Chronic Unease: Not forgetting to be afraid Dr L Chronic Unease: Not forgetting to be afraid Dr L. Fruhen Industrial Psychology Research Centre ESRC Seminar Learning from Incidents

The experience of discomfort and concern about the management of risks Chronic Unease I The experience of discomfort and concern about the management of risks A contrast to complacency, resulting from the absence of negative events, leading ‘people [to] forget to be afraid’ (Reason, 1997, p. 39). The resilience literature also uses the term ‘restless mind’ to label awareness that things can go wrong and alertness to weak signals (Westrum 2008). Pidgeon (2012) uses the term ‘safety imagination’ to describe similar approaches towards risks All of these contain aspects of chronic unease but are not necessarily identical We decided to focus on chronic unease, as It appeared earlier in the literature than mindfulness, restless mind or safety imagination when Reason (1997) introduced it. Mindfulness as a term is used with completely different meaning outside of the HRO literature Chronic unease has been explicitly associated with managerial impact on organisations (Burns 2002) (lead over to next slide)

Chronic Unease II Instead they rely on Imagination A concept from the High Reliability Organising (HRO) literature HROs don’t use trial and error to learn from incidents and accidents Instead they rely on Imagination Vicarious experience Stories Simulations Weick, 1987

Chronic unease III Chronic unease has been explicitly associated with managerial impact on organisations (Burns 2002) Managers can be most at risk of complacency in organisations They can be removed from the hazardous operations where their decisions will have an effect, giving problems an abstract quality. The resilience literature also uses the term ‘restless mind’ to label awareness that things can go wrong and alertness to weak signals (Westrum 2008). Pidgeon (2012) uses the term ‘safety imagination’ to describe similar approaches towards risks All of these contain aspects of chronic unease but are not necessarily identical We decided to focus on chronic unease, as It appeared earlier in the literature than mindfulness, restless mind or safety imagination when Reason (1997) introduced it. Mindfulness as a term is used with completely different meaning outside of the HRO literature Chronic unease has been explicitly associated with managerial impact on organisations (Burns 2002)

Senior Managers & Learning from Accidents Accident Investigations Clapham Junction rail crash “Large schemes need firm, positive and sufficiently senior control in order that they are carried through properly, which means safely, efficiently and economically. “(Hidden, 1989, p.161) Herald of Free Enterprise sinking “But a full investigation into the circumstances of the disaster leads inexorably to the conclusion that the underlying or cardinal faults lay higher up in the company...” (Sheen, 1987, p.14) Piper Alpha “The quality of safety management by operators is fundamental to offshore safety. No amount of detailed regulations for safety improvements could make up for deficiencies in the way that safety is managed by operators.” (Cullen, 1990, p.301) BP Texas City refinery explosion BP has not provided effective leadership or established appropriate operational expectations regarding process safety performance at its U.S. refineries [and} the panel believes that the lack of effective leadership is systemic, touching all level of BP’s corporate management having responsibility for BP’S U.S. refineries (Baker, 2007, p. 66) Überlingen Mid-Air collision “[…], managers can change and improve existing corporate culture by establishing safety – recognisable for all staff members – as high priority. Feedback and continual reinforcement from the most senior management down will help develop dedication and accountability that is desirable.” (BFU, 2004; p. 90). Deepwater Horizon Oil Spill “...a single overarching failure – a failure of management” (p.90). “The critical common element is an unwavering commitment to safety at the top of an organization: the CEO and board of directors must create the culture and establish the conditions under which everyone in a company shares responsibility for maintaining a relentless focus on preventing accidents.” (National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, 2011 ;p.218)” Fukushima Nuclear accident As the nuclear power business became less profitable over the years, TEPCO’s management began to put more emphasis on cost cutting and increasing Japan’s reliance on nuclear power. While giving lip service to a policy of “safety first,” in actuality, safety suffered at the expense of other management priorities. (The Fukushima Nuclear Accident Independent Investigation Commission. p.44)

Senior managers and safety Academic views – literature reviews They are one of the main drivers of organisational safety (e.g. Flin et a., 2000; Guldenmund, 2000) “The prime theme deemed to be worthy of measurement in relation to a worksite's or organization's safety climate relates to perceptions of management attitudes and behaviours in relation to safety [...] (Flin et al., 2000; p.185). Management as a theme appears explicitly in 13 studies they identified as measuring safety culture Implicitly (from inspecting the items) every one of the 18 studies they identified considered management . The underlying psychological characteristics driving managerial influence on safety are not well understood

