How Could This Happen?
eBook - ePub

How Could This Happen?

Managing Errors in Organizations

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  2. ePUB (mobile friendly)
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eBook - ePub

How Could This Happen?

Managing Errors in Organizations

About this book

The first comprehensive reference work on error management, blending the latest thinking with state of the art industry practice on how organizations can learn from mistakes.

Even today the reality of error management in some organizations is simple: "Don't make mistakes. And if you do, you're on your own unless you can blame someone else." In most, it has moved on but it is still often centered around quality control, with Six Sigma Black Belts seeking to eradicate errors with an unattainable goal of zero.

But the best organizations have gone further. They understand that mistakes happen, be they systemic or human. They have realized that rather than being stigmatized, errors have to be openly discussed, analyzed, and used as a source for learning.

In How Could This Happen? Jan Hagen collects insights from the leading academics in this field – covering the prerequisites for error reporting, such as psychological safety, organizational learning and innovation, safety management systems, and the influence of senior leadership behavior on the reporting climate.

This research is complemented by contributions from practitioners who write about their professional experiences of error management. They provide not only ideas for implementation but also offer an inside view of highly demanding work environments, such as flight operations in the military and operating nuclear submarines.

Every organization makes mistakes. Not every organization learns from them. It's the job of leaders to create the culture and processes that enable that to happen. Hagen and his team show you how.

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Information

Š The Author(s) 2018
Jan U. Hagen (ed.)How Could This Happen?https://doi.org/10.1007/978-3-319-76403-0_1
Begin Abstract

1. Fast, Slow, and Pause: Understanding Error Management via a Temporal Lens

Zhike Lei1
(1)
Malibu, USA
Zhike Lei
End Abstract
When an error occurs, in the race to act, people may decide to quickly handle things on their own. However, although thesquick fixes seem to work well, and even create a sense of gratification for having swiftly solved a problem, they can preclude performance improvement over time by impeding operational and structural changes that would prevent the same errors and failures from happening again.
Still, fast action should not necessarily be discouraged. Rather, we should be alerted to the side effects of emphasizing speed over analysis. In the heat of the moment, it is hard to know the proper way to make sense of information and regain control. In fact, when hyperdynamic interactions of error signs and interruptions create an interlude, people may experience a blank, a freezing moment that calls into question the orderliness of a structure, a task, or a protocol. As a result, understanding and sensemaking collapse, and fast actions can be ill-conceived. When it comes to high-reliability organizations, we may even see paradoxes: Actions and responses happen at a rapid pace, yet people need to pause, reflect, explore various concerns, and come up with analyses and solutions.
Understanding error management via a temporal lens raises quantitative and methodological questions, and it promotes dialogues concerning behavioral options in organizational practice. Although the element of time has always been in the background of the theory and research on errors and error reporting, it has yet to be—and should be—brought to the foreground of observation.

