconfident in the company systems, failing to heed early
warning signs, focusing on inspecting physical conditions without considering human factors,
with a reluctance to question people in positions of authority, failing to monitor and verify
safe operations (RMIT 2014, p.30).
Loosemore et al (2010 p.22) note projects are cultural diverse workplaces which, if managed
well can positively effect productivity, problem solving, creativity and competitive advantage,
if managed poorly may lead to conflict, low morale, ineffective communication, mental stress.
Context of the Organisations Reviewed in this Paper
The project reviewed as an example in this paper is a $1.7 billion construction Joint Venture
(JV) made up of two companies XXXXX that both currently exist under an Australian holding
company, and a Spanish company XXXX affiliated to the major international shareholder
(Spanish), the 4th largest construction company in the world (See Figure 3).
Org chart has been removed.
A Sydney Morning Herald article (2014) describing the organisational structural changes
occurring within these companies at this time of this paper is contained in Appendix B
Appendix B has been removed. As illustrated by the newspaper article, due to rationalization
by the major shareholder, the three organisations discussed in this paper are undergoing a
period of uncertainly, redefinition, redundancy and re-organisation. Longstanding company
logos, symbols, discourse and trajectory are in a state of flux. A summary table of the
organisational characteristics of each company discussed in this paper along with the JV, is
provided in Appendix C. – Appendix C has been removed
Organising Culture of the Project
The study into the Australia Construction Industry undertaken by RMIT (2014) referred to
previously, noted that complex organisations have multiple sub cultures based on functional
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areas, location, profession. This is evident in the JV arrangement with three organisations
with different views on organising and risk management (see Appendix C – removed ).
Weick & Sutcliffe (2001, p.139) state that mindfulness is a culture as well as set of principles
that guide practice. Weick (1987) suggests tight coupling is required in an organisation
around a handful of core values with looser coupling around the means by which these are
realised. Shared expectations, assumptions and similar views of rationality constitute an
integrated culture (Weick & Sutcliffe 2001, p.112).
XXXX both have “cultural framework to guide expected behaviours”, originally developed as
part of the Holding Company’s behavioral safety programme.
The application of this
framework differs between companies and this is shown in Appendix D - removed.
Differing organisational beliefs and discourse means “shared meaning” required for pulling
together and organising may become confused, causing employees to revert back to parent
company beliefs.
Review of the Project and Organisational Mindfulness Questions
The JV is constructing twin 15 km tunnels for the Northwest Rail Link Project. Four Tunnel
Boring Machines (TBMs) are being used to construct the 6m diameter rail tunnels. The
project also involves civil works for five new stations and two service facilities5.
Paragraph removed
The Project sites are spread along the proposed rail alignment with each site operating under
its own budgets and management structures. This siloing by location and role effect can be
seen in Appendix E Stakeholder Maps - removed. Detailed weekly and monthly reporting of
safety (lead and lag indicators, incidents) and production facts using databases, spreadsheets
5 http://www.thiess.com.au/news/2013/thiess-john-holland-dragados-to-deliver-first-major-construction-for-north-west-
rail-link
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and posters is completed and accounted to management during weekly meetings. Reports are
checked independently by management.
Mindfulness question - Does the reporting processes contribute to the fallacy of centrality
(Westrum 1982), where without heedful interrelating, management may trust in the
numbers and a less comprehensive picture of risks? Is accuracy in reporting (ie. focus on
the details) more important than plausibility?
Many of the project senior leadership team have worked together previously on other large
infrastructure projects, one of which included the Lane Cove Tunnel where the roof area of a
ventilation tunnel collapsed6. This history of this event has created expectations relating to
communication and performance during a crisis.
Mindfulness question – Does organisational history provide the infrastructure to reduce the
impacts of a brutal audit in the event of a crisis?
The Project activities have transitioned from a site set up phase to an operational phase over
the last three months. Site setup and facility installations were dynamic and changing daily,
utilising many specialist contractors to excavate, install services, construct buildings, set up
associated facilities (precast facility, conveyors, grout and water treatment plants) all working
to achieve a tight programme driven by the fast tracking of delivery of the TBMs from China.
Tight coupling and complexity in construction sequencing is evident, and a necessity, to
complete and handover works in accordance with project contractual requirements.
