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Aug. 2011
uo noL clLe. ubllshed arLlcle ls avallable Lhrough SlenceulrecL.
Journal of Safety Research, Volume 42, Issue 4, August
2011, Pages 293-300

2010 8osa AnLonla Carrlllo, MSCu 4/3/12 2

C-)4".:?)("- ;* A.B,4 /?<&(-5 94"0&22"4 A#&4():2 6CD

LfforLs Lo make Lhe nuclear lndusLry safer are more lmporLanL Lhan ever ln Lhe wake of Lhe !apanese dlsasLer.
An enormous amounL has been wrlLLen abouL how Lo "creaLe a safeLy culLure," and lL usually ends up wlLh a long llsL of
aLLrlbuLes of a culLure and very llLLle lnslghL lnLo Lhe fundamenLal lssues LhaL underlle safeLy ln all hlgh hazard lndusLrles.
l have observed Lhe greaL energy and efforL LhaL goes lnLo Lhls process ln my role as a parL-Llme consulLanL and member
of Lhe Advlsory Councll of lnC.
Carrlllo's paper ls an lmporLanL addlLlon Lo Lhls dlfflculL dlalogue ln hlghllghLlng LhaL we may be uslng Lhe wrong
models of how Lo Lhlnk abouL safeLy ln Lhe flrsL place. Per emphasls on complexlLy Lheory, sense maklng and polarlLy
Lheory focus us on Lhe Lwo mosL fundamenLal problems of safeLy--1) We wlll never be able Lo predlcL all Lhe Lhlngs LhaL
can go wrong, LhaL naLure wlll Lhrow aL us, LhaL human belngs wlll, ln Lhelr efforLs Lo do Lhlngs beLLer, acLually make
Lhlngs more complex and, Lherefore, maybe worse, 2) We wlll never be able Lo avold Lhe polarlLy beLween absoluLe
safeLy (aL any cosL) and compeLlng economlc and psychologlcal values. ln our own dally behavlor, we can see how Lhe
need Lo accompllsh Lhlngs, geL Lo places, do Lhlngs ln a Llmely and saLlsfylng way, and have fun" LempLs us lnLo rlsky"
behavlor, seen mosL clearly ln Lhe way we drlve. 8uL we Lry Lo avold whaL some mlghL call reckless" behavlor, as
deflned by consensus of oLhers dolng Lhe same Lhlng. ln hlgh hazard lndusLrles recklessness ls LoLally unaccepLable buL
our goal would be Lo flnd ways of avoldlng even rlsky behavlor so LhaL Lhe publlc and Lhe employees are kepL safe.
LffecLlve managemenL ln hlgh hazard lndusLrles Lherefore musL focus on noL only avoldlng recklessness buL also
prepare employees for Lhe unexpecLed, whaL has usefully been labeled Lhe unknowable unknown." lf surprlses have
Lo be dealL wlLh, we hope LhaL employee lnnovaLlon wlll mlnlmlze rlsk and we hope LhaL managemenL can creaLe Lhe
condlLlons and lncenLlves Lo enable employees Lo balance or even lnLegraLe Lhe polarlLles lmplled by safeLy vs.
producLlvlLy. We should have learned by now LhaL beLLer deslgn or more deLalled procedures ls only a parLlal answer.
ln facL, Lhe more we Lry Lo deslgn fall-safe sysLems and Lhe more we wrlLe procedures for how Lo do Lhlngs, Lhe greaLer
Lhe complexlLy and Lhe poLenLlal for surprlses of all sorLs LhaL we hope Lhe operaLors ln our planLs have Lhe lngenulLy Lo
deal wlLh. WlLhouL Lhelr ablllLy Lo make sense ouL of surprlses and lnnovaLe Lo geL Lhe [ob done we would be much
worse off. lf we Lake complexlLy and polarlLy Lheory serlously lL wlll polnL Lhe way ouL of Lhese dllemmas--we have Lo
keep learnlng. We have Lo learn Lo Lhlnk ln Lerms of new models and develop some new skllls
8ecomlng skllled learners and sense makers wlll be Lhe keys Lo a safer fuLure. ln LhaL regard learnlng how Lo be
more helpful Lo each oLher wlll be Lhe key because learnlng and sense maklng ls a [olnL efforL LhaL hlnges on muLual
LrusL and muLual help. From working in the safety industry, l learned from employees LhaL Lhe blggesL obsLacle Lo
lmprovlng safeLy performance ls falled communlcaLlon and lack of LrusL. Lmployees feel managemenL doesn'L llsLen.
ManagemenL feels employees don'L undersLand Lhe blgger plcLure and suffer from enLlLlemenL. We can only flx LhaL
problem by creaLlng a cllmaLe where employees feel Lhey can Lell Lhelr boss Lhe LruLh. 8osses need Lo communlcaLe
LhaL Lhey really need employees' help. Managers need Lo know whaL ls golng on. Powever, employees won'L speak up
unless Lhey LrusL managemenL. 1he LrusL ls developed as Lhey see managemenL respond Lo Lhe lnformaLlon. 8eLLer
lnformaLlon leads Lo beLLer declslons. ln my experlence, Lhls happens when managers are able Lo ask for help and
employees feel Lhelr help ls needed and valued.
Pow we can consLrucL Lhe relaLlonshlps and communlcaLlon sLrucLures LhaL creaLe successful and safe
organlzaLlons? Pow do you develop LrusL? WhaL lf l wanL Lo LrusL more and l don'L know how? WhaL lf l LrusLed
someone and Lhey beLrayed me? Pelplng ls Lhe basls of LrusL. 1rusL ls Lhe basls of communlcaLlon. CommunlcaLlon ls
Lhe basls of organlzaLlonal effecLlveness. We have Lo pay more aLLenLlon Lo muLual helplng Lo creaLe boLh safeLy and
effecLlveness. l have reached Lhe concluslon LhaL helplng skllls aL all levels of an organlzaLlon wlll be Lhe necessary
lngredlenLs Lo a more effecLlve and safe nuclear lndusLry.
(Scheln, L. P. Pelplng: Pow Lo offer, glve and recelve help, 8erreLL/kohler, 2009)."

