Linköping Studies in Science and Technology

The cover photo is taken on Gotland, Sweden iii To cope with variations, disturbances, and unexpected events in complex socio-technical systems people are required to continuously adapt to the changing environment, sometimes in novel and innovative ways. This thesis investigates adaptive performance in complex work settings across domains, with a focus on examining what enables and disables successful adaptations, and how contextual factors shape performance. Examples of adaptive performance studies include a crisis command team dealing with the loss of key personnel, a crew coping with unreliable system feedback in the cockpit, and a nursing team managing an overload of patients. The two main contributions of this thesis is the analysis of cases of people coping with variations and disturbances, and the development of conceptual models to report findings, structure cases, and make sense of sharp-end adaptations in complex work settings. The findings emphasise that adaptive performance outside procedures and textbook scenarios at the sharp end is a critical ability to cope with variation and unexpected events. However, the results also show that adaptations may come at the cost of new vulnerabilities and system brittleness. Analysing adaptive performance in everyday events informs safety management by making visible limitations and possibilities of system design, organisational structures, procedures, and training. vii Throughout the journey of writing this thesis I have enjoyed the support of many wonderful people, and for this I am very grateful. There are a few I would like to thank in particular. First of all, I want to thank my advisors. Henrik Eriksson, for guiding and supporting me through the ups and downs of the thesis-writing process, with encouragement and assurance. I greatly appreciate you always taking the time to discuss any concern, no matter how big or small. Jonas Lundberg, for your enthusiasm, for offering new perspectives when I got stuck, and for always emphasising my successes rather than failures ;-). Rogier Woltjer, for being a source of inspiration, for your never-ending support, and generous sharing of your time and knowledge, and last, but not least, for being a great friend. The decision to become a graduate student was not something I had planned on when starting my undergraduate studies but the result of fun and interesting work while working on my master's degree. So, thank you Jiri Trnka, for encouraging me to continue my studies. Thank you also to my old flat mates Johan Blomkvist and Fabian …

[1]  David Woods,et al.  Incidents – Markers of Resilience or Brittleness? , 2017 .

[2]  David Woods,et al.  On the Origins of Cognitive Systems Engineering , 2017 .

[3]  Erik Hollnagel,et al.  Epilogue: RAG – The Resilience Analysis Grid , 2017 .

[4]  Erik Hollnagel,et al.  The Four Cornerstones of Resilience Engineering , 2016 .

[5]  Oliver Human Complexity: E-Special Introduction , 2016 .

[6]  J. Elliott Safety I and safety II: the past and future of safety management , 2016, Ergonomics.

[7]  Chandan Roy,et al.  An Informed System Development Approach to Tropical Cyclone Track and Intensity Forecasting , 2016 .

[8]  Håkan Warnquist,et al.  Troubleshooting Trucks : Automated Planning and Diagnosis , 2015 .

[9]  Allègre L. Hadida,et al.  Organizational Improvisation: A Consolidating Review and Framework , 2015 .

[10]  Johan Bergström,et al.  On the rationale of resilience in the domain of safety: A literature review , 2015, Reliab. Eng. Syst. Saf..

[11]  David D. Woods,et al.  Four concepts for resilience and the implications for the future of resilience engineering , 2015, Reliab. Eng. Syst. Saf..

[12]  Rogier Woltjer,et al.  Towards understanding work-as-done in air traffic management safety assessment and design , 2015, Reliab. Eng. Syst. Saf..

[13]  Tarcisio Abreu Saurin,et al.  A systematic literature review of resilience engineering: Research areas and a research agenda proposal , 2015, Reliab. Eng. Syst. Saf..

[14]  David Mendonça,et al.  Factors underlying organizational resilience: The case of electric power restoration in New York City after 11 September 2001 , 2015, Reliab. Eng. Syst. Saf..

[15]  Christopher P. Nemeth,et al.  Building change: Resilience Engineering after ten years , 2015, Reliab. Eng. Syst. Saf..

[16]  Kevin Crowston,et al.  A Taxonomy of Organizational Dependencies and Coordination Mechanisms , 2015 .

[17]  Jonas Lundberg,et al.  Resilience and vulnerability of small flexible crisis response teams: implications for training and preparation , 2014, Cognition, Technology & Work.

[18]  Wladimir Schamai,et al.  Model-Based Verification of Dynamic System Behavior against Requirements : Method, Language, and Tool , 2013 .

[19]  Paul M. Salmon,et al.  Improvisation: theory, measures and known influencing factors , 2013 .

[20]  Tom Kontogiannis,et al.  A sensemaking perspective on framing the mental picture of air traffic controllers. , 2013, Applied ergonomics.