Preface

Many people believe that to prevent catastrophe, the sooner an error is reported and declared, the higher the chances for organizational entities to detect and correct it, and vice versa. Yet, for the decision of error reporting, is it always true the faster the better? When is acting quickly an asset? When is it a liability? Is there a clear rule for timely reporting across cultures? These questions heighten why a temporal lens is needed to better understand error management and error reporting. As such, we begin to think not just about whether or not errors are reported, but also about how fast (or slowly) errors are reported, and when and why error reporting starts and stops. Moreover, we should be alerted to potential side effects of emphasizing speed over analysis. When it comes to high-reliability organizations, we may even see paradoxes: Actions and responses happen at a rapid pace, yet people need to pause, reflect, and explore various concerns, and come up with analyses and solutions. Understanding error management and error reporting via a temporal lens raises quantitative and methodological questions, and it promotes dialogues concerning behavioral options in organizational practice and across cultures. Although the element of time has always been in the background of the theory and research on errors and error reporting, it has yet to be—and should be—brought to the foreground of observation.
Errors are a recurring fact of organizational life and can have either adverse or positive organizational consequences. In organizational research, errors are defined as unintended—and potentially avoidable—deviations from organizationally specified goals and standards (Frese and Keith 2015; Hofmann and Frese 2011; Lei et al. 2016a). Consider the manufacturing errors that led to massive Samsung Galaxy Note 7 recalls, medical errors that are responsible for thousands of deaths in US hospitals each year, and positive mistakes that have led to product innovation at the 3M company. The wisdom of managing and learning from errors is incontrovertible.
Managing errors in real time requires errors to be reported in a timely manner so that remedies can be taken before harm occurs (Hagen 2013; Zhao and Olivera 2006). Yet, reporting errors or openly discussing them is not as easy as it sounds; it is a more natural tendency in organizations for people to be silent or cover errors up (Morrison and Milliken 2000; Nembhard and Edmondson 2006). I have attempted to use different lenses—psychological, structural, and system—to understand why and how errors are, or are not, reported. Although each of these lenses leads us to focus on certain variables and relationships, an overlooked and understudied perspective is the temporal lens . Putting the time and timing of error reporting front and center is important because the temporal lens offers its own view of the error-reporting phenomenon, its own set of variables and relationships, and its own set of parameters to guide organizational practice (Ancona et al. 2001a, b). The goal of this chapter is, thus, to sharpen the temporal lens so that we can use it to conduct error research and suggest managerial interventions.
Joining colleagues who have called for more temporal research (Ancona et al. 2001a; Goodman et al. 2011; Lei et al. 2016a), I suggest we begin to think not just about whether or not errors are reported but also about how fast (or slow) errors are reported and the trajectories and cycles they align with: when and why error reporting starts and stops. We should begin to examine the cultures of time and how tight versus loose and high versus low power-distance cultures affect the very nature of error-reporting behavior and what happens as we move across temporal cultures. Overall, it is time to rethink and reframe error reporting via a new temporal lens and examine some new variables and issues (e.g., timing, pace, cycles, rhythms, and temporal differences) in this direction.

Rationale: Why Take on a Temporal Lens?

To better understand the rationale behind adopting a temporal lens , let us start with a real-life example: the 89th Academy Awards ceremony that took place on the night of February 26, 2017 (Buckley 2017). The night ended with a dramatic finish when Warren Beatty and Faye Dunaway awarded the Best Picture award to the makers of the film La La Land instead of the rightful winner, Moonlight. The extraordinary mix-up occurred live on stage after Brian Cullinan, a partner at the accounting firm PwC, handed Beatty the incorrect envelope moments before the actor went onstage with Dunaway to present the Oscar. PwC, the accounting firm based in London and formerly known as PricewaterhouseCoopers, has been tabulating the votes for the Academy Awards for 83 years.
Reaction to the mistake was swift and harsh. Some criticisms were directed at Beatty. Standing before some 33 million television viewers, he appeared confused by the contents of the envelope. The actor explained that he read the card in the envelope: “I thought, ‘This is very strange because it says best actress on the card.’ And I felt that maybe there was some sort of misprint.” Beatty did not stop the show and say so. As for PwC, the company admitted that “protocols for correcting it (the error) were not followed through quickly enough by Mr. Cullinan or his partner [Ruiz].”
This spectacular Oscars mishap highlights some key temporal dimensions in error situations. First, error disclosing or reporting can manifest as a tipping point for some hidden problem, issue, or mistake that crosses a threshold over time. Although the act of error reporting may be a one-time event, Perrow (1984) has noted that error occurrence or potentially adverse consequences are often the end products of long strings of seemingly inconsequential issues and conditions that accumulate and are chained together. Many questioned why the two PwC partners were serving as “balloting leader” to the Oscars team, why there were no rehearsals, and why electronic gadgets were even allowed (which seemed to be the reason that Mr. Cullinan was distracted moments before he handed out the wrong envelope).
Second, an outsized share of accidents happen near the end of projects or missions. So it was with the Oscars mishap, which occurred during the presentation of the biggest, and final, award of the night. As such, time and timing are deeply embedded in our discussion on error detection and reporting.
Third, error situations are sometimes characterized by feedback loops and unexpected interruptions . What is hard—in the heat of the moment—is knowing the proper way to make sense of the shock and regain control (Weick 1993). When hyperdynamic interactions of error signs and interruptions create an interlude, one experiences a blank, a freezing moment that calls into question the orderliness of a structure, a task, or a protocol; understanding and sensemaking collapse together. As such, the seemingly lackadaisical reactions of Beatty, Cullinan, and Ruiz are surprisingly common in the midst of trouble and disasters.
The Oscars story helps explain why we should utilize a temporal lens: It provides an important framework for explaining and understanding the error phenomena as emergent, dynamic constructs, rather than discrete, static ones. For this, the temporal view not only broadens the meaning and accounting of error reporting, but it also connects psychological, structural, and/or system perspectives—time is implicitly embedded in all of these aspects. Moreover, applying a temporal lens sharpens our empirical approaches to studying error reporting. The timing of the reporting and the duration before—or time lags in—noticing and reporting errors are fundamental issues, despite the challenges of including the variables of duration, pacing, and shocks in most field studies and experiments of organizational research (although it has been done; see Gersick 1988; Lei et al. 2016b).
In the remainder of the chapter, I take a closer look at three key temporal issues of error reporting in organizations: (1) timing, pace, and rhythms; (2) feedback loops and latent errors; and (3) temporal differences in cross-cultural settings. I explicitly discuss some counterintuitive, paradoxical issues embedded in the act of reporting errors in organizations. I then propose recommendations for future research and for organizational practice in the domain of disclosing, reporting, and discussing errors. I hope to add to organizational scholars’ efforts to make inroads into embracing the complexity and flux in management thinking and enable managers to operate effectively when a substantive error situation emerges and evolves.

