Australian & New Zealand Journal of Psychiatry, 2020
Objective: The prevailing paradigm in suicide prevention continues to contribute to the nihilism ... more Objective: The prevailing paradigm in suicide prevention continues to contribute to the nihilism regarding the ability to prevent suicides in healthcare settings and a sense of blame following adverse incidents. In this paper, these issues are discussed through the lens of clinicians’ experiences as second victims following a loss of a consumer to suicide, and the lens of health care organisations. Method: We discuss challenges related to the fallacy of risk prediction (erroneous belief that risk screening can be used to predict risk or allocate resources), and incident reviews that maintain a retrospective linear focus on errors and are highly influenced by hindsight and outcome biases. Results: An argument that a Restorative Just Culture should be implemented alongside a Zero Suicide Framework is developed. Conclusions: The current use of algorithms to determine culpability following adverse incidents, and a linear approach to learning ignores the complexity of the healthcare sett...
Following other contributions about the MAX accidents to this journal, this paper explores the ro... more Following other contributions about the MAX accidents to this journal, this paper explores the role of betrayal and moral injury in safety engineering related to the U.S. federal regulator’s role in approving the Boeing 737MAX—a plane involved in two crashes that together killed 346 people. It discusses the tension between humility and hubris when engineers are faced with complex systems that create ambiguity, uncertain judgements, and equivocal test results from unstructured situations. It considers the relationship between moral injury, principled outrage and rebuke when the technology ends up involved in disasters. It examines the corporate backdrop against which calls for enhanced employee voice are typically made, and argues that when engineers need to rely on various protections and moral inducements to ‘speak up,’ then the ethical essence of engineering—skepticism, testing, checking, and questioning—has already failed.
In this study we identify the differences in goal realisation when applying two conflicting parad... more In this study we identify the differences in goal realisation when applying two conflicting paradigms regarding rule perception and management. We gathered more than 30 scenarios where goal conflicts were apparent in a military operational unit. We found that operators repetitively utilized certain routines in executing their tasks in an effort to realize several conflicting goals. These routines were not originally intended nor designed into the rules and not explicitly included in documentation. They were not necessarily at odds with the literal wording and/or the intent of rules and regulations, although we did find examples of this. Our data showed that local ingenuity was created innovatively within the frame of existing rules or kept invisible to those outside the unit. The routines were introduced and passed on informally, and we found no evidence of testing for the introduction of new risks, no migration into the knowledge base of the organisation, and no dissemination as ne...
This paper discusses the literature that shows that declaring a zero vision for everything bad (i... more This paper discusses the literature that shows that declaring a zero vision for everything bad (including unsafe behaviours, incidents, injuries) does not prevent fatalities or major accidents. In fact, parts of the literature show that a reduction in minor badness increases the risk of major accidents and fatalities. This is true in several industries. Two families of explanations are discussed. The first is the concern that declaring a zero vision can reduce operational knowledge. The second is the unsubstantiated assumption that minor injuries and fatalities have the same causal pattern. In general, evidence for or against the utility of a zero vision is dogged by confouding factors (other variables responsible for changes in safety outcomes) and what Giddens called the double hermeneutic, where the results of such studies are only as stable as the attributions the original reporter (e.g. OHS official, case worker) and the subsequent analyst (e.g. researcher) made about a particu...
This article examines the emergence of "accurate situation awareness (SA)" as a legal a... more This article examines the emergence of "accurate situation awareness (SA)" as a legal and moral standard for judging professional negligence in medicine. It argues that SA constitutes a status, an outcome resulting from the confluence of a wide array of factors, some originating inside and others outside the agent. SA does not connote an action, a practice, a role, a task, a virtue, or a disposition--the familiar objects of moral and legal appraisal. The argument contends that invoking SA becomes problematic when its use broadens to include professional or legally appraisable norms for behaviour, which expect a certain state of awareness from practitioners.
More than 20 years ago, Woods proposed a model that accounts for the inherent complexity faced by... more More than 20 years ago, Woods proposed a model that accounts for the inherent complexity faced by operators when managing abnormal and emergency situations in highly complex sociotechnical systems. The model was reviewed a decade later and only a few studies have applied it to aviation. This paper proposes adjustments to the original model, based on recent theoretical developments and empirical evidence on the anomaly management activity in aviation. The model was divided into five components; three of which-activity, types of reasoning involved, and resources-were revisited and further developed. The two other components-fault behaviour and unit of analysis-were not updated and only dicussed in the aviation context. As a result, the revisited model descriptively clarifies how the activity of anomaly management emerges from the use of a wide repertoire of strategies, involving a spectrum of types of reasoning and a set of resources for action, which are not limited to those anticipated by designers, such as checklsits and the warning system. An instantiation of the revisited model highligths the implications of false alarms, which trigger a cascade of disturbances that, in turn, requires adaptive strategies based on heuristics and analogies and supported by pilot's experience. The revisited model can support a more accurate analysis of anomalous situations and the redesign of work systems to achieve a better performance.