[21]  Jonas Lundberg,et al.  A case study of factor influencing role improvisation in crisis response teams , 2013, Cognition, Technology & Work.

[22]  Erik Hollnagel,et al.  Resilience Engineering in Practice: A Guidebook , 2012 .

[23]  David Campbell,et al.  Public Managers in Integrated Services Collaboratives: What Works Is Workarounds , 2012 .

[24]  J. Flach Complexity: learning to muddle through , 2012, Cognition, Technology & Work.

[25]  Jonas Lundberg,et al.  Strategies for dealing with resistance to recommendations from accident investigations. , 2012, Accident; analysis and prevention.

[26]  Erik Hollnagel,et al.  Coping with complexity: past, present and future , 2011, Cognition, Technology & Work.

[27]  Robert R. Hoffman,et al.  Beyond Simon's Slice: Five Fundamental Trade-Offs that Bound the Performance of Macrocognitive Work Systems , 2011, IEEE Intelligent Systems.

[28]  Robert L. Wears,et al.  Exploring the Dynamics of Resilient Performance , 2011 .

[29]  S. Dekker,et al.  The complexity of failure: Implications of complexity theory for safety investigations , 2011 .

[30]  Robert R. Hoffman,et al.  Reasoning difficulty in analytical activity , 2011 .

[31]  Tom Kontogiannis,et al.  A contemporary view of organizational safety: variability and interactions of organizational processes , 2010, Cognition, Technology & Work.

[32]  Sterling Wiggins,et al.  Team sensemaking , 2010 .

[33]  J. Simmie,et al.  The economic resilience of regions: towards an evolutionary approach , 2010 .

[34]  Jonas Lundberg,et al.  Speaking of human factors: emergent meanings in interviews with professional accident investigators. , 2010 .

[35]  E. Hollnagel,et al.  What-You-Look-For-Is-What-You-Find - The consequences of underlying accident models in eight accident investigation manuals , 2009 .

[36]  Michael D. McNeese,et al.  A History for Macrocognition , 2009 .

[37]  Björn J. E. Johansson,et al.  Collaborative Command and Control Practice: Adaptation, Self-Regulation and Supporting Behavior , 2009, Int. J. Inf. Syst. Crisis Response Manag..

[38]  Stefanie Huber,et al.  Learning from organizational incidents: Resilience engineering for high‐risk process environments , 2009 .

[39]  Gudela Grote,et al.  Coordination in high-risk organizations: the need for flexible routines , 2009, Cognition, Technology & Work.

[40]  Bertil Hamberger,et al.  KAMEDO Report No. 92 Evacuation of Swedes from Lebanon—Observational Studies in Connection with the War in Lebanon in Summer 2006 , 2008, Prehospital and Disaster Medicine.

[41]  Gary Klein,et al.  Naturalistic Decision Making , 2008, Hum. Factors.

[42]  Stephanie E. Chang,et al.  Fostering resilience to extreme events within infrastructure systems: Characterizing decision contexts for mitigation and adaptation , 2008 .

[43]  Richard I. Cook,et al.  Regularly irregular: how groups reconcile cross-cutting agendas and demand in healthcare , 2007, Cognition, Technology & Work.

[44]  Jennifer K. Phillips,et al.  A Data–Frame Theory of Sensemaking , 2007 .

[45]  David D. Woods,et al.  Discovering the events expert practitioners extract from dynamic data streams: the modified unit marking technique , 2007, Cognition, Technology & Work.

[46]  R. Wears Resilience Engineering: Concepts and Precepts , 2006 .

[47]  Siambabala Bernard Manyena,et al.  The concept of resilience revisited. , 2006, Disasters.

[48]  David Mendonça,et al.  Training for improvisation in emergency management: opportunities and limits for information technology , 2006 .

[49]  Elaine H. Ferneley,et al.  Resist, comply or workaround? An examination of different facets of user engagement with information systems , 2006, Eur. J. Inf. Syst..

[50]  Emily S. Patterson,et al.  Elicitation by critiquing as a cognitive task analysis methodology , 2006, Cognition, Technology & Work.

[51]  Neil Pollock,et al.  When Is a Work-Around? Conflict and Negotiation in Computer Systems Development , 2005 .

[52]  C. Boddy A rose by any other name may smell as sweet but “group discussion” is not another name for a “focus group” nor should it be , 2005 .

[53]  Sanjaya Mishra Research methods in the social sciences , 2005, Br. J. Educ. Technol..

[54]  Dusya Vera,et al.  Improvisation and Innovative Performance in Teams , 2005, Organ. Sci..

