There is a lot of research on how teams make disasters happen, and the answer is clear: teams use cues to make sense of the situation, and disasters happen when sensemaking differs from reality. That’s useful to know, but we would also like to know how it can be prevented. We know that expertise and experience do not help. Experienced commercial pilots, space shuttle subcontractor engineers, chemical plant operators, and fighter pilots have all been studied and found to do faulty sensemaking. The examples I just gave have led to a total of 4,000 confirmed deaths and more than 10,000 likely deaths.
Finally, an article in Administrative Science Quarterly by Marlys Christianson has some answers. She studied how medical teams went through an emergency room training procedure – treating a young asthma patient with increasing breathing failure – in a simulation designed to invite incorrect sensemaking in the beginning, so they would need to recover later. Fortunately, in simulations the patients are not real, because one quarter of them would have died. Even among the teams that managed to identify and correct the problem (replacing a piece of broken equipment), the speed of doing so varied a lot, so thanks to this research we now know a lot more about how sensemaking can recover.
Teams are in organizations for doing work, not for solving puzzles. Whenever a situation involves a puzzle that needs to be solved, such as faulty sensemaking that needs to be corrected, the regular work done by the team takes effort and attention away from the correction. This means that cues that may look obvious to someone outside the team are not at all clear to team members who are focused on the regular work and who do this work premised on their sensemaking. In an emergency room, the team will look for cues to how the patient is doing, but they spend much of their time treating the patient. Treating and observing clues are related, but they compete for time.
This means that emergency room teams can solve puzzles only if they manage two trajectories at once – the regular treatment and the interpretation of cues from the patient’s condition. The interpretation trajectory is how sensemaking is updated, and it is complex because it moves from noticing cues that suggest something is wrong, to interpreting them to indicate what the problem is, to acting to check the interpretation. Usually the actions involve changing the treatment, so treatment and interpretation need to be in sync. The trajectory management can fail in multiple places. For example, the treatment takes too much time so cues are not interpreted, or the treatment is based on current sensemaking so changing it to check interpretation does not make sense.
The emergency room teams had a sensemaking problem because the simulation was designed to involve treatment equipment that did not work correctly, so the usual sensemaking (“our equipment works, so all problems can be found in the patient”) was faulty. Similar sensemaking problems are found in many places. In the Black Hawk shooting incident, the fighter pilots saw helicopters without correct friend–foe identification signals and concluded they would be hostile because friendlies signal who they are. Any cues they could see were drowned out by the tasks of flying the aircraft low in mountainous terrain, keeping alert for possible threats, and going through a modified foe identification and engagement procedure while communicating with each other.
Trajectory management can easily fail, with tragic consequences. Now that we know more about the differences between teams that succeed and teams that fail, we may be able to work to make teamwork more reliable, especially when lives are at stake.
Christianson, Marlys K. 2017. More and Less Effective Updating: The Role of Trajectory Management in Making Sense Again. Administrative Science Quarterly, forthcoming.
On a personal note, I’ve experienced the benefits of the sort of updated sensemaking described in the article. When I was in the emergency room after an accident, the team scanned me to look for internal bleeding based on their experience of how body folding from being hit by a car while riding a motorcycle can break blood vessels. They found none. The cue of falling blood pressure after closing the external wounds made them re-scan over a broader range, and they found the broken vessel and fixed it. I am alive, thanks to the team’s updated sensemaking.