Thursday, November 1, 2012

Practice Makes Perfect

In this post we call attention to a recent article from The Wall Street Journal* that highlights an aspect of safety culture “learning” that may not be appreciated with approaches currently in vogue in the nuclear industry.  The gist of the article is that, just as practice is useful in mastering complex, physically challenging activities, it may also have value in honing the skills inherent in complex socio-technical issues.

“Research has established that fast, simple feedback is almost always more effective at shaping behavior than is a more comprehensive response well after the fact. Better to whisper "Please use a more formal tone with clients, Steven" right away than to lecture Steven at length on the wherefores and whys the next morning.”

Our sense is current efforts to instill safety culture norms and values tend toward after-the-fact lectures and “death by PowerPoint” approaches.  As the article correctly points out, it is “shaping behavior” that should be the goal and is something that benefits from feedback, and “An explicit request can normalize the idea of ‘using’ rather than passively "taking" feedback.”

It’s not a long article so we hope readers will just go ahead and click on the link below.

*  Lemov, D., “Practice Makes Perfect—And Not Just for Jocks and Musicians,” Wall Street Journal online (Oct. 26, 2012).

Monday, October 29, 2012

Nuclear Safety Culture Research

This is a subject that has been on our minds for some time.  Many readers may have eagerly jumped to this post to learn about the latest on research into nuclear safety culture (NSC) issues.  Sorry, you will be disappointed just as we were.  The painful and frankly inexplicable conclusion is that there is virtually no research in this area.  How come?

There is the oft-quoted 2002 comment by then ACRS Chairman, Dr. George Apostolakis:

"For the last 20 to 25 years this agency [the NRC] has started research projects on organizational-managerial issues that were abruptly and rudely stopped because, if you do that, the argument goes, regulations follow. So we don't understand these issues because we never really studied them."*

A principal focus of this blog has been to bring to the attention of our readers relevant information from academic and research sources.  We cover a wide range of topics where we see a connection to nuclear safety culture.  Thus we continually monitor additions to the science of NSC through papers, presentations, books, etc.  In doing so we have come to realize, there is and has been very little relevant research specifically addressing nuclear safety culture.  Even a search of secondary sources; i.e., the references contained in primary research documents, indicates a near vacuum of NSC-specific research.  This is in contrast to the oil and chemical industries and the U.S. manned space program.  In an August 2, 2010 post we described research by  Dr. Stian Antonsen of the Norwegian University of Science and Technology on “..whether it is possible to ‘predict’ if an organization is prone to having major accidents on the basis of safety culture assessments” [short answer: No].

Returning to the September 2012 DOE Nuclear Safety Workshop (see our Oct. 8, 2012 post), where nuclear safety culture was a major agenda item, we observe the only reference in all the presentations to actual research was from the results of an academic study of 17 offshore platform accidents to identify “cultural causal factors”. (See Mark Griffon’s presentation, slide 17.)

With regard to the manned space program, recall the ambitious MIT study to develop a safety culture simulation model for NASA and various independent studies, perhaps most notably
Diane Vaughan's The Challenger Launch Decision.  We have posted on each of these.

One study we did locate that is on topic is an empirical analysis of the use of safety culture surveys in the Millstone engineering organization performed by Professor John Carroll of MIT.  He found that “their [surveys'] use for assessing and measuring safety problematic…”**  It strikes us as curious that the nuclear industry which has so strongly embraced culture surveys hasn’t followed that with basic research to establish the legitimacy and limits of their application.