Construction is by its nature tightly coupled in time, design, budgets and methodology, driven
by programme. Scott (1987) remarks tight coupling requires a centralised decision making
strategy due to interconnectivity, loss of independence and the inability to see across processes
(sites, management structures, staging), and must be accompanied by an increase in vertical
and horizontal communication patterns to allow negotiation and mutual ongoing adjustment.
6 The four workers carrying out the excavation works within the tunnel evacuated without physical injury. The roof collapse
caused the road above the area to subside and damage a three storey building in close proximity to the area of the subsidence
(WorkCover NSW, 2005). (<http://pandora.nla.gov.au/pan/59517/20060606-0000/tunnelreport1.pdf>)
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Mindfulness question – Does the organisation have the culture and communications in
place to support decentralised teams or does the command and control nature of senior
management provide for centralisation?
Perrow (1984) notes that complex system have characteristics such as tight spacing of
equipment, proximate production steps, personnel specialisation, unfamiliar and unintended
feedback loops and limited understanding of some processes.
From a construction
perspective, the need to install “hard engineered controls” and more procedures to control
hazards and risk is driven by parent companies, the Client and regulators. Rochin (1999)
warns safety devices and other levels of additional technical redundancy can increase overall
complexity and coupling resulting in systems that are more prone to errors by interfering with
the less explicitly observable processes by which safety is maintained.
The paradox of complexity involves the need for specialisation, following Weick’s notion of
requisite variety (2001) and Schulman comments (1993, p.364) on requisite variety and
diversity sensitising an organisation to greater variety of inputs, with the potential to cause
conflict and requiring a premium on interpersonal skills.
To undertake the work, civil,
electrical, mechanical engineers work the frontline crews to design, operate and maintain the
plant and equipment. Specialist input is also provided from subcontractors, the French TBM
manufacturers, XXXX with worldwide tunneling experience.
Mindfulness question - Does variety allow for problem detection and understanding of
trajectory or does it undermine reliability and conformance?
In complex systems, operators, teams and organisations may over-estimate their
knowledge, misread the state of their systems or try to do more than they are capable of
because it is expected of them. It may be difficult to decompose the interlocking set of
organisationally and technically framed social constructs (La Porte and Consolini, 1991).
Some organisations possess interactive social characteristics that enable then to manage
complex systems well (RMIT, 2014).
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Mindfulness question - Is a mindful organisation in equilibrium or does organising
continually change depending on the environment and culture?
Performance is subject to constraints or controls that supervise, regulate or restrict the flow of
activity (Eurocontrol, 2014, p.16). Constraints seek to suppress variability or keep it within
certain boundaries. Constraints are necessary for system stability but can limit flexibility,
variability and ability to achieve goals. Safety management is often characterised by the
imposition of constraints. If constraints run counter to purpose and flow of work, they become
problematic, people work around constraints in ways that are not visible from afar.
Mindfulness question - Dynamic organising and disorganizing within sub-organisations
versus bureaucracy?
The JV Project Management Systems have been adapted and altered from parent company
systems in an attempt to “take the best from each” requiring project staff to re-learn and reunderstand processes and procedures. Weekly co-ordination meetings are held to transfer
knowledge across the JV.
Mindfulness question - Are humans hazards (a sources of risk through error and violations)
or heroes (resourceful, adjusting and recovering from unexpected events)?
In line with the idea of organising, plans, procedures and rules save time and effort, prevent
reinvention, provide clarity of task and responsibility, and create more predictability (Dekker
2014, p.35). Conversely, these take time to supervise, may generate blindness to situations
that do no fit process patterns or expectations, and result in loss of freedom for imagination
and innovation (Hale and Boyrs 2013, p.214). The Project has 8 “Non Negotiables” and over
100 “site safey rules”, with the requirement to undertaken prescribed number of safety
inspections, observations and SWMS reviews each site per week. Reporting on compliance
occurs weekly.
Mindfulness question - Do these policies and processes limit, constrain and control what
people do, spreading error if mis-specified or processes misunderstood or to the policies and
processes empower them to share and innovate?
Currently, the maintenance crews are working at maximum capacity to detect and repair issues
on the TBMs. Daily and weekly planning meetings between the foreman, engineers and
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maintenance staff, including the support services (subcontractors, safety, environment,
community, manufacturers), allow for updating, questioning and respectful interactions for
exchange of information on preventative action, corrections and process interactions in an
attempt to prevent unforeseen events and maintain production. Feedback is requested and
given on proposed or implemented fixes. Production, quality, safety and environmental events
are investigated and engineered or procedural control measures reviewed and modified.