[55]  R. Cook,et al.  “Going solid”: a model of system dynamics and consequences for patient safety , 2005, Quality and Safety in Health Care.

[56]  Erik Hollnagel,et al.  Joint Cognitive Systems: Foundations of Cognitive Systems Engineering , 2005 .

[57]  Sidney Dekker,et al.  Ten Questions About Human Error : A New View of Human Factors and System Safety , 2004 .

[58]  Christopher Nemeth,et al.  The Messy Details: Insights From the Study of Technical Work in Healthcare , 2004 .

[59]  Gary R. Webb Role improvising during crisis situations , 2004 .

[60]  W. Wallace,et al.  Studying Organizationally-situated Improvisation in Response to Extreme Events , 2004, International Journal of Mass Emergencies & Disasters.

[61]  Snorre Sklet,et al.  Comparison of some selected methods for accident investigation. , 2004, Journal of hazardous materials.

[62]  Dusya Vera,et al.  Theatrical Improvisation: Lessons for Organizations , 2004 .

[63]  José Orlando Gomes,et al.  Handoff strategies in settings with high consequences for failure: lessons for health care operations. , 2004, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[64]  M. Cunha,et al.  Towards a Theory of Organizational Improvisation: Looking Beyond the Jazz Metaphor , 2003 .

[65]  Philip Koopman,et al.  Work-arounds, Make-work, and Kludges , 2003, IEEE Intell. Syst..

[66]  Sidney W A Dekker,et al.  Reconstructing human contributions to accidents: the new view on error and performance. , 2002, Journal of safety research.

[67]  Louise Young,et al.  Learning to improvise, improvising to learn: a process of responding to complex environments , 2002 .

[68]  A. Masten Ordinary magic. Resilience processes in development. , 2001, The American psychologist.

[69]  D. Woods,et al.  Gaps in the continuity of care and progress on patient safety , 2000, BMJ : British Medical Journal.

[70]  Catherine M. Burns,et al.  There Is More to Monitoring a Nuclear Power Plant than Meets the Eye , 2000, Hum. Factors.

[71]  Sidney Dekker,et al.  Anticipating the effects of technological change: A new era of dynamics for human factors , 2000 .

[72]  G. Ropohl PHILOSOPHY OF SOCIO-TECHNICAL SYSTEMS , 1999 .

[73]  M. Cunha,et al.  Organizational improvisation: what, when, how, and why , 1999 .

[74]  Tom Kontogiannis,et al.  User strategies in recovering from errors in man–machine systems , 1999 .

[75]  Michael D. Myers,et al.  A Set of Principles for Conducting and Evaluating Interpretive Field Studies in Information Systems , 1999, MIS Q..

[76]  Anne S. Miner,et al.  Organizational Improvisation and Organizational Memory , 1998 .

[77]  Lorin M. Hitt,et al.  Beyond the productivity paradox , 1998, CACM.

[78]  Nigel Shadbolt,et al.  Use of the Critical Decision Method to Elicit Expert Knowledge: A Case Study in the Methodology of Cognitive Task Analysis , 1998, Hum. Factors.

[79]  Berend Wierenga,et al.  Improvisation in Action , 1998 .

[80]  K. Weick,et al.  Introductory Essay : Improvisation As a Mindset for Organizational Analysis , 1998 .

[81]  James T. Reason,et al.  Managing the risks of organizational accidents , 1997 .

[82]  Jens Rasmussen,et al.  Risk management in a dynamic society: a modelling problem , 1997 .

[83]  J. Walsh Managerial and Organizational Cognition: Notes from a Trip Down Memory Lane , 1995 .

[84]  Kevin Crowston,et al.  The interdisciplinary study of coordination , 1994, CSUR.

[85]  Matthew B. Miles,et al.  Qualitative Data Analysis: An Expanded Sourcebook , 1994 .

[86]  Henry Mintzberg,et al.  Cycles of organizational change , 1992 .

[87]  M. Patton,et al.  Qualitative evaluation and research methods , 1992 .

[88]  Rob Kling,et al.  Value conflicts in the design and organization of EFT systems , 1991 .

[89]  Sumantra Ghoshal,et al.  The Strategy Process: Concepts, Contexts, Cases , 1991 .

[90]  Wanda J. Orlikowski,et al.  Studying Information Technology in Organizations: Research Approaches and Assumptions , 1991, Inf. Syst. Res..

[91]  Roberta Calderwood,et al.  Critical decision method for eliciting knowledge , 1989, IEEE Trans. Syst. Man Cybern..

[92]  D. Morgan Focus groups for qualitative research. , 1988, Hospital guest relations report.