So what is chronic unease in managers? A state of psychological strain in which an individual experiences discomfort and concern about the control of risks in organisations Component Description Vigilance The ability to notice and identify (weak) indicators of risks in the environment. Propensity to worry A tendency to worry about risk and safety. This can include emotional and somatic reactions. Requisite Imagination The ability to mentally project the development of a situation into the future based on its current state Flexibility of thought The tendency to approach safety related issues from many angles, to think about them critically and to question assumptions. Pessimism A personality trait reflecting a tendency to resist complacency and to anticipate failure. Not only concerning the hazards per se but rather the extent to these are being managed And whether sufficient information is available to confirm this judgement. Some might be more prone to experience unease (and to consider it in their work) than others Can this support learning from incidents/ accidents? Fruhen et al., in press a

Interview study How relevant are these components to chronic unease? What behaviours are associated with the experience of unease? Sample: Senior managers (n = 27) Semi-structured interviews Using critical incident technique (Flanagan, 1954) Open questions Content analysis (deductive and inductive, Mayring, 2000), two independent coders (α = 0.86 (95% CILL 0.81 to CIUL 0.90) )

Results: the components of unease Flexible thinking (ƒ = 181 in 25 interviews) Pessimism (ƒ = 162 in 27 interviews) Propensity to worry (ƒ = 121 in 26 interviews) Vigilance (ƒ = 102 in 25 interviews) Requisite imagination (ƒ = 50 in 23 interviews) Experience (ƒ = 35 in 16 interviews) “It is constantly asking but why does it do that? Is that really the design and if it’s really the design why did we accept that for the design?” “I look at the trend of first aids; I look at the trend of small spills. I combine that with my own observations when I am on site and that’s how I make my assessments, how I think it is going.” Give quotes Say flexible thinking overlapped with behaviour

Results: the components of unease Flexible thinking (ƒ = 181 in 25 interviews) Pessimism (ƒ = 162 in 27 interviews) Propensity to worry (ƒ = 121 in 26 interviews) Vigilance (ƒ = 102 in 25 interviews) Requisite imagination (ƒ = 50 in 23 interviews) Experience (ƒ = 35 in 16 interviews) “Frankly one of these high consequence types of events could happen any time during that direction.” “[You] constantly say no, it’s still not good enough, no, it’s still not good enough.” Give quotes Flexible thinking “It is constantly asking but why does it do that? Is that really the design and if it’s really the design why did we accept that for the design?” “I look at the trend of first aids; I look at the trend of small spills. I combine that with my own observations when I am on site and that’s how I make my assessments, how I think it is going.” Pessimism “Frankly one of these high consequence types of events could happen any time during that direction.” Worry “I am constantly worried that someone is going to get hurt.” “So absolutely very tense, breaking into a sweat like, oh gosh, we need to act on this.” Vigilance “Chronic unease means for me having that alarm, that the radar, having my antennae up every time we do something different which we haven’t done before and really going back to the first principles.” Requisite imagination “If that gas cloud had ignited, it would have been a huge fireball and what the catastrophic event would have been” “Your nightmare is for someone to be killed.” Experience “If you have been involved with a process safety event or there has been a fatality and somebody has been killed, you never have to spend any time convincing those people of the importance of this subject.”

Results: the components of unease Flexible thinking (ƒ = 181 in 25 interviews) Pessimism (ƒ = 162 in 27 interviews) Propensity to worry (ƒ = 121 in 26 interviews) Vigilance (ƒ = 102 in 25 interviews) Requisite imagination (ƒ = 50 in 23 interviews) Experience (ƒ = 35 in 16 interviews) “I am constantly worried that someone is going to get hurt.” “So absolutely very tense, breaking into a sweat like, oh gosh, we need to act on this.” Give quotes Flexible thinking “It is constantly asking but why does it do that? Is that really the design and if it’s really the design why did we accept that for the design?” “I look at the trend of first aids; I look at the trend of small spills. I combine that with my own observations when I am on site and that’s how I make my assessments, how I think it is going.” Pessimism “Frankly one of these high consequence types of events could happen any time during that direction.” Worry “I am constantly worried that someone is going to get hurt.” “So absolutely very tense, breaking into a sweat like, oh gosh, we need to act on this.” Vigilance “Chronic unease means for me having that alarm, that the radar, having my antennae up every time we do something different which we haven’t done before and really going back to the first principles.” Requisite imagination “If that gas cloud had ignited, it would have been a huge fireball and what the catastrophic event would have been” “Your nightmare is for someone to be killed.” Experience “If you have been involved with a process safety event or there has been a fatality and somebody has been killed, you never have to spend any time convincing those people of the importance of this subject.”