The use of an assessment model has shown large variation (disagreement) in the scoring of airline... more The use of an assessment model has shown large variation (disagreement) in the scoring of airline professionals who judged the performance of a captain and first officer in multiple video scenarios. A better understanding was thus required of the source of assessors' disagreement in terms of both the scoring and reasoning of safety-critical crew performance and collaboration. In the first study, the present thesis quantitatively compared the scoring and assessment time of airline professionals (first officers, captains, and flight examiners) from two different airlines who were given versus not given an assessment model to judge performance. The demographics of the participants were compared in terms of their age, total flight hours, and years flown as commercial pilot. In contrast, the second and third studies qualitatively investigated and analysed assessors' reasoning further. The second study closely examined the reasoning of captain assessor pairs who assessed the perfo...
ABSTRACT: Our understanding and investigation of accidents in aviation is dominated by a mechanis... more ABSTRACT: Our understanding and investigation of accidents in aviation is dominated by a mechanistic worldview that seeks to find and fix broken parts. Even though “systems thinking ” has become quite fashionable over the past two decades, this still often reduces to finding broken parts further away in space and time from the accident. This is Systems Thinking 1.0. In contrast, complexity science, and its new conception of “cause, ” offers a route to Systems Thinking 2.0. In this, investigators and managers can be made aware of the consequences of path-dependence, open systems, the asymmetry between small inputs and large effects, and the unpredictability of efforts to control or regulate complexity. This paper uses a case study to compare Systems Thinking 1.0 and 2.0 and develop the latter.
Rational choice theory says that operators and others make decisions by systematically and consci... more Rational choice theory says that operators and others make decisions by systematically and consciously weighing all possible outcomes along all relevant criteria. This paper first traces the long historical arm of rational choice thinking in the West to Judeo-Christian thinking, Calvin and Weber. It then presents a case study that illustrates the consequences of the ethic of rational choice and individual responsibility. It subsequently examines and contextualizes Rasmussen's legacy of pushing back against the long historical arm of rational choice, showing that bad outcomes are not the result of human immoral choice, but the product of normal interactions between people and systems. If we don't understand why people did what they did, Rasmussen suggested, it is not because people behaved inexplicably, but because we took the wrong perspective.
Australian & New Zealand Journal of Psychiatry, 2020
Objective: The prevailing paradigm in suicide prevention continues to contribute to the nihilism ... more Objective: The prevailing paradigm in suicide prevention continues to contribute to the nihilism regarding the ability to prevent suicides in healthcare settings and a sense of blame following adverse incidents. In this paper, these issues are discussed through the lens of clinicians’ experiences as second victims following a loss of a consumer to suicide, and the lens of health care organisations. Method: We discuss challenges related to the fallacy of risk prediction (erroneous belief that risk screening can be used to predict risk or allocate resources), and incident reviews that maintain a retrospective linear focus on errors and are highly influenced by hindsight and outcome biases. Results: An argument that a Restorative Just Culture should be implemented alongside a Zero Suicide Framework is developed. Conclusions: The current use of algorithms to determine culpability following adverse incidents, and a linear approach to learning ignores the complexity of the healthcare sett...
Following other contributions about the MAX accidents to this journal, this paper explores the ro... more Following other contributions about the MAX accidents to this journal, this paper explores the role of betrayal and moral injury in safety engineering related to the U.S. federal regulator’s role in approving the Boeing 737MAX—a plane involved in two crashes that together killed 346 people. It discusses the tension between humility and hubris when engineers are faced with complex systems that create ambiguity, uncertain judgements, and equivocal test results from unstructured situations. It considers the relationship between moral injury, principled outrage and rebuke when the technology ends up involved in disasters. It examines the corporate backdrop against which calls for enhanced employee voice are typically made, and argues that when engineers need to rely on various protections and moral inducements to ‘speak up,’ then the ethical essence of engineering—skepticism, testing, checking, and questioning—has already failed.
In this study we identify the differences in goal realisation when applying two conflicting parad... more In this study we identify the differences in goal realisation when applying two conflicting paradigms regarding rule perception and management. We gathered more than 30 scenarios where goal conflicts were apparent in a military operational unit. We found that operators repetitively utilized certain routines in executing their tasks in an effort to realize several conflicting goals. These routines were not originally intended nor designed into the rules and not explicitly included in documentation. They were not necessarily at odds with the literal wording and/or the intent of rules and regulations, although we did find examples of this. Our data showed that local ingenuity was created innovatively within the frame of existing rules or kept invisible to those outside the unit. The routines were introduced and passed on informally, and we found no evidence of testing for the introduction of new risks, no migration into the knowledge base of the organisation, and no dissemination as ne...