To further test the waters for applicable research we reviewed the research plans for major nuclear organizations.  The NRC Strategic Plan Fiscal Years 2008-2013 (Updated 2012)*** cites two goals in this area, neither of which address substantive nuclear safety culture issues:

Promote awareness of the importance of a strong safety culture and individual accountability of those engaged in regulated activities. (p.9)

Ensure dissemination of the Safety Culture Policy Statement to all of the regulated community. [Supports Safety Implementation Strategy 7] (p.12)

DOE’s 2010 Nuclear Energy Research and Development Roadmap identifies the following “major challenges”:

- Aging and degradation of system structures and components, such as reactor core internals, reactor pressure vessels, concrete, buried pipes, and cables.
- Fuel reliability and performance issues.
- Obsolete analog instrumentation and control technologies.
- Design and safety analysis tools based on 1980s vintage knowledge bases and computational capabilities.*

The goals of these nuclear research programs speak for themselves.  Now compare to the following from the Chemical Safety Board Strategic Plan:

“Safety Culture continues to be cited in investigations across many industry sectors including the Presidential Commission Report on Deepwater Horizon, the Fukushima Daiichi incident, and the Defense Nuclear Facilities Safety Board’s recommendation for the Hanford Waste Treatment and Immobilization Plant. A potential study would consider issues such as how safety culture is defined, what makes an effective safety culture, and how to evaluate safety culture.”

And this from the VTT Technical Research Centre of Finland, the largest energy sector research unit in Northern Europe.

Man, Organisation and Society – in this area, safety management in a networked operating environment, and the practices for developing nuclear safety competence and safety culture have a key role in VTT's research. The nuclear specific know-how and the combination of competencies in behavioural sciences and fields of technology made possible by VTT's multidisciplinary expertise are crucial to supporting the safe use of nuclear power.#

We invite our readers to bring to our attention any NSC-specific research of which they may be aware.

*  J. Mangels and J. Funk, “Davis-Besse workers' repair job hardest yet,” Cleveland Plain Dealer (Dec. 29, 2002).  Retrieved Oct. 29, 2012.

**    J.S. Carroll, "Safety Culture as an Ongoing Process: Culture Surveys as Opportunities for Inquiry and Change," work paper (undated) p.23, later published in Work and Stress 12 (1998), pp. 272-284.

***  NRC "Strategic Plan: Fiscal Years 2008–2013" (Feb. 2012) published as NUREG-1614, Vol. 5.

****  DOE, "Nuclear Energy Research and Development Roadmap" (April 2010) pp. 17-18. 

*****  CSB, "2012-2016 US Chemical Safety Board Strategic Plan" (June 2012) p. 17.
#  “Nuclear power plant safety research at VTT,” Public Service Review: European Science and Technology 15 (July 13, 2012).  Retrieved Oct. 29, 2012.

Friday, October 26, 2012

Communicating Change

One of our readers suggested we look at Communicating Change* by T.J. and Sandar Larkin.  The Larkins are consultants so I was somewhat skeptical of finding any value for safety culture but they have significant experience and cite enough third-party references (think: typical Wikipedia item) to give the book some credibility. 

The book presents three principles for effectively communicating change, i.e., delivering a top-down message that ultimately results in better performance or acceptance of necessary innovations, workplace disruptions or future unknowns.

Transmit the message through the first-line supervisors.  They will be the ones who have to explain the message and implement the changes on a day-to-day basis after the executives board their plane and leave.  Senior management initiatives to communicate directly with workers undermines supervisors’ influence.

Communicate face-to-face.  Do not rely on newsletters, videos, mass e-mail and other one-way communication techniques; the message is too easily ignored or misunderstood.  Face-to-face, from the boss, may be even more important in the age of social media where people can be awash in a sea of (often conflicting) information.

Make changes relevant to each work area, i.e., give the supervisor the information, training and tools necessary to explain exactly what will change for the local work group, e.g., different performance standards, methods, equipment, etc.

That’s it, although the book goes on for almost 250 pages to justify the three key principles and explain how they might be implemented.  (The book is full of examples and how-to instructions.)

Initially I thought this approach was too simplistic, i.e., it wouldn’t help anyone facing the challenge of trying to change safety-related behavior.  But simple can cut through the clutter of well-meaning but complicated change programs, one size fits all media and training, and repetitive assessments.

This book is not the complete answer but it does provide a change agent with some perspective on how one might go about getting the individual contributors (trade, technical or professional) at the end of the food chain to understand, respond to and eventually internalize required behavioral changes. 

Please contact us if you have a suggestion for a resource that you’d like us to review.