[93]  Kalle Lyytinen,et al.  Information systems failures—a survey and classification of the empirical literature , 1988 .

[94]  J. E. Groves,et al.  Made in America: Science, Technology and American Modernist Poets , 1989 .

[95]  Erik Hollnagel,et al.  Cognitive Systems Engineering: New Wine in New Bottles , 1983, Int. J. Man Mach. Stud..

[96]  Michael L. Tushman,et al.  Information Processing as an Integrating Concept in Organizational Design. , 1978 .

[97]  C. Trevarthen Review: Cognition and Reality: Principles and Implications of Cognitive Psychology , 1977 .

[98]  R. Belfield The process of innovation. , 1977, Science.

[99]  Dale E. Zand,et al.  Designing Interactive Systems for Organizational Change. , 1976 .

[100]  J. Rasmussen,et al.  Mental procedures in real-life tasks: a case study of electronic trouble shooting. , 1974, Ergonomics.

[101]  C. S. Holling Resilience and Stability of Ecological Systems , 1973 .

[102]  A. J. P. Martin,et al.  The problem of detection , 1973 .

[103]  R. Ackoff Towards a System of Systems Concepts , 1971 .

[104]  Herbert A. Simon,et al.  The Sciences of the Artificial , 1970 .

[105]  E. Rogers,et al.  Diffusion of innovations , 1964, Encyclopedia of Sport Management.

[106]  J. C. Flanagan Psychological Bulletin THE CRITICAL INCIDENT TECHNIQUE , 2022 .

[107]  F. H. Adler Cybernetics, or Control and Communication in the Animal and the Machine. , 1949 .

[108]  G. Petrangeli Safety Analysis , 2020, Nuclear Safety.

[109]  Sociotechnical Systems , 2018, Encyclopedia of Social Network Analysis and Mining. 2nd Ed..

[110]  Monika Richter,et al.  Cognition In The Wild , 2016 .

[111]  Erland Jungert,et al.  Design and evaluation of a role improvisation exercise for crisis and disaster response teams , 2016, Int. J. Inf. Technol. Manag..

[112]  M. Mulder,et al.  Experimental Investigation of Flight Crew Strategies in Handling Unexpected Events , 2015 .

[113]  Erik Brynjolfsson,et al.  The Productivity Paradox of Information Technology: Review and Assessment , 2014 .

[114]  Joris Field,et al.  “Staying ahead of the aircraft ” and Managing Surprise in Modern Airliners , 2013 .

[115]  Andrew Zolli,et al.  Resilience: Why Things Bounce Back , 2012 .

[116]  Tomas Bengtsson,et al.  Testing and Logic Optimization Techniques for Systems on Chip , 2012 .

[117]  Mohammad Saifullah,et al.  Biologically-Based Interactive Neural Network Models for Visual Attention and Object Recognition , 2012 .

[118]  Lisa Nilsson Påverkan och störningar : En kvalitativ studie om yttre påverkan på trafikledare i störda lägen på DLC Hallsberg , 2012 .

[119]  David Woods,et al.  How Human Adaptive Systems Balance Fundamental Trade-offs: Implications For Polycentric Governance Architectures , 2011 .

[120]  Soheil Samii,et al.  Quality-Driven Synthesis and Optimization of Embedded Control Systems , 2011 .

[121]  Ann Blandford,et al.  A resilience markers framework for small teams , 2011, Reliab. Eng. Syst. Saf..

[122]  Jeremy Walker,et al.  Genealogies of resilience : From systems ecology to the political economy of crisis , 2011 .

[123]  Alexander Siemers,et al.  Contributions to Modelling and Visualisation of Multibody Systems Simulations with Detailed Contact Analysis , 2010 .

[124]  D. Woods,et al.  Behind Human Error , 2010 .

[125]  David Broman,et al.  Meta-Languages and Semantics for Equation-Based Modeling and Simulation , 2010 .

[126]  Amy Rankin,et al.  Episode Analysis for Evaluating Response Operations and Identifying Training Needs , 2010, NordiCHI 2010.

[127]  Christopher Nemeth,et al.  Preparation and restoration , 2009 .

[128]  Amy Rankin,et al.  Rollimprovisation vid responsinsatser : En studie av en ledningsövning för Svenska Stödstyrkan , 2009 .

[129]  Gary Klein,et al.  Anticipatory Thinking , 2008 .

[130]  A. Skjerve,et al.  Resilience , Adaptation and Improvisation – increasing resilience by organising for successful improvisation , 2008 .

[131]  Christopher Nemeth,et al.  Remaining sensitive to the possibility of failure , 2008 .