This paper discusses the literature that shows that declaring a zero vision for everything bad (i... more This paper discusses the literature that shows that declaring a zero vision for everything bad (including unsafe behaviours, incidents, injuries) does not prevent fatalities or major accidents. In fact, parts of the literature show that a reduction in minor badness increases the risk of major accidents and fatalities. This is true in several industries. Two families of explanations are discussed. The first is the concern that declaring a zero vision can reduce operational knowledge. The second is the unsubstantiated assumption that minor injuries and fatalities have the same causal pattern. In general, evidence for or against the utility of a zero vision is dogged by confouding factors (other variables responsible for changes in safety outcomes) and what Giddens called the double hermeneutic, where the results of such studies are only as stable as the attributions the original reporter (e.g. OHS official, case worker) and the subsequent analyst (e.g. researcher) made about a particu...
This article examines the emergence of "accurate situation awareness (SA)" as a legal a... more This article examines the emergence of "accurate situation awareness (SA)" as a legal and moral standard for judging professional negligence in medicine. It argues that SA constitutes a status, an outcome resulting from the confluence of a wide array of factors, some originating inside and others outside the agent. SA does not connote an action, a practice, a role, a task, a virtue, or a disposition--the familiar objects of moral and legal appraisal. The argument contends that invoking SA becomes problematic when its use broadens to include professional or legally appraisable norms for behaviour, which expect a certain state of awareness from practitioners.
More than 20 years ago, Woods proposed a model that accounts for the inherent complexity faced by... more More than 20 years ago, Woods proposed a model that accounts for the inherent complexity faced by operators when managing abnormal and emergency situations in highly complex sociotechnical systems. The model was reviewed a decade later and only a few studies have applied it to aviation. This paper proposes adjustments to the original model, based on recent theoretical developments and empirical evidence on the anomaly management activity in aviation. The model was divided into five components; three of which-activity, types of reasoning involved, and resources-were revisited and further developed. The two other components-fault behaviour and unit of analysis-were not updated and only dicussed in the aviation context. As a result, the revisited model descriptively clarifies how the activity of anomaly management emerges from the use of a wide repertoire of strategies, involving a spectrum of types of reasoning and a set of resources for action, which are not limited to those anticipated by designers, such as checklsits and the warning system. An instantiation of the revisited model highligths the implications of false alarms, which trigger a cascade of disturbances that, in turn, requires adaptive strategies based on heuristics and analogies and supported by pilot's experience. The revisited model can support a more accurate analysis of anomalous situations and the redesign of work systems to achieve a better performance.
The use of an assessment model has shown large variation (disagreement) in the scoring of airline... more The use of an assessment model has shown large variation (disagreement) in the scoring of airline professionals who judged the performance of a captain and first officer in multiple video scenarios. A better understanding was thus required of the source of assessors' disagreement in terms of both the scoring and reasoning of safety-critical crew performance and collaboration. In the first study, the present thesis quantitatively compared the scoring and assessment time of airline professionals (first officers, captains, and flight examiners) from two different airlines who were given versus not given an assessment model to judge performance. The demographics of the participants were compared in terms of their age, total flight hours, and years flown as commercial pilot. In contrast, the second and third studies qualitatively investigated and analysed assessors' reasoning further. The second study closely examined the reasoning of captain assessor pairs who assessed the perfo...
ABSTRACT: Our understanding and investigation of accidents in aviation is dominated by a mechanis... more ABSTRACT: Our understanding and investigation of accidents in aviation is dominated by a mechanistic worldview that seeks to find and fix broken parts. Even though “systems thinking ” has become quite fashionable over the past two decades, this still often reduces to finding broken parts further away in space and time from the accident. This is Systems Thinking 1.0. In contrast, complexity science, and its new conception of “cause, ” offers a route to Systems Thinking 2.0. In this, investigators and managers can be made aware of the consequences of path-dependence, open systems, the asymmetry between small inputs and large effects, and the unpredictability of efforts to control or regulate complexity. This paper uses a case study to compare Systems Thinking 1.0 and 2.0 and develop the latter.
Rational choice theory says that operators and others make decisions by systematically and consci... more Rational choice theory says that operators and others make decisions by systematically and consciously weighing all possible outcomes along all relevant criteria. This paper first traces the long historical arm of rational choice thinking in the West to Judeo-Christian thinking, Calvin and Weber. It then presents a case study that illustrates the consequences of the ethic of rational choice and individual responsibility. It subsequently examines and contextualizes Rasmussen's legacy of pushing back against the long historical arm of rational choice, showing that bad outcomes are not the result of human immoral choice, but the product of normal interactions between people and systems. If we don't understand why people did what they did, Rasmussen suggested, it is not because people behaved inexplicably, but because we took the wrong perspective.
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Papers by Sidney Dekker