Jan Hayes

Knowing stories that matter: learning for effective safety decision-making

Ongoing safe operation of hazardous industries such as hydrocarbon production and transportation, air traffic control and nuclear power generation depends on effective decision-making by those in key positions. Safety studies often focus on the extent to which actions of operational personnel in particular are dictated by procedures or rules and hence reinforce the need for compliance to ensure the best outcomes. This article directs attention to a different area – the judgements made by experts in the cases that are not covered by rules and, in particular, the key role of stories and storytelling. This ethnographic research draws on literature related to high-reliability theory, organisational learning and naturalistic decision-making to examine how experts working in diverse critical contexts use stories to share and make sense of their experiences. It argues that such stories are vital to effective decision-making as a result of both the general and specific lessons that they embody. Our analysis shows that experts use stories as parables to nurture their ability to imagine possible outcomes and maintain a safety imagination. Stories are also embedded in work practices to support decision-making in the moment. Finally, stories are strongly linked to organisational learning for experts as a group and in mentoring less-experienced colleagues. We argue that the increased focus on incident reporting systems in hazardous industries, which is driven at least in part by a consideration of organisational learning, is failing in this regard because such systems do not facilitate story-based learning. We appeal to organisations to support story-based learning with as much vigour as formal systems for professional development and reporting.

Experts under the microscope: the Wivenhoe Dam case

Prosecution of experts in the wake of disasters has emerged as common in the context of increasing social intolerance of risk. This paper examines expert blame using as a case study the decisions of engineers who operated Wivenhoe Dam during the Queensland floods in January 2011 and the criticisms of those decisions by the subsequent Commission of Inquiry. Our analysis draws on the literature on organisational safety, organisational learning and expertise to examine the relevance of the criteria against which the engineers were judged, the relevant competence of those who made this assessment and the broader implications of such exercises. Our analysis shows that lay judgements of expert practice can be misleading, as evidenced by the Commission of Inquiry’s misguided focus on procedural adherence. We argue that such inquiries—where the focus is on assigning blame—detract from opportunities to learn from incidents and can negatively impact on professional practices. If the aim is to make future disasters less likely, then inquiries that take this approach may be failing in this endeavour, or at least not maximising their contribution.

Lessons for effective integrity management from the San Bruno pipeline rupture

In September 2010, eight members of the public were killed when a gas transmission pipeline ruptured at San Bruno, California. This article describes the causes of this serious organizational failure with a view to learning by other organizations that operate hazardous facilities. The rupture occurred when a longitudinal seam weld failed. The weld had been poorly made at the time the pipeline was fabricated and installed in 1956. The line had not been inspected or tested since that time. While the details are specific to the case at hand, organizational lessons are valid for other organizations operating complex sociotechnical systems that face the problem of sleeping or latent faults that can remain dormant for many years. This analysis focuses on the organizational arrangements that led to such ineffective integrity management, in particular how the potential for an event such as the one that occurred was systematically ignored by the operating company for many years. The key to effective management of the potential for disaster is to ensure that risk management does not become a “fantasy” but remains grounded in the reality of the dangers that the assets pose to workers, the public, and to the organization itself.

Preventing black swans: incident reporting systems as collective knowledge management

In hazardous industries, disasters are mercifully rare and yet the potential is ever present. For this reason, companies and industries as a whole put substantial effort into gathering information about past small failures and their causes in an attempt to learn how to prevent more serious events. Despite these efforts, recent research has captured how organizations can ‘fail’ to learn. Disastrous events can become ‘black swans’ and remain unpredicted despite the existence of information warning of them. This article engages with this challenge by analyzing incident-reporting systems as a tool for collective knowledge. Drawing together the literatures on organizational knowledge management and incident reporting, we examine incident-reporting systems as used and as structured. We explore the potential use of incident-reporting systems for mediation and synchronization of knowledge within and across groups of professionals and organizations. We also address the social practices that translate information in databases into collective knowledge. Building on the work of Hecker, we argue that research concerned with incident reporting and organizational learning would benefit from using ‘knowledge’ and specifically ‘collective knowledge’ as its reference point. We show that conceptualizing this problem in terms of ‘reporting’ and ‘learning’ distracts attention from the knowledge needs for people to learn. We argue that we must ask: What do people need to know to play their part in major accident prevention? And how is that knowledge effectively shared? We conclude with an empirical research agenda in light of this investigation.