A.B,4 EF /?<&(-
94"0&22"4 A#&4():2
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2010 8osa AnLonla Carrlllo, MSCu 4/3/12 3

!"#$%&'()* ,-. /,0&)*
8osa AnLonla Carrlllo, MSCu
Aprll 9, 2011
!"#$%&'$(

1be potpose of tbls ottlcle ls to explote bow '*+,-./0$1 $2.*%1 ptovlJes fottbet loslqbt loto wby
cbooqe effotts lo sofety foll, ooJ bow lt coo be oseJ to cteote oew opptoocbes tbot ptoJoce sostolooble
tesolts. 1bls ottlcle wlll oome some of tbe fooJomeotol teosoos cbooqe effotts foll ooJ wbot leoJets coo Jo to
ocbleve soccess. lo otbet wotJs, bow coo moooqets ooJ sofety ptofessloools lofloeoce employees to embtoce
tbe oeeJ fot cbooqe ooJ to see tbe beoeflts of oJoptloq oew bebovlots, ptocesses ot ptoceJotes? 1be
ptoposeJ cooceptool ftomewotks teloteJ to complexlty focos oo %.-&$0*3#20, ,#1'2*-*41 (bomoo octloos ote
JlctoteJ by telotloosblps), #.3#.+&5034 (bow we Jetetmloe wbot ls ttoe wbeo tbe ttotb ls oot obvloos ot
tbete ls Jlsoqteemeot), ,%&'$0'&- 6%07$ (tbe teoJeocy fot people to ose tbelt expetleoce to oJjost estobllsbeJ
ptoceJotes), ooJ +&3&4034 ,*-&%0$1 (lJeotlfyloq ooJ tecoocllloq competloq ptlotltles
GF C-)4".:?)("-
1hls arLlcle addresses Lhe challenges of changlng Lhe way people make declslons abouL safeLy relaLed
acLlons ln a way LhaL leads Lo fewer ln[urles and lncldenLs. vlolaLlons of sLandard procedures occur rouLlnely
and someLlmes resulL ln ln[ury. eople walk by hazards LhaL laLer resulL ln lncldenLs. 1he quesLlon arlses,
Why dldn'L Lhls person follow procedure?" SafeLy experLs have long searched for Lhe answer Lo Lhls
quesLlon aL Lhe level of Lhe lndlvldual or even organlzaLlonal sysLems wlLh llmlLed success. A deeper LruLh
and Lhe poLenLlal soluLlons Lo Lhls conundrum may lle ln Lhe Lheorles of complexlty moooqemeot and
seosemokloq, whlch aLLempL Lo help us undersLand Lhe (-H(2(;%& dynamlcs LhaL drlve organlzaLlonal behavlor.
Changlng baslc assumpLlons abouL whaL ls safe or noL safe ls noL an easy mlsslon Lo Lake on. lL ls well
documenLed LhaL change efforLs fall over 70 percenL of Lhe Llme. (SLrebel 1996, 8eer and nohrla, 2000,
koLLer, 1996) Why? koLLer and Schleslnger (2008) explaln LhaL four common reasons accounL for reslsLance
Lo change. 1hese lnclude: a deslre noL Lo lose someLhlng of value, a mlsundersLandlng of Lhe change and lLs
lmpllcaLlons, a bellef LhaL Lhe change does noL make sense for Lhe organlzaLlon, and a low level of Lolerance
(p.42). ln addlLlon, Lhe exLenL Lo whlch Lhe change negaLlvely lmpacLs feellngs of self-worLh or self-
lmporLance also lncreases reslsLance Lo change. (WashlngLon and Packer, 2003, p.403). Managlng Lhls
complex web of emoLlons, moLlvaLlons, and feellngs Lled Lo self-ldenLlLy ls aL Lhe hearL of complexlLy
managemenL and lLs relaLed fleld, relaLlonshlp psychology (SLacey 2007).
1he lnherenL challenge ln presenLlng Lhese ldeas ls Lhe currenL vlew LhaL lL ls a manager's [ob Lo
conLrol and predlcL ouLcomes. CrganlzaLlons Lend Lo be vlewed as machlnes LhaL can be flxed Lhrough re-
englneerlng or re-deslgn. ComplexlLy Lheory polnLs Lo a very dlfferenL paradlgm, one of LrusL,
unpredlcLablllLy, and self-organlzaLlon. 1hese are radlcal ldeas buL Lhe dlfflculLy of changlng mlndseLs and Lhe
promlslng research ln Lhese flelds provlde Lhe lncenLlve Lo lnvesLlgaLe Lhelr pracLlcal appllcaLlon. 1he
recommendaLlons offered come from successful experlences wlLh complexlLy Lheory ln healLh care
(Anderson, 2003a, CrlfflLhs, 2007, !ordan eL al., 2009, MaLlow,WrlghL, Zlmmerman, 1homson, & valenLe,
2006, lsek &Wllson, 2001), as well as oLher lndusLrles (Welck 2003, Sardone and Wong 2010). 1hey also
come from Lhe auLhor's perspecLlve based on 20 years of documenLed research, dlalogues, lnLervlews, and
work wlLh Leams Lo lmplemenL culLure change (Slmon 1993, 1996, Carrlllo 1996, 1998, 2002, 2004, 2003,
2010a).
2010 8osa AnLonla Carrlllo, MSCu 4/3/12 4
1hree baslc assumpLlons underlle Lhls arLlcle. llrsL, Lhe mosL ferLlle area for lmprovlng safeLy
performance lles ln leadershlp's ablllLy Lo quesLlon lLs assumpLlons abouL Lhe naLure of Lhe problem and how
Lo solve lL. 1o do Lhls, leadershlp musL rely on Lhe second assumpLlon, LhaL Lhere ls a vasL wlsdom avallable ln
Lhe workforce. 1hlrd, Lhe appllcaLlon of complexlLy Lheory recognlzes LhaL organlzaLlons geL Lhlngs done noL
because of rules and procedures, buL Lhrough relaLlonshlps beLween lndlvlduals (Anderson eL al., 2003b,
SLacey, Crlffln, & Shaw, 2002). 8ased on Lhese assumpLlons, Lhls arLlcle examlnes how Lo apply Lhree Lheorles
LhaL show promlse for managlng change: complexlty, telotloosblp psycboloqy, and seosemokloq.
IF !"#$%&'()* 6,-,B&#&-) D<&"4*
complexlty moooqemeot tbeoty ls an area of organlzaLlonal research LhaL offers new ways Lo
undersLand whaL shapes safeLy performance and how we mlghL lnfluence lL. lL draws analogles from
complexlLy sclence, whlch looks aL complex sysLems and Lhelr envlronmenLs ln much Lhe same way as chaos
Lheory (Waldrop, 1992). Accordlng Lo lrlL[of Capra (2007), a physlclsL now focused on organlzaLlonal change
Lheory, our naLural envlronmenL demonsLraLes conLlnuous change, adapLaLlon, and creaLlvlLy, yeL our
buslness organlzaLlons seem Lo lack Lhe same ablllLy. 1hus, complexlLy's underlylng prlnclples offer new
lnslghLs for undersLandlng why change efforLs fall and how Lo deslgn change sLraLegles LhaL are more
successful because Lhey are more ln llne wlLh Lhe way people feel, Lhlnk, and acL.