Mindfulness question - Is entertaining doubt and updating of information on the minor and
major fixes (clues) especially important when dealing with complex systems, the detection
and containment of an unexpected event?
The frontline workers rotate between jobs and shifts providing a wider skill base. Workers are
encouraged and rewarded to report issues to the foreman and recognition for proactive self
reporting is given in the weekly toolbox meetings. Many of the frontline workers have
worked together on previous projects and based on previous experience, and may feel
comfortable raising concerns and reporting events with management. Using past experience,
knowledge and briolage7, the crews are working hard to overcome production issues with the
TBMs, in particular the minimising the generation of dust and improving the efficacy of the
ventilation system.
Mindfulness question - does deferring to experts on the front line mean that central
management gives away control and command?
Mindful organisations try to anticipate emergency and crisis by developing plans with many
scenarios8. Planning is often hindered by the fallacy of pre-determination (Mintzberg 1994,
p.43) where planners expect and assume things will unfold in a certain way, restricting views
of sensing and responding capabilities, confirming biases. To counteract these limitations,
Weick and Sutcliffe (2010) suggest the need for a rich set of ideas, combined with cognitive
attention and time to get the best inputs for scenario and response building. Further, these
7 People combine fragments of old routines with novel actions into a unique response to deal with a unique input.
Skilled bricolage occurs when knowledge of resources, careful observation, trust in ones intuition, listening, confidence
combine to develop solutions to unique problems (Weick, 1993).
8 Sutcliffe (2010) https://www.youtube.com/watch?v=45JK7Q81kRo
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authors articulate the need to recognise limitations associated with enacting plans depending
on the setting.
Mindfulness question - can actions change the setting; or does the setting lock in the
actions?
The TBMs were purchased from a French company and engineered in China, then
disassembled and shipped to Australia. Some months after commissioning and TBM
operations are underway, it has been recognised that the efficient functioning of the TBMs …
remainder of the sentence removed.
Mindfulness question - Is there a potential that the emergency response equipment and
processes installed may not operate as planned, coupled with the impracticality to test for
unexpected events?
Hindsight, Foresight, Legislation, Rules, Plans and Procedures
The NSW Work Health and Safety Act and Regulation 2011 is based on the philosophy of
“reasonably practicable” and “due diligence”, underpinned by the concept that potential for
prosecution lies in failures of foresight and the likelihood that some forewarning was
foreseeable and avoiding action is possible. This premise is hinged by the concept of foresight
ruling the thought and decision making processes, and contrast to Weick’s ideas of unlimited
hindsight, limited foresight (Weick, Sutcliffe & Obstfeld 2005), where sensemaking involves
the ongoing retrospective development of plausible images that rationalise what people are
doing (enactment).
Weick further comments that limitations of foresight may amplify
analytical errors. Legislation and Codes of Practice prescribe risk management considerations
for construction, emergency planning and many other requirements, setting the framework for
compliance within organisations.
Mintzberg (1994) describes planning as being about analysis, the breaking down of a goal or
set of intentions into steps, formalising those steps so they can be implemented almost
automatically, and articulating the anticipated consequences or results of each step. Formal
planning promotes strategies that are extrapolated from the past of copied from others. Plans
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by their nature contain assumptions and expectations, influence perception and reduce
observation, when small deviations occur people employ biases to get their thinking back on
track.
Rules are derived from events that have occurred in the past (failures and successes) that are
meant to give the future is understanding in terms of the past (Tsoukas & Hatch 2001, p. 992).
Success can lead to reduced perception and overconfidence. Rules and procedures do not
consider the context of the moment. Organisations and managers trust procedures to keep
them safe.
Eurocontrol (2014) report that new approach needed to explore gaps between “work as
imagined” (rules, regulations, safety systems) and “work as done”, continuous dialogue with
front line actors, to meet and balance conflicting goals in a complex and dynamic situation
where staff need to make tradeoffs and adapt to situations within a rigid regulatory
environment, that destroys capacity to adapt constantly to the environment.
Work cannot be specified precisely in procedures, people must make continuous adjustments,
therefore performance variation is necessary and normal. Variability is always there, even if
the procedures do not account for it and is also affected by variability of other functions when
coupled. These adjustments may lead to drift into an unstable situation, and drift may be slow
and hard to identify from the inside.
