Abstract
If learning is to be encouraged, error and the resulting increase in uncertainty need to be permitted, and even actively sought, even though they may collide with an organization’s concerns about proving that they are safe. As the author shows, when decisions are made on how uncertainty should best be managed for particular work processes, stability and flexibility requirements need to be analyzed in view of the specific necessities for control and adaptation. The author makes it clear that uncertainty may be beneficial for safety in situations where there is a danger of the over-routinization of behavior due to highly standardized and repetitive task requirements.
Much of this chapter draws on Grote (2015).
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsReferences
Air Accident Investigation Branch. 1990. UK AAIB report 4/90 on the 8 January 1989 accident of a British Midland B737–400 at Kegworth, Leicestershire, England. Aldershot: Air Accident Investigation Branch.
Anderson, P. 1999. Complexity theory and organization science. Organization Science 10: 216–232.
Anderson, N., K. Potocnik, and J. Zhou. 2014. Innovation and creativity in organizations: A state-of-the-science review, prospective commentary, and guiding framework. Journal of Management 40: 1297–1333.
Bainbridge, L. 1983. Ironies of automation. Automatica 19: 775–779.
Bienefeld, N., and G. Grote. 2012. Silence that may kill: When aircrew members don’t speak up and why. Aviation Psychology and Applied Human Factors 2: 1–10.
———. 2014. Speaking up in ad Hoc multiteam systems: Individual level effects of psychological safety, status, and leadership within and across teams. European Journal of Work and Organizational Psychology 23(6): 930–945.
Carroll, J.S. 1998. Organizational learning activities in high-hazard industries: The logics underlying self-analysis. Journal of Management Studies 35: 699–717.
Daft, R.L., and R.H. Lengel. 1984. Information richness: A new approach to managerial behavior and organizational design. In Research in organizational behavior, ed. L.L. Cummings and B.M. Staw, vol. 6, 191–233. Homewood: JAI Press.
Dekker, S. 2007. Just culture – Balancing safety and accountability. Aldershot: Ashgate.
Detert, J.R., and A. Edmondson. 2011. Implicit voice theories: Taken-for-granted rules of self-censorship at work. Academy of Management Journal 54: 461–488.
Edmondson, A. 1999. Psychological safety and learning behavior in work teams. Administrative Science Quarterly 44: 350–383.
Edmondson, A.C. 2003. Speaking up in the operating room: How team leaders promote learning in interdisciplinary action teams. Journal of Management Studies 40: 1419–1452.
Farber, D.A. 2011. Uncertainty. The Georgetown Law Journal 99: 901–959.
Farjoun, M. 2010. Beyond dualism: Stability and change as duality. Academy of Management Review 35: 202–225.
Feldman, S.P. 2004. The culture of objectivity: Quantification, uncertainty, and the evaluation of risk at NASA. Human Relations 57: 691–718.
Frese, M., and N. Keith. 2015. Action errors, error management and learning in organizations. Annual Review of Psychology 66: 661–687.
Galbraith, J. 1973. Designing complex organizations. Reading: Addison-Wesley.
Gebert, D., S. Boerner, and E. Kearney. 2010. Fostering team innovation: Why is it important to combine opposing action strategies? Organization Science 21: 593–608.
Gersick, C., and J.R. Hackman. 1990. Habitual routines in task-performing groups. Organizational Behavior and Human Decision Processes 47: 65–97.
Goodman, P.S., R. Ramanujam, J.S. Carroll, A.C. Edmondson, D.A. Hofmann, and K.M. Sutcliffe. 2011. Organizational errors: Directions for future research. Research in Organizational Behavior 31: 151–176.
Grote, G. 2009. Management of uncertainty. Theory and application in the design of systems and organizations. London: Springer.
———. 2011. Risk management from an organizational psychology perspective: A decision process for managing uncertainties. Die Unternehmung 65: 69–81.
———. 2012. Safety management in different high-risk domains – All the same? Safety Science 50: 1983–1992.
———. 2015. Promoting safety by increasing uncertainty – Implications for risk management. Safety Science 71: 71–79.
Grote, G., J.C. Weichbrodt, H. Günter, E. Zala-Mezö, and B. Künzle. 2009. Coordination in high-risk organisations: The need for flexible routines. Cognition, Technology & Work 11: 17–27.
Grote, G., M. Kolbe, and M.J. Waller. 2012. On the confluence of leadership and coordination in balancing stability and flexibility in teams. Paper presented at the Academy of Management conference, Boston, August.
Hale, A.R., and D. Borys. 2013a. Working to rule or working safety? Part 1: A state of the art review. Safety Science 55: 207–221.
———. 2013b. Working to rule or working safety? Part 2: The management of safety rules and procedures. Safety Science 55: 222–231.
Hale, A.R., and P. Swuste. 1998. Safety rules: Procedural freedom or action constraint? Safety Science 29: 163–177.