ComplexlLy managemenL models pose Lhe posslblllLy of order emerglng from dlsorder Lhrough
processes of sponLaneous self-organlzaLlon ln absence of dlrecLlon. (SLacey eL al 2002) 8alph SLacey, who
spenL many years explorlng how Lhe complexlLy sclences mlghL provlde a new way of undersLandlng sLablllLy
and change ln organlzaLlons, lnLroduced a radlcal shlfL from sysLems Lhlnklng Lo whaL he calls relaLlonshlp
psychology." SucclncLly sLaLed hls research lndlcaLes LhaL Lhe rooL cause of whaL Lakes place ln organlzaLlons
sLems from Lhe lnLeracLlon and communlcaLlon beLween lndlvlduals and wlLhln groups (2007). Cne of Lhe
examples of Lhls phenomenon ls research LhaL correlaLes Lhe quallLy of relaLlonshlps among sLaff members
wlLh Lhe quallLy of healLh care Lhey dellver (Andersen eL al, 2003b, ClLLell, !.P. 2009, Codwyn & ClLLell 2011).
1able 1, Comparlson of 1radlLlonal ManagemenL Lo ComplexlLy ManagemenL rlnclples," provldes a
qulck overvlew of Lhe paradlgm-shlfL Laklng place ln Lhe way sclenLlsLs vlew organlzaLlons. (McMlllan: 212)
Classlcal sclence prlnclples led Lo Lhe currenLly domlnanL managemenL pracLlces. ComplexlLy sclence ls
movlng managemenL pracLlces ln Lhe dlrecLlon of empowermenL, flaLLer organlzaLlons, dlverslLy, and
adapLablllLy.

1able 1. Comparlson of 1radlLlonal ManagemenL Lo ComplexlLy ManagemenL rlnclples

!%,22(?,% /?(&-?&
94(-?($%&2
D4,.()("-,% 6,-,B&#&-) 94(-?($%&2 !"#$%&'()* 94(-?($%&2
Llnear 8aLlonal plannlng non-llnear
Plerarchlcal Plerarchy non-hlerarchlcal
8educLlonlsL SpeclallzaLlon PollsLlc
ConLrolllng ConLrolllng Self-organlzlng
lnflexlble 8ules & procedures llexlble
unlform MalnLenance of order & sLablllLy ulverse
CenLrallzed CenLrallzed conLrol neLworked
Closed ComparLmenLallzed ConnecLed


ln sLark conLrasL Lo managemenL Lheorles LhaL speak abouL conLrol and predlcLablllLy, Lhls
perspecLlve moves from sysLems Lo human lnLeracLlon as Lhe prlmary acLor ln complexlLy. lL says LhaL
sysLems such as rewards, measuremenLs, or rules do noL conLrol ouLcomes. lnsLead, ouLcomes are lnfluenced
by 1) Lhe human Lendency for self-lnLeresL and relaLlng everyLhlng Lo Lhelr own experlence, 2) conversaLlons
2010 8osa AnLonla Carrlllo, MSCu 4/3/12 3
LhaL shape people's undersLandlng of whaL ls Lrue and whaL ls approprlaLe acLlon (alLhough someLlmes Lhe
conversaLlon Lakes place sllenLly wlLhln), and 3) Lhe radlcal unpredlcLablllLy of Lhe dlrecLlon ln whlch
connecLlons and relaLlonshlps evolve.
WlLhln Lhls complex web of lnLeracLlons beLween lndlvlduals, one observes people solvlng problems,
adapLlng, and geLLlng Lhe work done wlLhouL expllclL dlrecLlons. As people learn from each experlence,
organlzaLlons sLruggle Lo keep currenL on documenLaLlon of procedures, organlzaLlonal charLs, and sLraLeglc
plans yeL lL ls ulLlmaLely Lhe lndlvldual respondlng Lo a speclflc sLlmulus and hls/her ablllLy Lo adapL LhaL may
deLermlne success. Accordlng Lo Ldgar Scheln, soclologlsLs have long found LhaL, .wlLhouL such lnnovaLlve
behavlor on Lhe parL of employees, Lhe organlzaLlon mlghL noL be as effecLlve." (Scheln 2010:60)
lL may be LhaL safeLy professlonals also vlew Lhe lndlvldual's awareness and problem solvlng ablllLy as
poLenL lever Lo lmprovlng safeLy performance. ln 2011 semlnar, 30 safeLy professlonals ldenLlfled Lhelr
blggesL challenge as lL relaLed Lo creaLlng a poslLlve safeLy culLure. llfLy percenL of Lhe parLlclpanLs ldenLlfled
Changlng Lhe aLLlLude LhaL lL can'L happen Lo me," or l've been dolng lL Lhls way for a long Llme wlLhouL an
lncldenL." When asked whaL Lools Lhey were mosL llkely Lo use Lo address Lhese lssues, Lhe answers were
procedures, Lralnlng, hazard recognlLlon, and [ob plannlng." (Carrlllo 2011) 1he group acknowledged Lhese
Lools had helped Lo reduce accldenLs, buL were largely dlssaLlsfled wlLh progress ln Lhe arena of aLLlLude"
and behavlor."
1he research on complexlLy managemenL lends lnslghL lnLo Lhese sofL lssues," how human belngs
make sense of reallLy, and how LhaL guldes Lhelr declslons and acLlons. Change aL Lhls level means worklng
wlLh feellngs, emoLlons, and relaLlonshlps. 1he challenge ls Lhe dlfflculLy of measurlng progress ln Lhese
areas, and Lhe dlfflculLy of obLalnlng Lhe managemenL supporL Lo work aL Lhls level. 1o address Lhese
conslderable challenges, Lhls arLlcle offers research based Lools deslgned by respecLed sclenLlsLs, and
pracLlLloners. used wlLh sklll, Lhey can leverage Lhe effecLlveness of Lralnlng, rules, and procedures.
A Lheory LhaL focuses aLLenLlon on self-organlzlng processes and emergenL ouLcomes hardly flLs lnLo
Lhe menLal model of managlng safeLy Lhrough regulaLlon, rules and procedure. 1he proposal ls noL Lo
ellmlnaLe Lhose aspecLs of managemenL. lL ls Lo acknowledge LhaL Lhe reallLy of how Lhe work ls done ln
organlzaLlons flLs more ln Lhe complexlLy model Lhan Lhe newLonlan mechanlcal model. lgnorlng reallLy wlll
noL change lL. lnsLead, deslgnlng our Lralnlng, educaLlon, and communlcaLlon forums Lo flL Lhe way people
undersLand and solve problems could be whaL leads Lo Lhe nexL level of safeLy excellence.
