Difference between revisions of "Culture"

Revision as of 17:54, 8 September 2012

Establishing and managing cultures, values, and behaviors is a critical aspect of systems engineering, especially in the context of deploying SE within an organization (Fasser and Brettner 2002). The Columbia Accident Investigation Report (NASA 2003, 101), defines culture as “the basic values, norms, beliefs, and practices that characterize the functioning of a particular institution.”

Stable safety and process cultures are key to effective SE, and can be damaged by an overly-rapid pace of change, a high degree of churn (see the Nimrod Crash Report, Haddon-Cave 2009), or by change that engineers perceive as arbitrarily imposed by management (e.g. Challenger, discussed below). On the other hand, a highly competitive, adversarial or "blame" culture can impede the free flow of information and disrupt synergies in the workplace.

In the multi-national, multi-business, multi-discipline collaborative projects becoming increasingly prevalent in SE, these factors take on greater importance.

Effective handling of cultural issues is a major factor in the success or failure of SE endeavors.

Cultural Perspective

Cultural change to improve SE efficiency and effectiveness is possible through a systems approach (as described in Part 2: Overview of Systems Approaches and by Lawson (2010)) and by learning to think and act in terms of systems, organizations and their enterprises.

A general culture-related perspective is characterized by (Senge et al. 1994), who identify systems thinking as being the fifth discipline that promotes a learning organization culture. The four disciplines that are supported by systems thinking are

Personal mastery such that a person continually clarifies and deepens personal vision, focuses energy upon it, develops patience in seeking it and in this way apparently increasingly views reality in an objective manner.
Mental models aims to train people to appreciate that mental models do indeed occupy their minds and shape their action.
Shared vision refers to shared operating values, a common sense of purpose, and a basic level of mutuality.
Team learning to achieve alignment of people’s thoughts so that a common direction creates a feeling that the whole team achieves more than the sum of its team members.

A learning organization aims to absorb, diffuse, generate, and exploit knowledge (Sprenger and Have 1996). Organizations need to manage formal information and facilitate the growth and exploitation of tacit knowledge. They should learn from experience and create a form of corporate memory – including process, problem domain and solution space knowledge, and information about existing products and services. Fassner and Brettner (2002, 122-124) suggest that shared mental models are a key aspect of corporate knowledge and culture. (See also the knowledge area Systems Thinking)

Paradigms

Many authorities, including Jackson (2010), have found that cultural shortfalls can be summarized in a set of negative paradigms that are injurious to a system. Although there are many paradigms, the following two are typical:

Risk Denial holds that many people are reluctant to identify true risks . This paradigm is apparent in the Challenger and Columbia described above.
Titanic Effect holds that the individual believes the system is safe even when it is not. The name of this paradigm comes, of course, from the famous ocean liner catastrophe of 1912.

Approaches

Jackson and Erlick (Jackson 2010, 91-119) have found that there is a lack of evidence that a culture can be changed from a success point of view. However, they do suggest an approach founded on the principles of organizational psychology, namely, the Community of Practice (Jackson 2010, 110-112). The pros and cons of various other approaches are also discussed. These include training, the charismatic executive, Socratic teaching, teams, coaching, independent reviews, cost and schedule margins, standard processes, rewards and incentives, and management selection. Shields (2006) provides a comprehensive list of these and similar approaches.

Many official reports, such as for the Columbia Accident (NASA 2003) and the Triangle fire (NYFIC 1912), call for an improvement in leadership to address the cultural issues. However, this approach is usually accompanied by a more objective approach of auditing, such as the Independent Technical Authority. This authority has the following features:

Independent: The authority is separate from the program organization. It may be from another business/enterprise with an objective view of the program in question. In short, the authority cannot report to the program manager of the program in question.
Technical: The authority will address only technical as opposed to managerial issues.
Authority: The board has the right to take action to avoid failure including preventing launch decisions.

In addition to the specific safety related cultural issues, there are many management and leadership experts that have identified various means for leading cultural organizational change. For example, the usage of creative thinking promoted by, amongst others, Gordon (1961) in his work on the productive use of analogical reasoning called synectics. Another example, Kotter (1995) identifies needed steps in transforming an organization.

Other Cultural Factors

Cultures evolve over generations in response to the community's environment (physical, social, religious). However, as the environment changes, cultural beliefs, values and customs change more slowly. There are many definitions of culture, but one cited by the Columbia Accident Investigation Board is representative. (NASA 2003)

It is now generally considered that there are three main sources of cultural influence:

National (or ethnic) culture;
Professional culture; and
Organizational culture.

These sources of culture, their effects on aviation safety, and suggested implications on safety cultures in other domains such as medicine, are described in Helmreich and Merritt (2000) and other writings by these authors.

National (or ethnic) Culture

National culture is a product of factors such as heritage, history, religion, language, climate, population density, availability of resources, and politics. National culture is picked up at a formative age, and once acquired, is difficult to change. National culture affects attitudes and behavior, and has a significant effect on interactions with others, for example

Communication styles (direct and specific vs. indirect and non-specific);
Leadership styles (hierarchical vs. consultative);
Superior – inferior relationships (accepting vs. questioning decisions);
Attitudes to rules and regulations;
Attitudes to uncertainty; and
Displaying emotional reactions.

