How an institutional setting shape and limit the mitigation of accidents in complex work settings

IF 3.9 2区 工程技术 Q1 ERGONOMICS
Johan M. Sanne , Colin J. Pilbeam
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引用次数: 0

Abstract

Introduction:

Research suggests that accidents due to failed coordination arising from the disruption of everyday activity can be mitigated by empowered employees through sensemaking activities: observing or recognizing cues, voicing concern, and considering alternative perspectives. Unfortunately, the literature also observes limits to such activities due to the influence from technology, power, and language. However, there is negligible understanding of the mutual influence of these phenomena on (the failure of) sensemaking to prevent escalation.

Method:

Using an institutional and sociomaterial approach to sensemaking, we integrate the influence of technology, power, and language to investigate accident commission data (e.g., talk between different actors and interviews), from a railway accident in Sweden in 1987, showing how a minor disruption in everyday work escalated into a situation that exceeded the limits for effective sensemaking.

Results:

Technology, power, and language in institutional settings, expressed through actors’ habitual repertoire, influence sensemaking and its outcomes. The findings indicate that actors’ habits encourage the continuation of immanent sensemaking and that it takes strong, specific, cues to shift to deliberative sensemaking. Moreover, also deliberative sensemaking is influenced by actor’s habitual repertoire, limiting its quality.

Conclusions:

The efforts to mitigate the escalation to tragedy in this case failed because of the mutual influences of technology, power and language operating within an institutionalized and heavily regulated work environment. This resulted in fragmented or minimal sensemaking that, in hindsight, did not match the complexity in the accident and the response that would have been required.

Practical Applications:

To enable sufficient articulation of concerns and collaborative problem-solving in complex safety–critical systems, there is a need to break with hierarchical relations, to create a shared language, and employees should be made aware of the potential misleading signals from technologies designed to ensure safety.
在复杂的工作环境中,制度环境如何塑造和限制事故的缓解
研究表明,由于日常活动中断而导致的协调失败事故可以通过授权员工通过感知活动来减轻:观察或识别线索,表达关注,并考虑其他观点。不幸的是,由于技术、权力和语言的影响,文献也观察到这些活动的局限性。然而,对于这些现象对防止升级的意义构建(失败)的相互影响的理解可以忽略不计。方法:采用制度和社会材料的方法进行语义构建,我们整合了技术、权力和语言的影响来调查事故委员会数据(例如,不同参与者之间的谈话和访谈),这些数据来自1987年瑞典的一起铁路事故,显示了日常工作中的轻微中断如何升级为超出有效语义构建限制的情况。结果:制度设置中的技术、权力和语言,通过行为者的习惯曲目表达,影响意义制造及其结果。研究结果表明,演员的习惯鼓励内在意义的延续,并且需要强有力的、具体的线索才能转变为深思熟虑的意义。此外,深思熟虑的意义表达受演员习惯曲目的影响,限制了其质量。结论:在这种情况下,由于技术、权力和语言在制度化和严格监管的工作环境中运作的相互影响,减轻悲剧升级的努力失败了。事后看来,这导致了支离破碎或最低限度的意义构建,与事故的复杂性和所需的响应不匹配。实际应用:为了在复杂的安全关键系统中充分表达关注和协作解决问题,需要打破等级关系,创建共享语言,并且应该让员工意识到为确保安全而设计的技术可能产生的误导信号。
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来源期刊
CiteScore
6.40
自引率
4.90%
发文量
174
审稿时长
61 days
期刊介绍: Journal of Safety Research is an interdisciplinary publication that provides for the exchange of ideas and scientific evidence capturing studies through research in all areas of safety and health, including traffic, workplace, home, and community. This forum invites research using rigorous methodologies, encourages translational research, and engages the global scientific community through various partnerships (e.g., this outreach includes highlighting some of the latest findings from the U.S. Centers for Disease Control and Prevention).
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