Stakeholders In Emergency Planning, Fire and Life Risk Assessments - Examination of
Activity
Anticipation involves mindful attention to failure, simplification and operations, being able to
sense and stop, spot and understand. Anticipation leads to the development of contingency
plans, which are constrained by foresight and the fallacy of determination (Weick & Sutcliffe
2001, p.63). Plans and reactions to unexpected events may become mindless under the
influence of expectations, perception, observation, automaticity, limit opportunity for
bricolage, and based on assumptions of control by repetition of past actions.
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Using the idea of a conscious audit (Weick & Sutcliffe 2001, p.83), an organisation’s default
positions tell us about how mindful the organisation is, and its understanding of that
organisational context which may be dynamic and unpredictable. In emergency planning,
planners need to foster safety imagination – fear the worst, elicit various viewpoints, allow no
worst case scenario to go unmentioned, suspend assumption on how it was done in the past
and visualise near misses developing into accidents9.
Prior to commencing underground activities, Fire and Life Risk Assessment (Appendix F removed) meetings were undertaken to discuss and document likely scenarios and control
measures associated with a fire or other life threatening events in the tunnels. This risk
assessment was developed on the basis of information supplied during tendering, procurement
of plant and equipment, safety in design review, past experience (both mining and tunneling).
The risk meetings were attended by staff with a range of skills, and developed with the input
of subject matter experts including ventilation designers and hygienists.
The Safe Work Australia Code of Practice for Tunneling lists emergency scenarios for the
basis of identifying hazards, assessing risk and developing control measures. Underlying this
document was the requirements for emergency management specified by the parent
organisations’ management systems. Prior experience and hindsight (including the Lane Cove
Tunnel Collapse), played a large part in guiding discussion during the workshops with reliance
on past experience (no major fires in tunneling projects the team had been associated with in
the past).
An organisation’s ability to deal with an unexpected events depends on structures developed
before it arrives, preventing the situation becoming a brutal audit where unpreparedness
becomes complex and weaknesses come to the forward (Weick & Sutcliffe, 2010).
Centralised organisations loose the ability to response to an unexpected event at the local
9 Sutcliffe (2010) https://www.youtube.com/watch?v=45JK7Q81kRo
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level. As mentioned previously, some of the Project’s senior management team was involved
in the Lane Cove Tunnel Collapse, and thus an understanding of how these people may react
in a crisis has been tested to a degree in the past.
A draft risk assessment was developed using documents from previous projects and the
criteria listed in the Code of Practice for Tunneling. This assessment was used to progress two
workshops. Using the draft risk assessment and the Code of Practice for Tunneling for the
basis of discussion had the potential to contribute to confirmation bias, the fallacy of predetermination and automation.
Risk assessments themselves are paradoxical, using scoring systems and ranking to distill
complex information into simple numbers. On the Project, the outcome of risk assessments is
prioritisation where residual risk levels determines what type of action is required and
approval process for go-ahead. These risk rankings simplify the outcome of the assessment
process however they are industry accepted tools for organising and communicating using
common language across the Project.
Although the tunneling process itself is relatively well understood, causal loop diagrams
(Sterman, 2006, p. 149) in Appendix G shows the Fire and Life systems as a complex, tightly
coupled, and arrangement with modest slack to account for unexpected events. This diagram
also shows there are circular chains of cause-and-effect using feedback loops.
Positive
feedback loops reinforces change with even more change whilst negative feedback loops
balance interactions.
TBM tunnelling crews are small (20 or so per TBM) and the process of cutting rock and
building tunnel lining is relatively automated, leading to the potential for complacency with
time. Reliance and interaction with other support services such as conveyors, grout plant,
water treatment plant and logistics adds to complexity and interdependency.
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Skilled and experienced project teams (sub-cultures) had been brought together with little
explanation of the purpose of the workshops. The workshops were lead by a subject matter
expert external to the project. The stakeholder mapping (Appendix E - removed) exemplifies
the enactment of organisational cultures and subsultures, communication lines, and parent
company influences during the Fire and Lifer Risk Assessment workshops.
The time allocated to the workshops and the importance attributed to the process in a hurried
and overloaded work environment meant limited opportunity for mindful consideration of
mis-identification, mis-estimation, and mis-specification. Lessons learned from the Airport
link project, particularly in relation to Union interested were factored into to Risk assessment.