Results: the components of unease “Chronic unease means for me having that alarm, that radar, having my antennae up every time we do something different which we haven’t done before and really going back to the first principles.” “Leaders need to listen, hear when people are making comments that might be a little different in what they normally do because they might be trying to tell you something.” Flexible thinking (ƒ = 181 in 25 interviews) Pessimism (ƒ = 162 in 27 interviews) Propensity to worry (ƒ = 121 in 26 interviews) Vigilance (ƒ = 102 in 25 interviews) Requisite imagination (ƒ = 50 in 23 interviews) Experience (ƒ = 35 in 16 interviews) Give quotes Flexible thinking “It is constantly asking but why does it do that? Is that really the design and if it’s really the design why did we accept that for the design?” “I look at the trend of first aids; I look at the trend of small spills. I combine that with my own observations when I am on site and that’s how I make my assessments, how I think it is going.” Pessimism “Frankly one of these high consequence types of events could happen any time during that direction.” Worry “I am constantly worried that someone is going to get hurt.” “So absolutely very tense, breaking into a sweat like, oh gosh, we need to act on this.” Vigilance “Chronic unease means for me having that alarm, that the radar, having my antennae up every time we do something different which we haven’t done before and really going back to the first principles.” Requisite imagination “If that gas cloud had ignited, it would have been a huge fireball and what the catastrophic event would have been” “Your nightmare is for someone to be killed.” Experience “If you have been involved with a process safety event or there has been a fatality and somebody has been killed, you never have to spend any time convincing those people of the importance of this subject.”

Results: the components of unease “If that gas cloud had ignited, it would have been a huge fireball and what the catastrophic event would have been” “Your nightmare is for someone to be killed.” Flexible thinking (ƒ = 181 in 25 interviews) Pessimism (ƒ = 162 in 27 interviews) Propensity to worry (ƒ = 121 in 26 interviews) Vigilance (ƒ = 102 in 25 interviews) Requisite imagination (ƒ = 50 in 23 interviews) Experience (ƒ = 35 in 16 interviews) Give quotes Flexible thinking “It is constantly asking but why does it do that? Is that really the design and if it’s really the design why did we accept that for the design?” “I look at the trend of first aids; I look at the trend of small spills. I combine that with my own observations when I am on site and that’s how I make my assessments, how I think it is going.” Pessimism “Frankly one of these high consequence types of events could happen any time during that direction.” Worry “I am constantly worried that someone is going to get hurt.” “So absolutely very tense, breaking into a sweat like, oh gosh, we need to act on this.” Vigilance “Chronic unease means for me having that alarm, that the radar, having my antennae up every time we do something different which we haven’t done before and really going back to the first principles.” Requisite imagination “If that gas cloud had ignited, it would have been a huge fireball and what the catastrophic event would have been” “Your nightmare is for someone to be killed.” Experience “If you have been involved with a process safety event or there has been a fatality and somebody has been killed, you never have to spend any time convincing those people of the importance of this subject.”

Results: the components of unease Flexible thinking (ƒ = 181 in 25 interviews) Pessimism (ƒ = 162 in 27 interviews) Propensity to worry (ƒ = 121 in 26 interviews) Vigilance (ƒ = 102 in 25 interviews) Requisite imagination (ƒ = 50 in 23 interviews) Experience (ƒ = 35 in 16 interviews) “If you have been involved with a process safety event or there has been a fatality and somebody has been killed, you never have to spend any time convincing those people of the importance of this subject.” Give quotes Flexible thinking “It is constantly asking but why does it do that? Is that really the design and if it’s really the design why did we accept that for the design?” “I look at the trend of first aids; I look at the trend of small spills. I combine that with my own observations when I am on site and that’s how I make my assessments, how I think it is going.” Pessimism “Frankly one of these high consequence types of events could happen any time during that direction.” Worry “I am constantly worried that someone is going to get hurt.” “So absolutely very tense, breaking into a sweat like, oh gosh, we need to act on this.” Vigilance “Chronic unease means for me having that alarm, that the radar, having my antennae up every time we do something different which we haven’t done before and really going back to the first principles.” Requisite imagination “If that gas cloud had ignited, it would have been a huge fireball and what the catastrophic event would have been” “Your nightmare is for someone to be killed.” Experience “If you have been involved with a process safety event or there has been a fatality and somebody has been killed, you never have to spend any time convincing those people of the importance of this subject.”

Behaviours associated with unease Demonstrating safety commitment (ƒ = 72) Showing safety is a priority (ƒ = 24) Not compromising safety (ƒ = 19) Spending time on safety (ƒ = 15) Providing support (ƒ = 14) Transformational leadership (ƒ = 38) Intellectual stimulation (ƒ =20) Inspiring others (ƒ = 18) Transactional leadership (ƒ = 36) Management by exception active (ƒ =25) Contingent reward (ƒ = 11) Seeking information (ƒ = 49)

Summary Fruhen et al., in prep; Fruhen et al., in press

Thank you for your attention Feedback, questions, comments? e-mail l.fruhen@abdn.ac.uk