 *  T. Larkin and S. Larkin, Communicating Change: Winning Employee Support for New Business Goals (New York: McGraw-Hill, 1994).

Wednesday, October 17, 2012

NRC Non-Regulation of Safety Culture: Third Quarter Update

On March 17 we published a post on NRC safety culture (SC) related activities with individual licensees since the SC policy statement was issued in June, 2011.  On July 3, we published an update for second quarter 2012 activities.  This post highlights selected NRC actions during the third quarter, July through September 2012.

Our earlier posts mentioned Browns Ferry, Fort Calhoun and Palisades as plants where the NRC was undertaking significant SC-related activities.  It looks like none of those plants has resolved its SC issues and, at the current rate of progress,
I’m sure we’ll be reporting on all of them for quite awhile.

Browns Ferry

As we reported earlier, this plant’s SC problems have existed for years.  On August 23, TVA management submitted its Integrated Improvement Plan Summary* to address NRC inspection findings that have landed the plant in column 4 (next to worst) of the NRC’s Action Matrix.  TVA’s analysis of its SC and operational performance problems included an independent SC assessment.  TVA’s overall analysis identified fifteen “fundamental problems” and two bonus issues; for SC improvement efforts, the problems and issues were organized into five focus areas: Accountability, Operational Decision Making (Risk Management), Equipment Reliability, Fire Risk Reduction and the Corrective Action Program (CAP).

The NRC published its mid-cycle review of Browns Ferry on September 4.  In the area of SC, the report noted the NRC had “requested that [the Substantive Cross-Cutting Issue in the CAP] be addressed during your third party safety culture assessment which will be reviewed as part of the Independent NRC Safety Culture Assessment per IP 95003. . . .”**

Fort Calhoun

SC must be addressed to the NRC’s satisfaction prior to plant restart.   The Omaha Public Power District (OPPD) published its Integrated Performance Improvement Plan on July 9.***  The plan includes an independent safety culture assessment to be performed by an organization “that is nationally recognized for successful performance of behavior-anchored nuclear safety culture assessments.” (p. 163)  Subsequent action items will focus on communicating SC principles, assessment results, SC improvement processes and SC information.

The NRC and OPPD met on September 11, 2012 to discuss NRC issues and oversight activities, and OPPD’s performance improvement plan, ongoing work and CAP updates.  OPPD reported that a third-party SC assessment had been completed and corrective actions were being implemented.****


The NRC continues to express its concerns over Palisades’ SC.  The best example is NRC’s August 30 letter***** requesting a laundry list of information related to Palisades’ independent SC assessment and management's reaction to same, including corrective actions, interim actions in place or planned to mitigate the effects of the SC weaknesses, compliance issues with NRC regulatory requirements or commitments, and the assessment of the SC at Entergy’s corporate offices. (p. 5)

The NRC held a public meeting with Palisades on September 12, 2012 to discuss the plant’s safety culture.  Plant management’s slides are available in ADAMS (ML12255A042).  We won’t review them in detail here but management's Safety Culture Action Plan includes the usual initiatives for addressing identified SC issues (including communication, training, CAP improvement and backlog reduction) and a new buzz phrase, Wildly Important Goals.

Other Plants

NRC supplemental inspections can require licensees to assess “whether any safety culture component caused or significantly contributed to” some performance issue.#  NRC inspection reports note the extent and adequacy of the licensee’s assessment, often performed as part of a root cause analysis.  Plants that had such requirements laid on them or had SC contributions noted in inspection reports during the third quarter included Brunswick, Hope Creek, Limerick, Perry, Salem, Waterford and Wolf Creek.

One other specific SC action arose from the NRC’s alternative dispute resolution (ADR) process at Entergy’s James A. FitzPatrick plant.  As part of an NRC Confirmatory Order following ADR, Entergy was told to add a commitment to maintain the SC monitoring processes at Entergy’s nine commercial nuclear power plants.##

The Bottom Line

None of this is a surprise.  Even the new Chairman tells it like it is: “In the United States, we have . . . incorporated a safety culture assessment into our oversight program . . . . “###  What is not a surprise is that particular statement was not included in the NRC’s press release publicizing the Chairman’s comments.  Isn’t “assessment” part of “regulation”?