JF 3A/5 , /:??&22 /)"4* C%%:2)4,)(-B !"#$%&'()* 6,-,B&#&-) 94(-?($%&2
1he beneflLs of deslgnlng organlzaLlonal processes around complexlLy Lheory are based on
observaLlon of successful organlzaLlons. uennls 8akke, former CLC of ALS CorporaLlon, lead one of Lhe
largesL power companles ln Lhe world for many years. under hls leadershlp lL grew from a from a $1 mllllon
dollar lnvesLmenL lnLo an $8 bllllon company. As descrlbed by 8akke (2003), from lLs lncepLlon ALS seL ouL Lo
ellmlnaLe all formal approval mechanlsms aL Lhe company so LhaL Leams would make declslons aL Lhelr level
abouL everyLhlng from hlrlng Lo permlsslon for vacaLlons and budgeLs. Pe creaLed an envlronmenL where
leaders coached declslons more Lhan made Lhem. Pe was also a blg proponenL of bulldlng relaLlonshlps,
raLher Lhan rules.
under 8akke, Lhere was no safeLy or human resources deparLmenL. ALS held everyone responslble
for safeLy. SubsLanLlal bonuses were glven for reachlng safeLy relaLed goals. When Lhe company experlenced
faLallLles, Lhe bonus was reduced for everyone. 1he lnLenLlon was Lo moLlvaLe employees Lo parLlclpaLe ln
ldenLlfylng Lhe causes and prevenLlng Lhem ln Lhe fuLure. Pe descrlbes how Leams were responslble for
everyLhlng abouL Lhe area where Lhey worked. Pe felL speclallsLs dld noL undersLand operaLlons and
operaLlng groups dld noL undersLand flnance and sLraLeglc plannlng. 8y ellmlnaLlng speclallsLs," Leams of
people lnLeresLed ln Lhe whole operaLlon were creaLed. uurlng hls Lenure ALS had a beLLer Lhan average
safeLy record (2001 Manz & Slms)
8akke also emphaslzed Lhe promoLlon of relaLlonshlps Lhrough performance revlews and employee
surveys. WlLhln Lhe senlor Leam performance, revlews were done ln a group. er 8akke, lL honored each
2010 8osa AnLonla Carrlllo, MSCu 4/3/12 6
lndlvldual as an lmporLanL member of Leam, regardless of LlLle.lL allowed us Lo show our respecL for one
anoLher. lL broughL us closer LogeLher as a group." (110) Pe bullL Lhe same respecL wlLh employees by
readlng and respondlng Lo every slngle commenL senL Lo hlm Lhrough Lhe bl-annual percepLlon surveys. ln
Lhe beglnnlng, lL Look one hour Lo read Lhe commenLs Lowards Lhe end lL Look abouL flve monLhs Lo read
Lhem because employees reallzed lL was a real means of communlcaLlng Lhelr concerns. (114)
1he 2008 flnanclal crlsls ended Lhe ALS experlmenL as sLock prlces crashed ln energy relaLed sLocks
and 8akke was removed by Lhe board of dlrecLors. neverLheless, ALS was bullL and grew Lo an $8 bllllon
dollar company uslng prlnclples where lndlvlduals were empowered and LrusLed Lo make lmporLanL declslons
wlLhouL Lhe bureaucracy of corporaLe conLrol. AL leasL for a perlod of Llme, one leader found a way Lo brlng
proflL, englneerlng and human relaLlonshlps LogeLher. lf lL happened once, lL ls posslble for oLher leaders Lo
dupllcaLe Lhls success.
KF /&-2&#,L(-B
5eosemokloq has been applled exLenslvely Lo lnvesLlgaLe Lhe rooL cause of dlsasLers and Lhelr
prevenLlon (Welck 1993, Snook 2001, uekker & LuLzhofL, 2004). Smaller lncldenLs could beneflL from Lhe
sensemaklng process as well, parLlcularly Lo prevenL Lhe unlnLended ouLcome of new procedures or pollcles
LhaL don'L make sense Lo Lhe workforce or add Lo Lhe problem. ln one sLudy, Lhe percepLlon LhaL safeLy rules
LhaL do noL make sense" was ldenLlfled as Lhe second largesL lssue undermlnlng safeLy. 1rades people
descrlbed Lhe rules as knee-[erk" reacLlons and a dumblng down" of Lhelr knowledge and experlence
(Sardone & Wong 2010).
5eosemokloq and lLs relaLed concepLs, ,%&'$0'&- 6%07$ and ,*-&%0$1 +&3&4.+.3$ open Lhe way for
lnnovaLlve analysls of Lhe human facLor ln accldenLs and Lhelr prevenLlon. 8y uslng Lhese Lools Lo help
organlzaLlonal members undersLand why accldenLs happen or how Lo respond Lo Lhe rlsks Lhey are faclng ln a
safer manner, managers and supervlsors could creaLe self-enforclng soclal conLracLs Lo follow safeLy
procedures. Sensemaklng ls Lhe acLlvlLy humans use Lo make sense of Lhelr experlences and puL Lhem lnLo
conLexL wlLh Lhelr undersLandlng of Lhe way Lhe world works and Lo consLrucL meanlng. lL ls a consLanL
ongolng process LhaL wlll go on wlLh or wlLhouL Lhe leader's lnpuL. 1he leader's consclous use of sensemaklng
can help hlm/her galn greaLer success for change efforLs. karl Welck (1993, 1993) lnLroduced Lhe concepL of
sensemaklng Lo organlzaLlons. Cne of lLs sLrongesL conLrlbuLlons ls lLs emphasls on acLlon, whlch he
malnLalns ls Lhe prlmary process LhaL lnforms Lhe declslon Lo acL because acLlng on a bellef ls a way of LesLlng
lLs valldlLy. Sensemaklng ls relaLed Lo Lhe concepL of safeLy culLure" ln LhaL lL embraces Lhe human
propenslLy Lo form norms and assumpLlons around Lhe rlghL way Lo do Lhlngs. 1hese concluslons are arrlved
aL Lhrough sensemaklng, whlch may be a more accepLable word Lhan culLure change" Lo some porLlons of
Lhe workforce who mlghL vlew Lhe laLLer as bralnwashlng."
8%&'$0'&- 6%07$ (Snook, 2002) and ,*-&%0$1 (Carrlllo, 2003) were lnLroduced ln safeLy managemenL Lo
help explaln why people appear Lo dlsregard procedure and work unsafely. 8oLh concepLs wlll be descrlbed
under Lhe conLexL of sensemaklng because Lhey are processes LhaL Lhe human mlnd uses Lo make sense of lLs
envlronmenL. knowledge of how Lhese processes work can lead Lo more effecLlve communlcaLlon and
Lralnlng.
