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.
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.