Given the attention we pay to the issue of regulating SC, one may infer that we object to it.  We don’t.  What we object to is the back-door approach currently being used and the NRC’s continued application of the Big Lie technique to claim that they aren’t regulating SC.

*  P.D. Swafford (TVA) to NRC, “Integrated Improvement Plan Summary” (Aug. 23, 2012)  ADAMS ML12240A106.  TVA has referred to this plan in various presentations at NRC public and Commission meetings.

**  V.M. McCree (NRC) to J.W. Shea (TVA), “Mid Cycle Assessment Letter for Browns Ferry Nuclear Plant Units 1, 2, and 3” (Sept. 4, 2012)  ADAMS ML12248A296.

***  D.J. Bannister (OPPD) to NRC, “Fort Calhoun Station Integrated Performance Improvement Plan Rev. 3” (July 9, 2012)  ADAMS ML12192A204.

**** NRC, “09/11/2012 Meeting Summary of with Omaha Public Power District” (Sept. 25, 2012)  ADAMS ML12269A224.

*****  J.B. Giessner (NRC) to A. Vitale (Entergy), “Palisades Nuclear Plant – Notification of NRC Supplemental Inspection . . . and Request for Information” (Aug. 30, 2012)  ADAMS ML12243A409.

#  The scope of NRC Inspection Procedure 95001 includes “Review licensee’s evaluation of root and contributing causes. . . ,” which may include SC; IP 95002’s scope includes “Determine if safety culture components caused or significantly contributed to risk significant performance issues” and IP 95003’s scope includes “Evaluate the licensee’s third-party safety culture assessment and conduct a graded assessment of the licensee’s safety culture based on evaluation results.”  See IMC 2515 App B, "Supplemental Inspection Program" (Aug. 18, 2011)  ADAMS ML111870266.

##  M. Gray (NRC) to M.J. Colomb (Entergy), “James A. FitzPatrick Nuclear Power Plant - NRC Integrated Inspection Report 05000333/2012003” (Aug. 7, 2012)  ADAMS ML12220A278.

###  A.M. Macfarlane, “Assessing Progress in Worldwide Nuclear Safety,” remarks to International Nuclear Safety Group Forum, IAEA, Vienna, Austria (Sept. 17, 2012), p. 3 ADAMS ML12261A373; NRC Press Release No. 12-102, “NRC Chairman Says Safety Culture Critical to Improving Safety; Notes Fukushima Progress in United States” (Sept. 17, 2012) ADAMS ML12261A391.

Monday, October 8, 2012

DOE Nuclear Safety Workshop

The DOE held a Nuclear Safety Workshop on September 19-20, 2012.  Safety culture (SC) was the topic at two of the technical breakout sessions, one with outside (non-DOE) presenters and the other with DOE-related presenters.  Here’s our take on the outsiders’ presentations.

Chemical Safety Board (CSB)

This presentation* introduced the CSB and its mission and methods.  The CSB investigates chemical accidents and makes recommendations to prevent recurrences.  It has no regulatory authority. 

Its investigations focus on improving safety, not assigning blame.  The CSB analyzes systemic factors that may have contributed to an accident and recognizes that “Addressing the immediate cause only prevents that exact accident from occurring again.” (p. 5) 

The agency analyzes how safety systems work in real life and “why conditions or decisions leading to an accident were seen as normal, rational, or acceptable prior to the accident.” (p. 6)  They consider organizational and social causes, including “safety culture, organizational structure, cost pressures, regulatory gaps and ineffective enforcement, and performance agreements or bonus structures.” (ibid.)

The presentation included examples of findings from CSB investigations into the BP Texas City and Deepwater Horizon incidents.  The CSB’s SC model is adapted from the Schein construct.  What’s interesting is their set of artifacts includes many “soft” items such as complacency, normalization of deviance, management commitment to safety, work pressure, and tolerance of inadequate systems.

This is a brief and informative presentation, and well worth a look.  Perhaps because the CSB is unencumbered by regulatory protocol, it seems freer to go where the evidence leads it when investigating incidents.  We are impressed by their approach.

