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Human Factors & System Safety

Faculty of Engineering, LTH

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Organizational Resilience in Escalating Situations

Background

An escalating situation is one where an initial irregularity develops into a continually deteriorating situation and starts affecting other areas in an accelerating tempo, with consequences that are difficult to overview and impossible to predict (Woods & Patterson, 2003). The current of events in an escalating situation quickly reveals any deficiencies in the structures of the organisations involved in managing it, e.g. problems associated with institutional preparation, organisational design and cross-organisational communication. Timely and accurate organisational responses to the increasing magnitude and variety of problems as well as the higher tempo of the process are essential to be able to maintain organisational resilience and manage the escalation.

Unexpected and escalating situations create a range of cognitive and coordinative demands. As a concept escalation can be used in various domains, such as aviation (Dekker et. al., 2008), healthcare (examplified, but not made explicit in e.g. DeVita et al., 2006, ; Figueireido, Tsatsaris & Mignon, 2007), and civil crisis management at a regional as well as local level (Bergström, Dahlström & Petersen, 2008). As the tempo of operations rises and becomes more (if not entirely) event-driven, there is more to consider, communicate and coordinate, i.e. more data to process, distribute and act upon (Woods, Patterson & Roth, 2002). Goals can multiply, diversify and compete more steeply. Woods and Patterson (2003) characterises escalating situations by making the following points:

  • There is a cascade of effects in the monitored process
  • Demands for cognitive activity need to increase as the problem cascades
  • Demands for coordination need to increase as the problem cascades
  • The cascade and escalation is a dynamic process

The intervention decision

The most recent research that we have conducted into the issue of escalation concerns a, for safety crucial, decision: the decision to intervene. In cooperation with representatives from labour care we are planning to deepening the research on the very nature of escalation. The research is conducted using an ethographic approach (or a light version at least) where observatory field studies are complemented with narrative interviews. 

The decision to intervene can be scientifically analysed using a variety of techniques and theories. In the work that we are currently doing we show how signal detection theory, contingency theory, and Foucault’s theories of the relationship between structures of power and knowledge, all have deficiencies when it comes to explain intervention decisions in Swedish labour care. Instead we argue that we’ll need to extend the theoretical spectrum to also include social constructionism and diversity theory.

 

Team Performance in Escalating Situations

Measuring team performance has traditionally been done in terms of behavioral markers or attitude serveys. However these methods are tightly linked to the scientific school of studying humans as information processors. In research conducted in cooperation with the Brazilian university PUCRS we are developing methods to study team performance not in terms of behavior but in terms of coordination and control. This is done using the theoretical foundation of Cognitive Systems Engineering

Mid-Fidelity Simulation

Most of the data collections during the project has been made using a mid-fidelity ship bridge simulator, developed at the University of Bamberg (Strohschneider & Gerdes, 2004). The simulation, called MS Antwerpen, is constructed as a training program in which 5-7 participants manage unexpected and escalating situations onboard a poorly maintained cruise vessel during a stormy night in the Atlantic Ocean. The MS Antwerpen simulation represents a new type of simulation that is rarely used in crew training. The simulation is part of a two-day emergency management training course. However, quite apart from its training purposes, the simulation can be used as a research tool for providing data on group action and interaction in escalating events.

The M/S Antwerpen is the name for the simulation of a passenger cruising vessel.  The simulation is mid-fidelity. Fidelity refers to how closely a simulation imitates reality, how essentially naturalistic it is. Fidelity does not necessarily reflect the level or degree of technology. The M/S Antwerpen simulation is complex but not photorealistic or 3 dimensional.  In short, it is not intended to mimic in any direct or explicit way nature or the natural world.  However, all the structural and the major technical aspects of the ship are included in the simulation in an effort to approximate real maritime conditions as closely as possible. For example, conditions like passengers, sea, weather, and other traffic are also included in the simulation. All 193 of the ship’s crew members and 300 passengers are simulated individually, using a coarse human-factor model.

The simulation is designed for a group of 5 to 7 participants who act as the ship’s first officers. Each participant takes on a specified role, namely: the captain, the chief officer, the chief engineer, the chief steward, the ship’s doctor, the main engineer, or the navigation officer. Before the simulation begins, each participant is given general information that describes the features of the ship as well role specific information: his or her specific duties on the ship’s bridge. It is the participants’ task to safely navigate the ship through a stormy night in the North Atlantic. Due to the adverse conditions, and because the ship has been poorly maintained, the crew has to deal with a number of passenger-related problems and technical failures that towards the end of the simulation result in a state of emergency. 

To sail the ship and handle impending events, the participants have a wide variety of options and actions available to them. They have control over the technical facilities of the ship, including maintenance and repairs. They can direct the crew and give various orders relating to the passengers (including, e.g. sending drunken passengers to their cabins, closing sections of the ship, and having passengers man the life boats).  Participants do not have (are not provided with) a prescribed set list of possible responses. Instead they have to plan and execute actions as a team and deal with the possible consequences and side-effects of the actions they have chosen to initiate. The participants therefore find themselves in a dynamically developing situation – one that has a high level of uncertainty. Furthermore, they are presented with an overload of incoming information regarding the status of the ship, its passengers and surrounding environment. Moreover, they have to deal with all this under the threat of all the conceivable emergencies that come with navigating a poorly maintained ship in very bad weather.

Are you interested in having representatives from your organization participating in our research by going throught the MS Antwerpen training program? Please download our flyer (in Swedish) or contact Johan Bergström.

Scenario Guidelines

Scenarios developed to practice the generic competencies in escalating situations need to comprise some basic principles of escalating situations, as described by Woods and Patterson (2003):

  • There is a cascade of effects in the monitored process.
  • The cascade of effects should demand an increase of cognitive activities among the participants.
  • The nature of the cascade of effects should demand an increase in coordination among the participants. The process cascading should therefore not be isolated to one particular participant’s area of responsibility, but instead demand different reactions by all participants.
  • The cascade and escalation should be a dynamic process.

In addition, in order to maximally utilize the escalation scenario, and enhance people’s generic abilities to manage it, the scenario should:

  • Try to force people beyond their learned roles and routines. The scenario can contain problems that are not solvable within those roles or routines, and forces people to step out of those roles and routines.
  • Contain a number of hidden goals, at various times during the scenario, that people could pursue (e.g. different ways of escaping the situation or de-escalating it), but that they have to vocalize and articulate in order to begin to achieve them (as they cannot do so by themselves).
  • Include potential actions of which the consequences are both important and difficult to foresee (and that might significantly influence people’s ability to control the problem in the near future). This can force people into pro-active thinking and articulation of their expectations of what might happen.
  • Be able to trap people in locking onto one solution that everybody is fixedly working towards. This can be done by garden-pathing; making the escalating problem look initially (with strong cues) like something the crew could already familiar with, but then letting it depart (with much weaker cues) to see whether the crew is caught on the garden path and lets the situation escalate.
  • Or the scenario, by creating so much cognitive noise in terms of new warnings and events, should be able to trip people into thematic vagabonding—the tendency to redirect attention and change diagnosis with each incoming data piece, which results in a fragmentation of problem-solving.

References