Hollnagel, E., D.D. Woods, and N. Leveson. 2006. Resilience engineering: Concepts and precepts. Aldershot: Ashgate.
Kahneman, D., and G. Klein. 2009. Conditions for intuitive expertise – A failure to disagree. American Psychologist 64: 515–526.
Kahneman, D., and A. Tversky. 1979. Prospect theory: An analysis of decision under risk. Econometrica 47: 263–291.
Kerr, N.L., and R.S. Tindale. 2004. Group performance and decision making. Annual Review of Psychology 55: 23–655.
Kolbe, M., M.J. Burtscher, J. Wacker, B. Grande, R. Nohynkova, T. Manser, D.R. Spahn, and G. Grote. 2012. Speaking up is related to better team performance in simulated anesthesia inductions. An observational study. Anesthesia and Analgesia 115: 1099–1108.
Kolbe, M., M. Weiss, G. Grote, A. Knauth, M. Dambach, D.R. Spahn, and B. Grande. 2013. TeamGAINS: A tool for structured debriefings for simulation-based team trainings. BMJ Quality & Safety 22: 541–553.
Leana, C.R., and B. Barry. 2000. Stability and change as simultaneous experiences in organizational life. Academy of Management Review 25: 753–759.
Lei, Z., E. Naveh, and Z. Novikov. 2016. Errors in organizations: An integrative review via levels of analysis, temporal dynamism, and priority lenses. Journal of Management 42: 1315–1343.
Loh, V., S. Andrews, B. Hesketh, and B. Griffin. 2013. The moderating effect of individual differences in error-management training: Who learns from mistakes? Human Factors 55: 435–448.
Manz, C.C., and G.L. Stewart. 1997. Attaining flexible stability by integrating total quality management and socio-technical systems theory. Organization Science 8: 59–70.
March, J., M. Schulz, and X. Zhou. 2000. The dynamics of rules: Change in written organizational codes. Stanford: Stanford University Press.
Mellers, B.A., A. Schwartz, and A.D.J. Cooke. 1998. Judgment and decision making. Annual Review of Psychology 49: 447–477.
Morrison, E.W. 2011. Employee voice behavior: Integration and directions for future research. The Academy of Management Annals 5: 373–412.
NAIIC. 2012. The official report of the Fukushima nuclear accident independent investigation commission. Tokyo: National Diet of Japan.
Nembhard, I.M., and A.C. Edmondson. 2006. Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. Journal of Organizational Behavior 27: 941–966.
Nicolini, D., J. Waring, and J. Mengis. 2011. Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap. Social Science & Medicine 73: 217–225.
Paté-Cornell, E. 2012. On “Black Swans” and “Perfect storms”: Risk analysis and management when statistics are not enough. Risk Analysis 32: 1823–1833.
Perrow, C. 1984. Normal accidents – Living with high-risk technologies. New York: Basic Books.
Pian-Smith, M.C.M., R. Simon, R.D. Minehart, M. Podraza, J. Rudolph, T. Walzer, and D. Raemer. 2009. Teaching residents the two-challenge rule: A simulation-based approach to improve education and patient safety. Simulation in Healthcare 4: 84–91.
Rasmussen, J. 1997. Risk management in a dynamic society: A modelling problem. Safety Science 27: 183–213.
Schein, E.H. 1996. Three cultures of management: The key to organizational learning. Sloan Management Review 38: 9–20.
———. 2013. Humble inquiry: The gentle art of asking instead of telling. San Francisco: Berrett-Koehler Publishers.
Schöbel, M., and D. Manzey. 2011. Subjective theories of organizing and learning from events. Safety Science 49: 47–54.
Shafir, E., and R.A. LeBoeuf. 2002. Rationality. Annual Review of Psychology 53: 491–517.
Thompson, J.D. 1967. Organizations in action. New York: McGraw-Hill.
Van der Schaaf, T.W., D.A. Lucas, and A.R. Hale, eds. 1991. Near miss reporting as a safety tool. Oxford: Butterworth-Heinemann.
Weick, K.E., K.M. Sutcliffe, and D. Obstfeld. 1999. Organizing for high reliability: Processes of collective mindfulness. Research in Organizational Behavior 21: 81–123.
Author information
Authors and Affiliations
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2018 The Author(s)
About this chapter
Cite this chapter
Grote, G. (2018). Errors and Learning for Safety: Creating Uncertainty As an Underlying Mechanism. In: Hagen, J. (eds) How Could This Happen?. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-319-76403-0_2
Download citation
DOI: https://doi.org/10.1007/978-3-319-76403-0_2
Published:
Publisher Name: Palgrave Macmillan, Cham
Print ISBN: 978-3-319-76402-3
Online ISBN: 978-3-319-76403-0
eBook Packages: Business and ManagementBusiness and Management (R0)