The NRC presentation** reviewed the basics of the Reactor Oversight Process (ROP) and then drilled down into how potential SC issues are identified and addressed.  Within the ROP, “. . . a safety culture aspect is assigned if it is the most significant contributor to an inspection finding.” (p.12)  After such a finding, the NRC may perform an SC assessment (per IP 95002) or request the licensee to perform one, which the NRC then reviews (per IP 95003).

This presentation is bureaucratic but provides a useful road map.  Looking at the overall approach, it is even more disingenuous for the NRC to claim that it doesn’t regulate SC.


There was nothing new here.  This infomercial for IAEA*** covered the basic history of SC and reviewed contents of related IAEA documents, including laundry lists of desired organizational attributes.  The three-factor IAEA SC figure presented is basically the Schein model, with different labels.  The components of a correct culture change initiative are equally recognizable: communication, continuous improvement, trust, respect, etc.

The presentation had one repeatable quote: “Culture can be seen as something we can influence, rather than something we can control” (p. 10)


SC conferences and workshops are often worthless but sometimes one does learn things.  In this case, the CSB presentation was refreshingly complete and the NRC presentation was perhaps more revealing than the presenter intended.

*  M.A. Griffon, U.S. Chemical Safety and Hazards Investigation Board, “CSB Investigations and Safety Culture,” presented at the DOE Nuclear Safety Workshop (Sept. 19, 2012). 

**  U. Shoop, NRC, “Safety Culture in the U.S. Nuclear Regulatory Commission’s Reactor Oversight Process,” presented at the DOE Nuclear Safety Workshop (Sept. 19, 2012).

***  M. Haage, IAEA, “What is Safety Culture & Why is it Important?” presented at the DOE Nuclear Safety Workshop (Sept. 19, 2012).

Friday, October 5, 2012

The Corporate Culture Survival Guide by Edgar Shein

Our September 21, 2012 post introduced a few key elements of Prof. Edgar Schein’s “mental model” of organizational culture.  Our focus in that post was to decry how Schein’s basic construct of culture had been adopted by the nuclear industry but then twisted to fit company and regulatory desires for simple-minded mechanisms for assessing culture and cultural interventions.

In this post, we want to expand on Schein’s model of what culture is, how it can be assessed, and how its evolution can be influenced by management initiatives.  Where appropriate, we will provide our perspective based on our beliefs and experience.  All the quotes below come from Schein’s The Corporate Culture Survival Guide.*

What is Culture?

Schein’s familiar model shows three levels of culture: artifacts, espoused values and underlying assumptions.  In his view, the real culture is the bottom level: “Culture is the shared tacit assumptions of a group that have been learned through coping with external tasks and dealing with internal relationships.” (p. 217)  The strength of an organization’s culture is a function of the intensity of shared experiences and the relative success the organization has achieved.  “Culture . . . influences how you think and feel as well as how you act.” (p. 75)  Culture is thus a product of social learning. 

Our view does not conflict with Schein’s.  In our systems approach, culture is a variable that provides context for, but does not solely determine, organizational and individual decisions. 

How can Culture be Assessed?


“You cannot use a survey to assess culture.” (p. 219)  The specific weaknesses of surveys are discussed elsewhere (pp. 78-80) but his bottom line is good enough for us.  We agree completely.


Individual interviews can be used when interviewees would be inhibited in a group setting but Schein tries to avoid them in favor of group interviews because the latter are more likely to correctly identify the true underlying assumptions. 

In contrast, the NEI and IAEA safety culture evaluation protocols use interviews extensively, and we’ve commented on them here and here

Group discussion 

Schein’s recommended method for deciphering a company’s culture is a facilitated group exercise that attempts to identify the deeper (real) assumptions that drive the creation of artifacts by looking at conflicts between the artifacts and the espoused values. (pp. 82-87)   

How can Culture be Influenced?