KFG !<,-B& 3B&-) ,2 /&-2&#,L&4
Common sense" derlves from sensemaklng. When a group arrlves aL a consensus on whaL ls Lrue,"
and LhaL explanaLlon solves Lhe problem, over Llme Lhe explanaLlon becomes common sense." lor Lhls
reason, change lnlLlaLlves LhaL allgn wlLh Lhe holder's common sense have a much greaLer poLenLlal of
accepLance Lhan Lhose LhaL do noL. lL mlghL be concluded LhaL lf a manager aLLempLs Lo lnlLlaLe a change LhaL
vlolaLes common sense, hls or her capaclLy for sound [udgmenL may be quesLloned and, consequenLly, Lhelr
repuLaLlon may no longer remaln ln good sLandlng. (Moon 2008)
1hus, Lo effecLlvely use sensemaklng Lo geL employee buy-ln for change, Lhe leader observes and
llsLens closely, collaboraLlng wlLh organlzaLlon sLakeholders Lo make sense of Lhe besL way Lo proceed
2010 8osa AnLonla Carrlllo, MSCu 4/3/12 7
(!acobs & Coghlan, 2003). 1hls process of sensemaklng ls couched ln consLanL lnformal conversaLlons and
observaLlons ln whlch leaders engage durlng Lhelr lnLeracLlons wlLh Lhe organlzaLlon's sLakeholders
(McCormlck & WhlLe, 2000). 1he leader respecLs Lhe boundarles of common sense and presenLs evldence of
changed clrcumsLances for everyone Lo examlne. Culdellnes for faclllLaLlng Lhls conversaLlon are:
1. LlsLen for ways ln whlch Lhe deslred change vlolaLes common sense perspecLlves and why.
2. When a confllcL wlLh common sense ls uncovered, undersLand Lhe employee polnL of vlew and
resLaLe Lhe change so LhaL lL flLs wlLhln Lhe currenL framework of Lhe parLlclpanLs.
3. 1ralnlng and conversaLlon are conLlnuous unLll Lhe changes are accepLed and lnLegraLed (Welck eL
al., 2003).

Change agenLs become lmporLanL for Lhelr ablllLy Lo make sense (Welck 1993) of dynamlcs under
way. lnsLead of seelng hlm or herself as a mover who creaLes change, Lhe sensemaker ls someone who
recognlzes Lhe changes Laklng place and redlrecLs Lhem. S/he arLlculaLes whaL ls golng on and reframes lL so
LhaL lL makes sense wlLhln Lhe conLexL of people's experlence and Lhe deslred ouLcomes. 1he Lools of Lhe
change agenL are words LhaL explaln upheavals, where people are headed, whaL Lhey wlll produce lf a new
paLh ls followed, and how Lhlngs wlll be beLLer. 1hey do Lhls Lhrough dlalogue, and helplng people see Lhem
selves acLlng under a dlfferenL seL of bellefs.
8ecalllng earller research LhaL LhaL Lhe mosL frequenL causes of falled change efforLs reslde ln Lhe
fear of loss, mlsundersLandlng of Lhe change lLself, and anxleLy, Lhe sensemaklng process becomes a poLenL
Lool Lo lncrease Lhe posslblllLy of success. 1he lnfluence of Lhe change agenL as sensemaker ls Lwofold. llrsL,
s/he demonsLraLes an open mlnd and respecL for oLher's oplnlons. Second, by demonsLraLlng Lhelr own bellef
ln Lhe process, Lhey are able Lo help people engage desplLe posslble doubLs or fears. 1he acL of gaLherlng
lnformaLlon from all levels of Lhe organlzaLlon and Laklng Lhe Llme Lo exchange polnLs of vlew ls a powerful
lnLervenLlon. LlsLenlng and reflecLlng back whaL ls heard creaLes Lhe openlng Lo be heard ln reLurn. 1hls ls noL
a one-sLep process. ln a low LrusL envlronmenL, Lhe conversaLlon musL Lake place many Llmes before a
common sense emerges. 1oo ofLen, Lhe process ends when one of Lhe parLles becomes frusLraLed by slow
progress or a percelved beLrayal. MasLer change agenLs know LhaL change can happen qulckly. 1hey also
know LhaL lL ls a slow, gradual process. 1hey are able Lo provlde assurance by polnLlng ouL small sLeps of
progress and holdlng Lhe bellef LhaL lL can conLlnue Lo geL beLLer lf people follow Lhe process.
KFI 1&2(2),-?& )" C-H&2)(-B (- !"-H&42,)("-
Welck places an emphasls on face-Lo-face communlcaLlon for sensemaklng, buL lL ls ofLen leasL
preferred by managers because of Lhe Llme demands (Welck & SuLcllffe 2007). 1hus, complex lssues are
rouLlnely addressed Lhrough wrlLLen pollcles, emall, or perfuncLory Lralnlng. ?eL, we do have evldence LhaL lL
pays Lo Lake Lhe Llme Lo develop quallLy relaLlonshlps among sLaff members. PealLh care faclllLles LhaL have
long been concerned wlLh paLlenL safeLy found LhaL Lhe quallLy of relaLlonshlps correlaLe wlLh Lhe quallLy of
healLh care sLaff dellvers. (Andersen eL al, ClLLell, !.P. 2009, Codwyn & ClLLell 2011)
1he auLhor has found reslsLance Lo lncreaslng face-Lo-face communlcaLlon among mosL managers and
safeLy professlonals. referred communlcaLlon meLhods lnclude havlng lmporLanL pollcy changes read and
slgned. SafeLy commlLLees do rooL cause lnvesLlgaLlons and posL Lhe resulLs. ln absence of conversaLlon,
Lhere ls llLLle proof LhaL Lhe message was undersLood as lL was lnLended, or LhaL any agreemenL was reached
on how Lo solve Lhe problem. 8esearch and experlence show people favor plauslblllLy over accuracy ln
accounLs of evenLs and explanaLlons (Currle & 8rown, 2003, 8rown, 2003, Abolafla, 2010): "ln an equlvocal,
posLmodern world, lnfused wlLh Lhe pollLlcs of lnLerpreLaLlon and confllcLlng lnLeresLs. an obsesslon wlLh
accuracy seems frulLless, and noL of much pracLlcal help, elLher" when lL comes Lo lnfluenclng change. (Welck
1993: 61).
