organizational risk analysis: human nature and socio-technical systems john s. carroll mit sloan...
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Organizational Risk Analysis: Human Nature and
Socio-Technical Systems
John S. Carroll
MIT Sloan School
presented at
16.863 doctoral seminar
April, 2009
Agenda
Major approaches to organizations, organizational behavior, organization theory, and the like
Organizational analysis Organizational approaches to safety Let’s talk
Major Disciplinary Approaches to Organizations
Theory first Application/content first
Economics
Political Science
Anthropology
Sociology
Social Psychology
Individual Psychology
Business
Law
Public Policy
Military
Health Care Mgmt
I/O Psychology
Disciplines Work Within Level
Discipline
Economics
Political Science
Anthropology
Sociology
Social Psych
Individual Psych
Prototype
markets
states, parties
tribes
networks
families, teams
couples
Key Concept
efficiency
power
culture, kin
status, norm
motives
personality
Organizations Are In the Middle
Macro approaches start from institutions and work down to organizations, e.g., corporation as a legal entity. Org’n-in-environment
Micro approaches start from individuals and work up to organizations, e.g., “neurotic” organization. People–in–org’n
Meso approaches try to examine organizational phenomena at a middle level
No “Unified Field Theory”
Academic research rewards depth over breadth
Disciplines grow as communities with close ties within; weak ties across
All theories/models have boundaries This is a very difficult, complex problem The devil is in the details
Major Theoretical Approaches
Natural Selection: evolutionary metaphor, population ecology, environmental determinism
Structural Functionalism/Rational System: organizations have goals, create tasks and roles to adapt contingently to environment
Collective Action/Natural System: political negotiations, norms of cooperation, networks of relationships
Strategic Choice: individual enactment, retrospective rationality
Social Science/Management Principles
Humans are general purpose action learners (note limited rationality; attention is a scarce resource)
Individuals have varied inborn and learned capabilities, motives, values, styles
People live and work in groups/organizations Both hierarchy and networks are organizing principles and
forms Self-interest is both natural and learned, along with other
social motives (power, status, achievement, affiliation, self-actualization). [No real economist would have children (net loss) – note that people are becoming more economic.]
Purpose and meaning are socially constructed; the past, status quo, and future are invested with emotions
An Example: Power of Norms
Cialdini: how to get people to reuse hotel towels? Messages about how much water would be saved or
being good to the environment didn’t help at all Offering to donate savings to a cause helped a little Saying the hotel already donated, now “it’s your turn”
helped a lot (reciprocity, note who goes first) Saying “most people” in this hotel reuse their towels
helped a lot Saying “most people in this room” in this hotel reuse
their towels helped even more!
Open Systems Model
Inputs Transformation Processes Outputs
People
TasksFormal Org’n
Informal org’n
Products
Services
Satisfaction
Identity/Brand
Money
Information
People
Environment
History
Str
ateg
y
Strategic Design Lens
Model: organizations are designed (engineered) to achieve agreed-upon goals
Key processes: grouping (formal structure), linking, alignment, fit
Key concepts: goal-directed, information flows, interdependence
Leader: strategist, designer, architect Drivers of change: lack of fit to environment,
internal lack of alignment
Processes in Strategic Design
Assess Environment (threats, opportunities)
Assess Organization (competences, capabilities)
Strategic Intent
Strategic Organizational Design (grouping, linking, alignment)
Results(fit of output to environment, internal alignment)
Political Lens Model: organizations are contests for power and
autonomy among internal stakeholders Key processes: conflict, negotiation, coalition
building Key concepts: power, influence, autonomy,
interests, networks, dominant coalition Leader: coalition builder, negotiator Drivers of change: shifts in power of stakeholders
(can be influenced by changes in design, environment, or strategy)
Cultural Lens Model: organizations are shared
mental maps, identities, assumptions Key processes: meaning and interpretation,
attribution, “taken for granted” (cognitive), “invested with value” (normative)
Key concepts: artifacts, symbols, myths, values, assumptions, identities, subcultures
Leader: symbol of the culture, shaper of the culture, articulator of symbols and vision
Drivers of change: challenges to basic assumptions, new interpretations
Schein’s Model of Culture
Artifacts: what you see, objects, structures
Values: strategies, goals, philosophies, justifications
Assumptions: taken for granted beliefs, mental models, habits