In Schein’s view, culture cannot be directly controlled but managers can influence and evolve a culture.  In fact, “Managing cultural evolution is one of the primary tasks of leadership.” (p. 219)

His basic model for cultural change is creating the motivation to change, followed by learning and then internalizing new concepts, meanings and standards. (p. 106).  This can be a challenging effort; resistance to change is widespread, especially if the organization has been successful in the past.  Implementing change involves motivating people to change by increasing their survival anxiety or guilt; then promoting new ways of thinking, which can lead to learning anxiety (fear of loss or failure).  Learning anxiety can be ameliorated by increasing the learner’s psychological safety by using multiple steps, including training, role models and consistent systems and structures.  Our promotion of simulation is based on our belief that simulation can provide a platform for learners to practice new behaviors in a controlled and forgiving setting.

If time is of the essence or major transformational change is necessary, then the situation requires the removal and replacement of the key cultural carriers.  Replacement of management team members has often occurred at nuclear plants to address perceived performance/culture issues.
Schein says employees can be coerced into behaving differently but they will only internalize the new ways of doing business if the new behavior leads to better outcomes.  That may be true but we tend toward a more pragmatic approach and agree with Commissioner Apostolakis when he said: “. . . we really care about what people do and maybe not why they do it . . . .”

Bottom Line
Prof. Schein has provided a powerful model for visualizing organizational culture and we applaud his work.  Our own modeling efforts incorporate many of his factors, although not always in the same words.  In addition, we consider other factors that influence organizational behavior and feed back into culture, e.g., the priorities and resources provided by a corporate parent.

*  E.H. Schein, The Corporate Culture Survival Guide, new and revised ed. (San Francisco: Jossey-Bass, 2009).  

Friday, September 21, 2012

SafetyMatters and the Schein Model of Culture

A reader recently asked: “Do you subscribe to Edgar Schein's culture model?”  The short-form answer is a qualified “Yes.”  Prof. Schein has developed significant and widely accepted insights into the structure of organizational culture.  In its simplest form, his model of culture has three levels: the organization’s (usually invisible) underlying beliefs and assumptions, its espoused values, and its visible artifacts such as behavior and performance.  He describes the responsibility of management, through its leadership, to articulate the espoused values with policies and strategies and thus shape culture to align with management’s vision for the organization.  Schein’s is a useful mental model for conceptualizing culture and management responsibilities.*     

However, we have issues with the way some people have applied his work to safety culture.  For starters, there is the apparent belief that these levels are related in a linear fashion, more particularly, that management by promulgating and reinforcing the correct values can influence the underlying beliefs, and together they will guide the organization to deliver the desired behaviors, i.e., the target level of safety performance.  This kind of thinking has problems.

First, it’s too simplistic.  Safety performance doesn’t arise only because of management’s espoused values and what the rest of the organization supposedly believes.  As discussed in many of our posts, we see a much more complex, multidimensional and interactive system that yields outcomes which reflect, in greater or lesser terms, desired levels of safety.  We have suggested that it is the totality of such outcomes that is representative of the safety culture in fact.** 

Second, it leads to attempts to measure and influence safety culture that are often ineffective and even misleading.  We wonder whether the heavy emphasis on values and leadership attitudes and behaviors - or traits - that the Schein model encourages, creates a form versus substance trap.  This emphasis carries over to safety culture surveys - currently the linchpin for identifying and “correcting” deficient safety culture -  and even doubles down by measuring the perception of attitudes and behaviors.  While attitudes and behaviors may in fact have a beneficial effect on the organizational environment in which people perform - we view them as good habits - we are not convinced they are the only determinants of the actions, decisions and choices made by the organization.  Is it possible that this approach creates an organization more concerned with how it looks and how it is perceived than with what it does?   If everyone is checking their safety likeness in the cultural mirror might this distract from focusing on how and why actual safety-related decisions are being made?

We think there is good support for our skepticism.  For every significant safety event in recent years - the BP refinery fire, the Massey coal mine explosion, the shuttle disasters, the Deepwater oil rig explosion, and the many instances of safety culture issues at nuclear plants - the organization and senior management had been espousing as their belief that “safety is the highest priority.”  Clearly that was more illusion than reality.