Mapping illustrates the engineered and procedural controls implemented as part of the Fire
and Life Risk Assessment. Weick, Sutcliffe & Obstfeld (1999, p. 36) note that change goes
undetected because people are rushed, distracted, careless or ignorant, failure to detect faults
in machinery, substandard materials or declining compliance. 1 Sentence removed.
Paragraph removed
To prepare for emergencies, organisations need to over-learn and practice to prevent the
tendency to slip back to familiar ways, and revise plans to incorporate new learnings.
Conversely Lagadec (1993, p.27) suggested enacting doubt in a crisis may require strategic
judgment (wisdom) rather than predefined tactical responses.
The output of the Fire and Life Risk Assessment was then incorporated into a review of the
Project Emergency Response Plan, facilitated by the Project Environment Manager. This
process involves a series of meetings that included stakeholders from mined tunnels/stations
and TBM tunneling, subject matter experts and regulatory bodies.
The output from these meetings was a new revision of the Project Emergency Response Plan
(Appendix H removed.), along with need to develop training and awareness packages to
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transfer the requirements of the plan to front end operators and to practice the response in the
form of drills and in the field training. 1 Sentence removed.
Dekker (2014, p34) describes elements of safety systems and cultures and emergency response
planning was critiqued with respect to the bureaucracy and worthwhileness10. Dekker notes
that emergency response planning documents bear little resemblance to actual requirements or
conditions and are only rarely tested against reality. Weick (1988, p.306) remarked that the
situation will determine appropriate actions or does actions determine the situation. Rather
preconceptions determine appropriate action, appropriateness is governed by retrospective
reasoning.
In the last week of October 2014, emergency response training and drills were carried out in
relation to medical evacuations. The drills provided situational awareness training for the
TBM crews in relation to rescue of an injured person in restricted work areas. The drills were
debriefed with the crews and highlighted some deficiencies in action plans contained within
the Project Emergency Response Plan and these action plans are being re-assessed.
Considering the complexity and tightly coupled nature of fire and life scenarios in
(Appendix G) did the planning process really facilitate acknowledgment of unexpected
scenarios and allow for the development of action responses?
Conclusion
Weick (2009) suggests it is the quality of organising that makes the difference in management
equivocality. Concepts, routines and text momentarily impose some permanence on flux, but
conversations, experiences and wary improvisation reinstate the flux. Social order is
precarious and continually re-accomplished.
Mindfulness both increases the comprehension of complexity and loosened tight coupling
(Weisk, Sutcliffe Obstfeld 1999 p. 51) by creating alternative paths for task performance that
10 Hallowell, M. and Gambatese, J. (2009). ”Construction Safety Risk Mitigation.” J. Constr. Eng. Manage., 135(12), 1316–
1323. Research completed in USA indicated that the most effective safety program elements are upper management
support and commitment and strategic subcontractor selection and management and the least effective elements are
recordkeeping and accident analyses and emergency response planning.
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loosens coupling. By paying attention to complexity the details can be rearranged to avoid
tight invariant sequences, time dependencies.
Although the NRWL project has invested much time and effort in planning for emergency
scenarios, the cultural setting and enacted environments makes effective anticipation difficult
to carry out, any will only be truly tested during an unwanted and expected event.
Is it really rare to have optimistic plans, insufficient staff, misestimated complexity, broken
promises, overlooked details, turf battles, loss of control, unanticipated consequences? (Weick
& Sutcliffe 2001)
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Appendices
Appendix A
Flowchart Developed on the Basis of Concepts Explored in
Weick and Sutcliffe (2001).
Appendix B
Removed
Appendix C
Removed
Appendix D
Removed
Appendix E
Removed
Appendix F
Removed
Appendix G
Causal Loop Mapping Fire and Life
Appendix H
Removed
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Appendix A: Flowchart Developed on the Basis of Concepts Explored in Weick and Sutcliffe (2001).
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Appendix B: Context of Organisations Reviewed in this Paper - Removed
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Appendix C. Organisational Characteristics of CompanyX, CompanyY and Company Z and the JV 11 taken from corporate websites. Removed
11 Taken from company websites
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Appendix D. Cultural Framework Removed
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Appendix E. Stakeholder Maps Removed
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Appendix F. Causal Loop Mapping Fire and Life
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Examine a project or activity in the light of Weick’s theories of organizational sense
making and collective mindfulness
Appendix G: Emergency Response Plan – Underground Works Removed
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