An Example: Project Teams Team composition
Strategic design: know-how & capabilitiesPolitical: represent key stakeholdersCultural: variety of mental maps
Key roles and behaviors Strategic design: project & task management, expertisePolitical: manage conflict, get commitment, build coalitionCultural: reframe and communicate, give meaning
Key outcomes Strategic design: create results within budget, schedule Political: broader coalitions, shared interests, new status Cultural: value openness & learning, new assumptions
Organizational Safety Design
Traditional safety management is heavily “strategic design” oriented
Calculate risks (PRA, etc.) Design redundancies, defense in depth Monitor and regulate key factors Train and supervise people Proceduralize
Political and Cultural Critique
Perrow’s NAT was skeptical of design, e.g., redundancy adds complexity and invisibility, elites only care about their own safety
Vaughan analysis of Challenger argued that people have to maintain systems (cf. Giddens’ structuration)
Professional subcultures create barriers and miscommunications (Schein, Carroll)
Different Worlds J. S. Carroll, J. Mgmt Studies, 1998, p. 712
Design EngineersEquipment/Drawings
VisualPlanning/Fixing
OperatorsEquipment/People
TactileAdapting
ExecutivesMoney
NumericalPlanning
Social ScientistsIdeas/Systems
VerbalLearning
ANTICIPATION RESILIENCE
AB
ST
RA
CT
CO
NC
RE
TE
HRO Theory
HRO took the “appreciative inquiry” approach to characterizing excellence
After early observational studies, many HRO scholars have tended to focus on culture: sensemaking, mindfulness, respect for expertise, preoccupation with failure, building communities-of-practice
Conundrum: hard to change culture by trying to change culture (Schein)
Example #1: CR Problem
During an outage, a design modification was installed to replace old electromechanical indicators in the control room with new computer-based indicators
Operators were trained, and told “there is nothing you can do to harm the new system”
A few months later, an operator entered improper keystrokes and the computer system froze
Root causes were traced to operators and designers Operators were disciplined No one in engineering is “singularly responsible”
Fall From Roof
Joe Smith, an electrical maintenance worker, climbed onto the thin roofing of a shed inside the hot machine shop, an area used to decontaminate equipment with radiological residue. His goal was to replace burned-out fluorescent lights. Joe was advised to stay on the 1.5” steel frame of the shed. As he crawled on the roof, his hand slipped through a Plexiglas skylight, but he caught himself and continued. He then slipped again off the steel frame and fell through the roof to the floor 10 feet below. His injuries included 5 fractures and severe lacerations. Joe had been counseled two months before for failing to use fall protection while painting.
Report’s Cause Maps
V ie w e d asro u tine
W a rn in gsig n ored
F a iled to u sem a nu a l
T u n n e lv is ion
E m plo yee In ju redfro m F a ll
H a za rdsn o t assessed
N o fa llp ro tec tion
M isu seds te p la dd er
F a iled to u sem a nu a l
E m plo yee In ju redfro m F a ll
Corrective actions:Reinforce expectationsDetail/training on working aloftCounsel workers involved
Learning Activities Mature
ReactiveComponentsInputsSingle-loop
ProactiveSystemsProcessesDouble-loop
Comply w/rules
Fix symptoms
Find “root causes”
Benchmark the best
Systems models
Challenge assumptions
Deny problems
Bounded know-how
LOCAL OPEN DEEP INQUIRYCONSTRAINED
Major Philosophical Approaches Positivist: cause-effect relations, empiricist
(data are “objective reality”) Naturalistic: description, classification Interpretive/constructive: subjective
perceptions and interpretations Action research: participate in change
efforts Critical/Postmodern: deconstruct, politicize,
self-referent, ironic, views of the marginalized
The Nature of Theorizing
What is an “organization”? What is a “system” or, gasp, an “engineering system”?
Abstraction of “reality” into “concepts: “Organization”, “Profit”, “Leadership”, “Information”, “Authority” are created, not given
Heavy use of analogy, e.g., evolution Cause-effect linkages, usually simple or
conditional, sometimes feedback loops
Controversies of Ideology: Theories of Human Nature Rational goal seeking vs. environmental
determinism Can general laws explain organizations? Competition vs. cooperation as basis of
society: individual vs. collective success Efficiency/optimality vs. relativistic
values/culture Seek to describe, understand, or help?
Current Controversies
Are organizations getting larger, smaller, or both?
What new theories do we need in dealing with networked and distributed organizations?
How much is different across national cultures? Will we have a mono-culture?
What is the role of emotions (cf. POS)? Structuration: structure and action Is diversity good or bad? ESD seems to be creating a “design science”