Web viewExamine a project or activity in the light of Weick’s theories of organisational sense making and collective mindfulness. Introduction. Social networks

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 CurranStudent 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

response plans to critique the organising, sensemaking and mindfulness processes employed

1 Insight SBS, 16 Sept 2014 (http://www.sbs.com.au/news/insight/tvepisode/memories)


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”.


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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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

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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.


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.


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.

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Figure 2: A Mindful Structure for High ReliabilitySource: 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.


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 ExpertiseDeference 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


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

combinations. Mindful organisations are also able to simultaneously believe and doubt their

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 )


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 become

3 Requiste variety involves specialisation and sensitivity to a variety of inputs (Weick, 2001, p.95).


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 co-

ordination 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


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.


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


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,

5 http://www.thiess.com.au/news/2013/thiess-john-holland-dragados-to-deliver-first-major-construction-for-north-west-rail-link


spreadsheets 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>)


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).


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 re-

understand 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

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,

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


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

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

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.

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

9 Sutcliffe (2010) https://www.youtube.com/watch?v=45JK7Q81kRo


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

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 pre-

determination 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.

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

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.

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.


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

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)


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).


Appendix B: Context of Organisations Reviewed in this Paper - Removed


Appendix C. Organisational Characteristics of CompanyX, CompanyY and Company Z and the JV 11 taken from corporate websites. Removed

11 Taken from company websites


Appendix D. Cultural Framework Removed


Appendix E. Stakeholder Maps Removed


Appendix F. Causal Loop Mapping Fire and Life


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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