Professional Culture

Medical doctors, airline pilots, the military, teachers and many others possess particular professional cultures that overlay their ethnic or national cultures. Professional culture is usually manifested in its members by a sense of community and by the bonds of a common identity (Helmreich and Merritt 2000). Features associated with professional culture typically include some or all of the following:

Selectivity, competition and training in order to gain entry to the profession
Member-specific expertise
A shared professional jargon
Prestige and status with badges or defining uniform
Binding norms for behavior and common ethical values
Professional and gender stereotyping
Self-regulation
Institutional and individual resistance to change

Professional culture overlays a person’s national culture. If there are conflicts between the two cultures, during threat situations in particular, the professional culture may dominate, or the earlier-acquired national culture may rise to the fore. Elements of professional culture that are of particular importance (e.g. to safety or survivability) need to be inculcated by extensive training programs, and reinforced at appropriate intervals.

Organizational Culture

Organizational culture arises out of the history of an organization, including its leadership, products and services. Although there will be a common layer across the organization, significant differences will emerge in organizations with a high level of multinational integration due to differing national cultures. These will appear as differing leadership styles, manager-subordinate relationships, etc. Organizations have a formal hierarchy of responsibility and authority; therefore organizational culture is more amenable to carefully-planned change than are either professional or national cultures. Organizational culture channels the effects of the other two cultures into standard working practices; therefore changes to it that are sympathetic to national culture (rather than a culture in the distant group head office) can bring significant performance benefits.

Organizational culture is also unique; what works in one organization is unlikely to work in another. Some of the factors thought to influence or engender organizational culture include

Strong corporate identity;
Effective leadership;
High morale and trust;
Cohesive team working and cooperation;
Job security;
Development & training;
Confidence, e.g. in quality and safety practices, management communication and feedback; and
High degree of empowerment.

Culture and Safety

Reason (1997, 191-220) identifies four components of a culture with a focus on safety:

A reporting culture encourages individuals to report errors and near misses including their own errors and near misses.
A just culture is an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety related information.
A flexible culture abandons the traditional hierarchical reporting structure in favor of more direct means of team-to-team communications.
A learning culture is the willingness to draw the right conclusions from information and to implement reforms when necessary.

The Nuclear Regulatory Agency (2011) has issued its final report on safety culture. This report focuses mainly on leadership and individual authority.

Weick and Sutcliffe (2001, 3) introduced the term high reliability organizations (hros) . HROs are in domains subject to catastrophic events, and are organizations that operate under trying conditions and have fewer than their fair share of accidents. Example HROs include power grid dispatching centers, air traffic control systems, nuclear aircraft carriers, nuclear power generation plants, hospital emergency departments, and hostage negotiation teams. Weick and Sutcliffe (2001, 10) identify five hallmarks of HROs:

Preoccupation with Failure: HROs do not ignore errors, large or small, learn from near misses and avoid complacency.
Reluctance to Simplify Interpretations: HROs simplify less and see more. They “encourage skepticism towards received wisdom.”
Sensitivity to Operations: HROs pay attention to possible latent conditions, defined by James Reason (1997) to be deficiencies in the system that have not yet resulted in an accident but are waiting to happen. They have well developed situational awareness and make continuous adjustments to keep errors from accumulating and enlarging.
Commitment to Resilience: HROs keep errors small and improvise “workarounds that keep the system functioning.” They have a deep understanding of the technology and constantly create worst case situations to make corrections.
Deference to Expertise: HROs “push decision making down.” Decisions are made “on the front line.” They avoid rigid hierarchies and go directly to the person with the expertise.

Historical Safety Related Cases

Culture has been cited as a key factor in the success or failure of many systems. In all of the following cases, culture was cited in official reports or by authoritative experts as a factor in the success or failure of the systems involved.

Table 1. Examples of Culture Discussion in Safety Critical Incidents. (SEBoK Original)

Example	Cultural Discussion
Apollo	According to Feynman (1988), Apollo was a successful program because it was a culture of common interest. Then over the next 20 years there was loss of common interest. This loss is the cause of the deterioration in cooperation, which . . . produced a calamity.
Challenger	Vaughn (1997) captured what she called normalization of deviance. She states that rather than taking risks seriously, NASA simply ignored them by calling them normal. She summarizes this idea by saying that flying with acceptable risks was normative in NASA culture.
Columbia	The Columbia Accident Investigation Report (NASA 2003, 102) echoed Feynman’s view and declared that NASA had a broken safety culture. The board concluded that NASA had become a culture in which bureaucratic procedures took precedence over technical excellence.
Texas City - 2005	On August 3, 2005, a process accident occurred at the BP refinery in a Texas City refinery in the USA resulting in 19 deaths and more than 170 injuries. The Independent Safety Review Panel (2007) found that a corporate safety culture existed that has not provided effective process safety leadership and has not adequately established process safety as a core value across all its five U.S. refineries. The report recommended an independent auditing function.
The Triangle Fire	On August 11, 1911, a fire broke out in the borough of Manhattan in New York City in which 145 people died, mostly women (NYFIC 1912). The New York State Commission castigated the property owners for their lack of understanding of the human factors in the case. The report called for the establishment of standards to address this deficiency.
Nimrod	On September 2, 2006, a Nimrod British military aircraft caught fire and crashed killing its entire crew of 14. The Haddon-Cave report (Haddon-Cave 2009) focused on the cultural aspect. This report specifically references the Columbia Accident Investigation Report and the conclusions in it. A system of detailed audits is recommended.