To give a final upward thrust to the apple cart, we don’t think that the current focus on nuclear safety culture is primarily about culture.  Rather we see “safety culture” more as a proxy for management’s safety performance - and perhaps a back door for the NRC to regulate while disclaiming same.*** 

*  We have mentioned Prof. Schein in several prior blog posts: June 26, 2012, December 8, 2011, August 11, 2010, March 29, 2010, and August 17, 2009.

**  This past year we have posted several times on decisions as one type of visible result (artifact) of the many variables that influence organizational behavior.  In addition, please revisit two of Prof. Perin’s case studies, summarized here.  They describe well-intentioned people, who probably would score well on a safety culture survey, who made plant problems much worse through a series of decisions that had many more influences than management’s entreaties and staff’s underlying beliefs.

***  Back in 2006, the NRC staff proposed to enhance the ROP to more fully address safety culture, saying that “Safety culture includes . . . features that are not readily visible such as basic assumptions and beliefs of both managers and individuals, which may be at the root cause of repetitive and far-reaching safety performance problems.”  It wouldn’t surprise us if that’s an underlying assumption at the agency.  See L.A. Reyes to the Commissioners, SECY-06-0122 “Policy Issue Information: Safety Culture Initiative Activities to Enhance the Reactor Oversight Process and Outcomes of the Initiatives” (May 24, 2006) p. 7 ADAMS ML061320282.  

Tuesday, September 4, 2012

More on Cynefin

Bob Cudlin recently posted on the work of David Snowden, a decision theorist and originator of the Cynefin decision construct.  Snowden’s Cognitive Edge website has a lot of information related to Cynefin, perhaps too much to swallow at once.  For those who want an introduction to the concepts, focusing on their implications for decision-making, we suggest a paper “Cynefin: repeatability, science and values”* by Prof. Simon French.

In brief, the Cynefin model divides decision contexts into four spaces: Known (or Simple), Knowable (or Complicated), Complex and Chaotic.  Knowledge about cause-and-effect relationships (and thus, appropriate decision making approaches) differs for each space.  In the Simple space, cause-and-effect is known and rules or processes can be established for decision makers; “best” practices are possible.  In the Complicated space, cause-and-effect is generally known but individual decisions require additional data and analysis, perhaps with probabilistic attributes; different practices may achieve equal results.  In the Complex space, cause-and-effect may only be identified after an event takes place so decision making must work on broad, flexible strategies that can be adjusted as a situation evolves; new practices emerge.  In the Chaotic space, there are no applicable analysis methods so decision makers must try things, see what happens and attempt to stabilize the situation; a novel (one-off) practice obtains.   

The model in the 2008 French paper is not in complete accord with the Cynefin model currently described by Snowden but French’s description of the underlying considerations for decision makers remains useful.  French’s paper also relates Cynefin to the views of other academics in the field of decision making.  

For an overview of Cynefin in Snowden’s own words, check out “The Cynefin Framework” on YouTube.  There he discusses a fifth space, Disorder, which is basically where a decision maker starts when confronted with a new decision situation.  Importantly, a decision maker will instinctively try to frame the decision in the Cynefin decision space most familiar to the decision maker based on personal history, professional experience, values and preference for action. 

In addition, Snowden describes the boundary between the Simple and Chaotic as the “complacent zone,” a potentially dangerous place.  In the Simple space, the world appears well-understood but as near-misses and low-signal events are ignored, the system can drift toward the boundary and slip into the Chaotic space where a crisis can arise and decision makers risk being overwhelmed.

Both decision maker bias and complacency present challenges to maintaining a strong safety culture.  The former can lead to faulty analysis of problems, forcing complex issues with multiple interactive causes through a one-size-fits-all solution protocol.  The latter can lead to disasters, great and small.  We have posted many times on the dangers of complacency.  To access those posts, click “complacency” in the Labels box.

*  S. French, “Cynefin: repeatability, science and values,” Newsletter of the European Working Group “Multiple Criteria Decision Aiding,” series 3, no. 17 (Spring 2008).  Thanks to Bill Mullins for bringing this paper to our attention.