KFJ !"-0%(?) 1&2"%:)("-
CrganlzaLlonal change cannoL be achleved by changlng Lhe lndlvldual (SLacey 2007). 1he consclous
faclllLaLlon of Lhe sensemaklng ofLen Lakes place ln one-on-one conversaLlons, buL ls a powerful managemenL
2010 8osa AnLonla Carrlllo, MSCu 4/3/12 8
Lool ln groups because lndlvlduals emerge wlLh a common deflnlLlon of Lhe problem and how Lo solve lL. 1hls
common sense" Lhen becomes Lhe rlghL way Lo do Lhlngs. Lmploylng sensemaklng as a managemenL Lool
faclllLaLes a common undersLandlng of whaL ls expecLed, and reduces amblgulLy, Lhus has Lhe poLenLlal Lo
reduce sLress and confllcL. (Welck 1993) Cne of Lhe mosL poLenL uses of sensemaklng may be durlng mergers,
downslzlng and acqulslLlons because as Welck noLes, when Lhe formal hlerarchles are dlsmanLled, mlcro
dynamlcs such as Lhose assoclaLed wlLh close relaLlonshlps may be more lnfluenLlal ln organlzaLlonal
sensemaklng." (1993:174)
Sensemaklng ls Lhe ulLlmaLe confllcL resoluLlon when lL ls used Lo arrlve aL a common undersLandlng,
a common purpose, and a sense of muLual respecL. 1he Parvard negoLlaLlon ro[ecL presenLs many useful
Lechnlques Lo creaLe learnlng conversaLlons." (2000 SLone, aLLon & Peen) owerful examples lllusLraLe
how changlng Lhe sLory abouL how someLhlng happened, changes Lhe feellngs, concluslons and relaLlonshlps.
Pow does Lhe sLory change ln sensemaklng? lL changes when dlfferenL perspecLlves brlng ln new daLa LhaL
blrLh new concluslons. SLorles are powerful communlcaLlons. 1hey can elLher supporL Lhe change efforL or
slnk lL.
4.4 ConfllcLlng rlorlLles: Managlng olarlLy
lL ls a managemenL funcLlon Lo clarlfy prlorlLles. ln several focus groups and semlnars held ln 2010 Lo
lnLroduce sensemaklng ln a large regulaLory agency, Lhe auLhor conflrmed Scheln's (1996) flndlngs LhaL flrsL
llne supervlsors are consLanLly faced wlLh chooslng beLween lnevlLable Lrade off's and would llke upper
managemenL Lo recognlze Lhe dlfflculLy of Lhelr role. 1hls was especlally prevalenL ln Lhe safeLy arena. Cne of
Lhe lnslghLs LhaL emerged for Lhe supervlsors LhaL parLlclpaLed was LhaL Lhelr dlrecL reporLs suffered from Lhe
same sense of lsolaLlon and lack of supporL from managemenL. 8y lncreaslng Lhelr one-Lo-one and group
communlcaLlon wlLhln Lhelr work unlL, Lhey experlenced a quallLaLlve lncrease ln collaboraLlon and decrease
ln frusLraLlon wlLh Lhe workload. 1hese conversaLlons are real world examples of sensemaklng-arrlvlng aL a
common undersLandlng of whaL ls lmporLanL. Lven a very speclflc llsL of Lasks, deadllnes, and cosL consLralnLs
leaves plenLy of room for amblgulLy as unexpecLed hold ups and lnformaLlon surfaces. 8elaLlonshlp bulldlng
and sensemaklng are powerful managemenL Lools Lo help people arrlve aL common sense of Lough quesLlons
llke WhaL does safe looks llke?" WhaL ls accepLable rlsk?" or Why should l change Lhe way l've always
done lL lf l've never goLLen hurL?"
Lxamples of confllcLlng prlorlLles exlsL beLween fleld and offlce, headquarLers and operaLlons, or even
wlLhln Leams. 1he local Leam may feel Lhe besL way for Lhe organlzaLlon Lo succeed ls Lo focus on geLLlng Lhe
work done raLher Lhan meeLlng demands for paperwork from corporaLe. Meanwhlle headquarLers vlews lLs
demands as necessary for Lhe survlval of Lhe organlzaLlon, and Lhe local behavlors as reslsLance Lo change.
1he Lerm polarlLy or paradox has galned popularlLy ln descrlblng Lhese Lypes of confllcLs because Lhe Lerm
capLures a baslc dllemma consLanLly faced ln organlzaLlons. WhaL makes Lhese confllcLlng prlorlLles ,*-&%0$0.#
ls LhaL for an organlzaLlon Lo be successful boLh ob[ecLlves musL be meL. lf managemenL focuses on geLLlng
Lhe work done buL neglecLs plannlng and admlnlsLraLlon, Lhe buslness suffers. lf employees fulflll all
corporaLe demands unquesLlonlngly lmporLanL lnformaLlon may noL emerge LhaL would save Lhe company
Llme and money. AnoLher useful dynamlc lncluded ln Lhe Lerm, polarlLy, ls LhaL Lhe parLles ln confllcL only see
Lhe up slde of Lhelr perspecLlve, and Lhe downslde of Lhe oLher.
Leaders ldenLlfy and communlcaLe abouL polarlLles ln a way LhaL can be undersLood and worked wlLh.
WhaL should we work on flrsL? Pow far can we leL Lhe oLher one sllde? Accordlng Lo Scheln, some of Lhe
prlnclpal ways leader's lnfluence behavlor ls Lhrough whaL Lhey pay aLLenLlon Lo, measure and reward.
(2010:236) A ma[or challenge ls maklng sure LhaL whaL followers percelve as lmporLanL ls acLually whaL Lhe
leader lnLends. When managers assume LhaL managerlal Loplcs are undersLood ln Lhe same way by
everyone, Lhey surrender Lhe opporLunlLy Lo lead effecLlvely. Leaders who expllclLly say whaL Lhey mean are
beLLer able Lo leverage Lhe energy and commlLmenL of Lhelr followers." (Pamm 2006)
1he challenge of communlcaLlng Lhe same message across Lhe organlzaLlon ls enormous because
mulLlple subculLures exlsL, each wlLh Lhelr own language and assumpLlons (Scheln, 1996). AL Llmes a manager
feel s/he has been very clear on whaL Lhey wanL done or correcLed only Lo flnd LhaL some Llme laLer Lhelr
2010 8osa AnLonla Carrlllo, MSCu 4/3/12 9
requesLs have noL been fulfllled. Many accepLed managemenL pracLlces exlsL Lo address how Lo handle such
a slLuaLlon. Powever, managlng polarlLy (koesLenbaum, 2002, !ohnson, 1992, Carrlllo, 2003, Colllns and
orras, 2002) offers a new way Lo look aL Lhls recurrlng challenge.