Implications for Systems Engineering

As SE increasingly seeks to work across national, ethnic, and organizational boundaries, systems engineers need to be aware of cultural issues and how these affect expectations and behavior in collaborative working environments. Different cultures and personal styles make best use of information presented in different ways and in different orders (levels of abstraction, big picture first or detail, principles first or practical examples). Sensitivity to cultural issues will make a difference to the success of SE endeavors; e.g., (Siemieniuch and Sinclair 2006).

References

Works Cited

Fasser, Y. and D. Brettner. 2002. Management for Quality in High-Technology Enterprises. New York, NY, USA: Wiley.

Feynman, R. 1988. "An Outsider's Inside View of the Challenger Inquiry." Physics Today. 41(2) (February 1988): 26-27.

Gordon, W.J.J. 1961. Synectics: The Development of Creative Capacity. New York, NY, USA: Harper and Row.

Haddon-Cave, C. 2009. An Independent Review into the Broader Issues Surrounding the Loss of the RAF Nimrod MR2 Aircraft XV230 in Afganistan in 2006. London, UK: The House of Commons.

Helmreich, R.L., and A.C. Merritt. 2000. "Safety and Error Management: The Role of Crew Resource Management." In Aviation Resource Management, edited by B.J. Hayward and A.R. Lowe. Aldershot, UK: Ashgate. (UTHFRP Pub250). p. 107-119.

Independent Safety Review Panel. 2007. The Report of the BP U.S. Refineries Independent Safety Panel. Edited by J.A. Baker. Texas City, TX, USA.

Jackson, S. 2010. Architecting Resilient Systems: Accident Avoidance and Survival and Recovery from Disruptions. Hoboken, NJ, USA: John Wiley & Sons.

Kotter, J.P. 1995. "Leading Change: Why Transformation Efforts Fail." Harvard Business Review. (March-April): 59-67.

Lawson, H. 2010. A Journey Through the Systems Landscape. London, UK: College Publications, Kings College.

NASA. 2003. Columbia Accident Investigation Report. Washington, DC, USA: National Aeronautics and Space Administration (NASA). August 2003.

Nuclear Regulatory Agency. 2011. "NRC Issues Final Safety Culture Policy Statement." NRC News (14 June 2011). Available at: pbadupws.nrc.gov/docs/ML1116/ML11166A058.pdf.

NYFIC. 1912. Preliminary Report of the New York Factory Investigating Commission. R. F. Wagner (ed). New York, NY, USA: New York Factory Investigating Commission (NYFIC).

Reason, J. 1997. Managing the Risks of Organisational Accidents. Aldershot, UK: Ashgate Publishing Limited.

Senge, P.M., A. Klieiner, C. Roberts, R.B. Ross, and B.J. Smith. 1994. The Fifth Discipline Fieldbook: Strategies and Tools for Building a Learning Organization. New York, NY, USA: Currency Doubleday.

Shields, J.L. 2006. "Organization and Culture Change." In Enterprise Transformation, W.B. Rouse (ed.). Hoboken, NJ, USA: John Wiley & Son.

Siemieniuch, C.E. and M.A. Sinclair. 2006. "Impact of Cultural Attributes on Decision Structures and Interfaces." Paper presented at the 11th ICCRTS Coalition Command and Control in the Networked Era. Cambridge, MA, USA. p. 1-20.

Sprenger, C. and S.T. Have. 1996. "4 Competencies of a Learning Organization." (Original title: "Kennismanagement als moter van delerende organisatie"). Holland Management Review Sept–Oct, p. 73–89.

Vaughn, D. 1997. The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. Chicago, IL, USA: University of Chicago Press.

Weick, K.E. and K.M. Sutcliffe. 2001. Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco, CA, USA: Jossey-Bass (Jossey-Bass acquired by Hoboken, NJ, USA: Wiley Periodicals, Inc.).

Primary References

Fasser, Y. and D. Brettner. 2002. Management for Quality in High-Technology Enterprises. New York, NY, USA: Wiley.

Helmreich, R.L., and A.C. Merritt. 2000. "Safety and Error Management: The Role of Crew Resource Management." In Aviation Resource Management, edited by B.J. Hayward and A.R. Lowe. Aldershot, UK: Ashgate. (UTHFRP Pub250). p. 107-119.

Hofstede, G. 1984. Culture’s Consequences: International Differences in Work-Related Values. London, UK: Sage.