[132]  B. Bergman,et al.  Kvalitet från behov till användning , 2007 .

[133]  Gary Klein,et al.  Working Minds: A Practitioner's Guide to Cognitive Task Analysis , 2006 .

[134]  M. Lind,et al.  Coping with complexity. , 2006, Nature.

[135]  Sang Joon Kim,et al.  A Mathematical Theory of Communication , 2006 .

[136]  K. Weick,et al.  Organizing and the Process of Sensemaking , 2005 .

[137]  Christopher D. Wickens,et al.  ANALYSIS OF PILOTS' MONITORING AND PERFORMANCE ON AN AUTOMATED FLIGHT DECK , 2001 .

[138]  David Mendonça,et al.  Decision support for improvisation during emergency response operations , 2001 .

[139]  Eleanor T. Loiacono,et al.  Communications of the Association for Information Systems , 2001 .

[140]  Victoria Wibeck Fokusgrupper : Om fokuserade gruppintervjuer som undersökningsmetod , 2000 .

[141]  J. Flach Discovering Situated Meaning: An Ecological Approach to Task Analysis , 2000 .

[142]  Natascha Korolija,et al.  Episodes in talk: Constructing coherence in multiparty conversation , 1998 .

[143]  Michael S. Floater,et al.  Error formulas for divided difference expansions and numerical differentiation , 2003, J. Approx. Theory.

[144]  Per-Erik Ellström,et al.  Arbete och lärande. Förutsättningar och hinder för lärande i dagligt arbete , 1996 .

[145]  M. Weggeman Sensemaking in organisations , 1996 .

[146]  Per Linell,et al.  Episodes: coding and analyzing coherence in multiparty conversation , 1996 .

[147]  Erik Brynjolfsson,et al.  The Matrix of Change: A Tool for Business Process Reengineering , 1996 .

[148]  A. Werr,et al.  The Functions of Methods and Tools in the Work of Management Consultants , 1996 .

[149]  Anders Berger,et al.  Perspectives on Manufacturing Development - Discontinuous Change and Continuous Improvement , 1996 .

[150]  Peter Holm,et al.  On the design and usage of information technology and the structuring of communication and work , 1996 .

[151]  Malin Bergvall Systemförvaltning i Praktiken : en kvalitativ studie avseende centrala begrepp, aktiviteter och ansvarsroller , 1995 .

[152]  Per Levén,et al.  Från användning till handling : Om kvalitet i ett marknadsorienterat informationssystem , 1995 .

[153]  Thomas K. Landauer,et al.  The trouble with computers , 1995 .

[154]  E. Bohlin Economics and management of investments : an international investigation of new technology decision-making in telecommunications , 1995 .

[155]  I. Persson The Capital Investment Process and New Technology , 1994 .

[156]  M. Lynne Markus,et al.  PRECONDITIONS FOR BPR SUCCESS And How to Prevent Failures , 1994 .

[157]  Richard J. Murray,et al.  Getting ready for strategic change: surviving business process redesign , 1993 .

[158]  F. Naschold Constructing the new industrial society , 1993 .

[159]  R. Dué,et al.  The Productivity Paradox , 2018, The Productivity-Inclusiveness Nexus.

[160]  Kalle Lyytlnen,et al.  Penetration of Information Technology in Organizations: A Comparative Study Using Stage Models and Transaction Costs , 1991, Scand. J. Inf. Syst..

[161]  Erik Stolterman,et al.  Designarbetets dolda rationalitet en studie av metodik och praktik inom systemutveckling , 1991 .

[162]  F Meehan,et al.  Shaping the future. , 1991, Nursing.

[163]  Claes Tunälv Manufacturing strategies in the Swedish engineering industry , 1991 .

[164]  Johan P. Olsen,et al.  Makten att reformera , 1990 .

[165]  Per Lindberg,et al.  Manufacturing strategy and implementation of advanced manufacturing technology , 1990 .

[166]  Markku Nurminen,et al.  People or Computers: Three Ways of Looking at Information Systems , 1988 .

[167]  Colin Potts,et al.  Design of Everyday Things , 1988 .

[168]  J. Rassmusen,et al.  Information Processing and Human - Machine Interaction: An Approach to Cognitive Engineering , 1986 .

[169]  R. de Tornyay Up and running. , 1983, The Journal of nursing education.

[170]  Descriptors Higher Annual Meeting of the International Communication Association , 1974 .

[171]  Viktor Mikhaĭlovich Glushkov,et al.  An Introduction to Cybernetics , 1957, The Mathematical Gazette.

[172]  L. von Bertalanffy,et al.  The theory of open systems in physics and biology. , 1950, Science.