olarlLy lllusLraLes one of Lhe causes for Lhe apparenL lack of clarlLy ln prlorlLles or goals LhaL exlsLs ln
mosL organlzaLlons ln splLe of leader's aLLempLs Lo clearly arLlculaLe Lhem. 1he purpose for explorlng how
leaders mlghL deal wlLh polarlLy Lhrough sensemaklng ls Lo lllusLraLe LhaL Lo communlcaLe, leaders need Lo
Lake lnLo accounL Lhe role of Lhe llsLener ln consLrucLlng lnLenLlon. lurLhermore, Lhe meanlngs Lhey come up
wlLh may depend more upon shared background and culLure Lhan Lhelr lndlvldual skllls ln managlng
lmpresslons and devlslng rheLorlcally senslLlve messages." (Zlegler eL al, p.290)
1he leader cannoL declde prlorlLles ln lsolaLlon. Mangusson (2010) noLed ln hls sLudy LhaL, CLher
facLors, such as Lhe commlLmenL and wllllngness from employees Lo accepL and undersLand whlch facLor
should be ln flrsL hand beLween safeLy and producLlon, are also seen as deLermlnanLs of Lhe safeLy success ln
Lhe company." (22) Slnce leadershlp cannoL be presenL Lo make each declslon, sLrucLures and guldellnes are
necessary Lo relnforce Lhe prlorlLles. neverLheless, polarlLy managemenL musL begln wlLh leadershlp slnce lL
enLalls recognlLlon, educaLlon, and an envlronmenL of LrusL and open communlcaLlon LhaL allows for open
dlscusslon of Lhe percelved confllcLs.
Some suggesLlons on Lhe use of sensemaklng wlLh seLLlng prlorlLles would be:
! CulLlvaLe dlscusslon abouL seLLlng prlorlLles LhaL goes beyond a leader-cenLrlc approach Lo
leadershlp. uurlng [ob brleflngs, flrsL, address Lhe employee's role ln lnLerpreLlng prlorlLy
sLaLemenLs, lncludlng Lhelr aLLrlbuLlons Lo leader's lnLenL.
! Conslder shlfLlng Lhe vocabulary away from seLLlng prlorlLles" Lo communlcaLlng prlorlLles as
a process. Conslder how Lhls mlghL Lransform Lhe brleflng process lnsLead of addlng anoLher
lLem Lo an exlsLlng brleflng checkllsL. lndeed, expand Lhe noLlon of leader's lnLenL beyond Lhe
lnlLlal brleflng, and engage ln exerclses LhaL help subordlnaLes Lo lnLerpreL and relnLerpreL Lhe
leader's lnLenL when condlLlons change.
! lnvolve employees ln seLLlng prlorlLles and explore when and how a work group can pracLlce
resolvlng shlfLlng prlorlLles. 1he goal of Lhls exerclse would be Lo culLlvaLe a shared mlndseL for
evaluaLlon and quesLlonlng.

KFM 6,L(-B /&-2& "0 @<* 9&"$%& 8"-N) O"%%"P 94"?&.:4&
toctlcol Jtlft ls Lhe human characLerlsLlc of noL followlng procedure when negaLlve consequences fall
Lo maLerlallze afLer sLopplng. 1he drlfL occurs for Lhe purposes of pracLlcallLy and efflclency. ScoLL Snook
(2002) colned Lhe Lerm pracLlcal drlfL" afLer a Lwo-year lnvesLlgaLlon of Lhe accldenLal frlendly flre shooL
down of u.S. 8lack Pawks over norLhern lraq. uslng organlzaLlonal psychology and soclal consLrucLlon
Lheorles Lo analyze Lhe resulLs, he wroLe, 1here weren'L any bad guys, hence, no one Lo blame. 1here were
noL any caLasLrophlc fallures of maLerlal or equlpmenL, hence noLhlng Lo flx. no gross negllgence or acL of
Cod caused Lhls Lragedy. 1he more l looked for LradlLlonal culprlLs, Lhe more l reallzed LhaL Lhls accldenL
occurred as Lhe resulL of normal people behavlng ln normal ways ln normal organlzaLlons." (Snook: 202)
MosL of Lhe Llme, Lhere are no adverse consequences Lo pracLlcal drlfL. Many Llmes, Lhere are
beneflLs, and employers rely on lL Lo lmprove efflclencles ln Lhe way work ls done. A sensemaklng focus
group Lo deLermlne why employees were noL followlng procedures ln lab LesLlng ylelded an lnLeresLlng
perspecLlve. Lveryone had been Lralned ln one meLhod buL a monLh laLer, no one was followlng Lhe wrlLLen
procedure. 1he experlenced operaLors saw noLhlng wrong wlLh Lhls. ln Lhelr mlnd, lL was expecLed Lo Lake
Lhe baslc lnformaLlon and lmprove upon lL based on experlence. ln facL, Lhe operaLors ln lndlvldual lnLervlews
lnslsLed LhaL Lhey were followlng procedure, buL uslng dlfferenL Lechnlques." 1he unlformlLy of language
lndlcaLed LhaL conversaLlons abouL Lhe maLLer had Laken place and agreemenL had been reached among Lhe
operaLors. AfLer Lhe focus group and reLralnlng of Lhe personnel, Lhe operaLors followed Lhe lab procedures
for a perlod of Llme. 1he lab manager changed [obs, and afLer a whlle drlfL reLurned.
lurLhermore, research shows (Scheln 1996) Lhe operaLlonal culLure belleves LhaL no maLLer how
2010 8osa AnLonla Carrlllo, MSCu 4/3/12 10
clearly Lhe rules are speclfled Lhey cannoL cover every conLlngency because Lhe producLlon process ls
dependenL on a sysLem of lnLerdependenL funcLlons. Scheln concludes, 1he Lragedy of mosL organlzaLlons ls
LhaL Lhe operaLors know LhaL.nelLher Lhe lncenLlve sysLem nor Lhe day-Lo-day managemenL sysLem may
supporL Lhose assumpLlons. CperaLors Lhus learn Lo subverL whaL Lhey know Lo be Lrue and "work Lo rule," or
use Lhelr learnlng ablllLy Lo LhwarL managemenL's efforLs Lo lmprove producLlvlLy." (1996: 14)
osslble lessons from Lhls example are LhaL lf a procedure ls crlLlcal, lL wlll requlre conslsLenL
monlLorlng and reLralnlng. 1he use of sensemaklng as a managemenL Lool could make Lhe effecL of Lhe
Lralnlng lasL longer because people are lnvolved ln deflnlng besL pracLlces.