Tempo of Acts: Timing, Pace, and Rhythms of Error Reporting

The pace of organizational life is the flow or movement of time that people experience (Levine 1997). Consider how goods are produced and services delivered, or how employees are trained, socialized, and engage with one another. Organizational life is characterized by rhythms (What is the pattern of work time to downtime? Is there a regularity to meetings or social events?), by sequences (Is it one particular procedure before another one or the other way around?), and by synchronization (To what extent are employees and their activities attuned to one another?). First and foremost, the pace of organizational life is a matter of tempo, like the tempo of a music piece: We may play the same notes in the same sequence, but there is always that question of tempo (Levine 1997). Similarly, error reporting has much to do with tempo, which refers to the speed, pace, and timing at which an error is disclosed and reported, and it has dramatic effects on organizational performance and outcomes.
Many people believe that to prevent a catastrophe, the sooner an error is reported and declared, the higher the chances for organizational entities to detect and correct it, and vice versa (Hagen 2013; Reason 1990). This seems to make perfect sense because only when an error situation is reported and declared can organizational entities and actors then...

Table of contents

  1. Cover
  2. Front Matter
  3. 1. Fast, Slow, and Pause: Understanding Error Management via a Temporal Lens
  4. 2. Errors and Learning for Safety: Creating Uncertainty As an Underlying Mechanism
  5. 3. When Silence Is Not Golden
  6. 4. Executive Perspectives on Strategic Error Management
  7. 5. The Strategic Imperative of Psychological Safety and Organizational Error Management
  8. 6. Learning Failures As the Ultimate Root Causes of Accidents
  9. 7. Understanding Safety Management Through Strategic Design, Political, and Cultural Approaches
  10. 8. Errors and Error Management in Biomedical Research
  11. 9. Empowerment
  12. 10. Open Error Communication in a High-Consequence Industry
  13. 11. Confidence and Humility
  14. 12. Just Culture
  15. 13. Error Management in the German Armed Forces’ Military Aviation
  16. 14. Crew Resource Management Revisited
  17. 15. Error Reporting and Crew Resource Management in the Israeli Air Force
  18. 16. Lessons from a Nuclear Submarine Mishap
  19. 17. The War on Error: A New and Different Approach to Human Performance
  20. Back Matter