Shifting risk to the frontline: case studies in different contract working environments

An extensive body of safety literature and research discusses the integral role of rules and procedures in managing workplace hazards, ensuring worker safety, and safeguarding the environment. Nevertheless, organizational accidents and workplace injuries continue to occur, and individual employees often bear the brunt of responsibility. This paper examines how risk becomes shifted to individuals at the bottom of supply chains, focusing on two different groups of contract workers. Specifically, it draws on case studies conducted in Australia – one on civil contractors working around hazardous infrastructure and one on athletes who are subject to anti-doping requirements. A comparison of the two cases and their distinctive elements illuminates the ways in which structural pressures, organizational dynamics, and context-specific conditions influence the risks shouldered by individuals. Our analysis shows that, in both cases, adverse outcomes are widely seen as the responsibility of contract workers, prompting other actors to judge them as blameworthy. In doing so, risk in various forms (e.g. safety, financial, reputational) becomes shifted onto workers who are constrained by contracts and away from away from higher level actors and organizations that are generally in more powerful positions than frontline workers. This finding suggests that the burden of accountability and potentially liability is borne primarily by frontline workers. Because of this focus, it is easy to lose sight of organizational and structural conditions that contribute to the risks revealed at the individual level. Through an analysis of 57 interviews across both sectors, complemented by participant observations and a media review, this paper underscores the importance of critically considering not only individual worker actions, but also how regulation can support the diversion of risk, responsibility, and liability onto frontline workers.

Stories and Standards: The Impact of Professional Social Practices on Safety Decision Making

Organisational influences on safety outcomes are the subject of much attention in both academia and industry with a focus on how workplace factors and company systems, both formal and informal, influence workers. Many individuals who make important decisions for safety are not simply employees of a particular firm, but also members of a profession. This second social identity is little studied or acknowledged and yet is it critical for safety. This chapter addresses two key social practices that influence safety outcomes. The first is professional learning for disaster prevention. Research has shown that much professional learning is profoundly social including sharing stories and using stories directly as an input to key decisions. Another critical professional activity is development of standards. Standards are seen as authoritative sources and so ‘called up’ in legislation and yet the processes by which they are developed are opaque to those outside the small group of professionals involved. Again, this important social practice of groups of professionals remains little studied. Professional social practices such as these are worthy of much more attention from both academia and industry.

The effects of power relationships: knowledge, practice and a new form of regulatory capture*

Abstract In the wake of disasters, criticism tends to target regulatory failures and regulatory capture. In this status quo, the roles of regulators are black-boxed and criticism fails to explore what has been happening within and around regulatory institutions. This paper explores how relationships between regulators of hazardous industry and those who interact with them affect regulatory practice. Actor-network theory was utilised to generate findings drawn from a study of the Australian pipeline industry in order to reveal perspectives and the approaches of regulators in regulating pipeline risks. The findings indicate that pipeline regulators have a particular logic in practicing risk analysis. This paper argues that such a logic can be theorised as a new form of regulatory capture that limits the way regulators regulate risks and constrains the potential of regulatory outcomes. It is urged that a new form of logics of practice needs to be developed so as to improve the process of risk regulation in preventing catastrophic accidents.

The rise of defensive engineering: How personal liability considerations impact decision-making

Abstract Based on a survey of Australian engineers (n = 275) this paper examines the impact of personal liability considerations on engineering decision-making. Almost all respondents who make high-stakes decisions saw questions of liability as having both positive (90%) and negative (87%) impacts. Our analysis shows that awareness of personal liability acts to focus the attention of many engineers on the moral dimension of their work. However, it also encourages more expensive decision-making, inhibition of innovation and professional paralysis. We argue that while personal legal liability is a legitimate way to focus engineers’ attention on the potential impact of their work, a problem arises when decision-makers are held responsible for disasters over which they had little control. The focus then shifts to ‘defensive engineering’ practices that are aimed at limiting individual liability rather than disaster prevention. Legal processes that are seen to unfairly allocate blame do not encourage practices that support future disaster prevention.

Constructing safety: investigating senior executive long-term incentive plans and safety objectives in the construction sector

Abstract In the private sector, incentive plans are one of the major means used by Boards of Directors to align the interests of senior management with organizational interests. However, research conducted in the energy and resources sector revealed a poor alignment between incentive plans and the need to have senior management focus on safety. The research discussed here examined long-term incentive plans (LTIPs) for senior executives in the construction sector to investigate whether these direct senior managers attention to long-term safety objectives and if they include any long-term safety indicators. Annual Reports of publicly listed companies in the Australian non-domestic construction sector were used as the major information source and subjected to content analysis. Despite a strong safety commitment expressed by all the companies, LTIPs were exclusively associated with financial indicators. Although safety indicators are included in Annual Reports, these only appear in short-term incentive plans, indicating that senior executives are not incentivized to align their long-term decision-making with long-term safety objectives. Findings from the research demonstrate that valid and meaningful safety indicators should be developed and included in LTIPs in order to better align the focus of senior management to include safety performance in the construction industry.