A suggesLlon for plannlng a sensemaklng sesslon on pracLlcal drlfL may lnclude:
1. ueflnlLlon of racLlcal urlfL
2. ldenLlfy an area where alLernaLlve pracLlces have emerged LhaL vary from procedure
3. ldenLlfy (1) where Lhere has been an lmprovemenL and why, (2) where Lhe drlfL mlghL have
creaLed a poLenLlal danger. A person LhaL ls an experL ln Lhe lnner worklngs of Lhe process or
equlpmenL needs Lo be presenL.
4. 8ecord flndlngs ln Lwo columns for poslLlve and negaLlve poLenLlal. Pold an open dlalogue Lo
look for paLLerns LhaL can lead Lo arrlvlng aL a consensus on whaL ls accepLable drlfL, and
whaL ls noL.
3. WhaL ls Lhe process for recordlng or communlcaLlng changes Lo procedure?
6. ldenLlfy any cardlnal" safeLy rules LhaL musL never be vlolaLed.
KFQF !"#$%&'()* 6,-,B&#&-) D<&"4* (- 94,?)(?&
ComplexlLy Lheory lnforms LhaL you cannoL change a group by changlng Lhe lndlvldual. Slnce humans
undersLand Lhe world around Lhem Lhrough LhoughLs and words, conversaLlon ls Lhe prlmary Lool for
creaLlng change. noLe LhaL conversaLlon ls noL Lop-down, one way, nor ls lL wrlLLen documenLaLlon. Changes
ln conversaLlons reflecL Lhe lnLernal changes ln Lhe way people wlll feel, Lhlnk, and acL. lL mlghL change from,
"Why do we have Lhls mlndless bureaucraLlc rule Lo always lock Lhe gaLe?" Lo "Locklng Lhe gaLe remlnds us
we are enLerlng an area where safeLy rlsks are hlgher." Sensemaklng descrlbes how conversaLlons move lnLo
Lhe prlvaLe LhoughLs of Lhe lndlvldual Lo become common sense, whlch dlrecLs behavlor. Pow can Lhls
process be uLlllzed Lo shape Lhe safeLy declslons and behavlors of an organlzaLlon? lour common approaches
are:

1. Cne-Lo-one conversaLlons Lo sollclL safeLy concerns, ldeas for lmprovemenL, and obsLacles Lo
geLLlng Lhe [ob done. 1he conversaLlon ls Lwo-way so Lhere ls opporLunlLy for Lhe leader Lo
express hls/her expecLaLlons and concerns as well. lollow up and feedback on Lhese
conversaLlons ls necessary for Lhem Lo have Lhe deslred effecL. 1he ob[ecLlve ls Lo evenLually
arrlve aL a common sense of whaL ls needed Lo be safe, how Lo deflne safe, and Lhe besL way for
Lhe supervlsor/manager Lo supporL Lhe work.
2. "AppreclaLlve lnqulry," a group lnLeracLlon Lechnology deslgned by uavld Cooperrlder (2003), has
shown very good resulLs ln solvlng complex problems whlle creaLlng LrusL and open
communlcaLlon. 1hls approach gaLhers people Lo learn from whaL ls golng rlghL. oLenLlal
soluLlons emerge ln a way LhaL promoLes buy-ln. 1here ls an appreclaLlve lnqulry webslLe LhaL
has many successful case sLudles aL hLLp://appreclaLlvelnqulry.case.edu/
3. Surveys, focus groups, and acLlon plannlng processes can be very producLlve when parLlclpanLs
recelve feedback and Lhelr suggesLlons are responded Lo or lmplemenLed ln a Llmely manner. ln
Lhe ALS case, Lhe facL LhaL Lhe CLC was readlng Lhe commenLs and responded proved Lo be a
powerful relnforcemenL Lo Lhe culLure of personal accounLablllLy. Many of Lhese efforLs fall
because lL Lakes Lo long Lo respond or employees see no response Lo Lhelr feedback.
4. use of Lask forces and cross-funcLlonal Leams ls anoLher powerful Lool for sensemaklng wlLh Lhe
caveaL LhaL Lhe Leam musL be Lralned ln Lhe arL of dlalogue. lnvesLlng ln faclllLaLlon Lralnlng ls
2010 8osa AnLonla Carrlllo, MSCu 4/3/12 11
also lmporLanL lf new ldeas and perspecLlves are Lo emerge. 1wo oLher lmporLanL elemenLs Lo
Lhe success of Lhls approach are supplylng Lhe supporL and resources Lo lmplemenL Leam resulLs.

1he above processes work because Lhey bulld relaLlonshlps Lhrough LrusL and open communlcaLlon.
Common purpose and expecLaLlons develop as people keep commlLmenLs. When managemenL does noL
respecL Lhe work of Lhe Leams or feedback from employees, Lhe relaLlonshlp LermlnaLes or ls damaged. 1he
resulLlng ouLcome ls Lyplcally unsupporLlve of organlzaLlonal performance. Cn Lhe oLher hand, when a leader
acknowledges Lhe wlsdom lnherenL ln Lhe group and learns from lL, s/he ls able Lo communlcaLe new ldeas
and Lhe need for change wlLhln a conLexL LhaL people are more llkely Lo accepL. AcLlng from Lhls poslLlon of
respecL and recognlLlon sLrengLhens relaLlonshlps and fuels Lhe movemenL Lowards more successful
ouLcomes.
4.7 Sensemaklng 1ools
1he ablllLy Lo see and selecL correcL daLa lncreases Lhe quallLy of declslon-maklng, however, lL ls qulLe
Lhe challenge Lo moLlvaLe people Lo lnvesL ln Lhe Llme and efforL lL Lakes Lo geL pasL Lhe apparenL LruLh" Lo
whaL mlqbt be Lhe real LruLh." (Chengalur-SmlLh eL al, 1999, llsher 2003, kerr & 1lndale, 2004). Whlle
sensemaklng ls a consLanLly ongolng process, here lL ls belng examlned as a consclous Lool Lo solve problems,
lmprove Lhe quallLy of communlcaLlon, and ralse safeLy awareness. ConsLrucLlve sensemaklng conversaLlons
help people see hldden problems and lnnovaLlve soluLlons LhaL were prevlously lnvlslble because Lhey were
mlsundersLood or noL parL of Lhe collecLlve common sense.
Leaders are naLural sensemakers, buL Lhey can be Lrapped by Lhelr own assumpLlons, and Lhus mlss
lmporLanL lnformaLlon LhaL would help Lhem make beLLer declslons. 1he lncorporaLlon of sensemaklng lnLo
supervlsory and managemenL Lralnlng would help managers learn how Lo lncrease Lhelr own awareness and
problem solvlng capablllLy by observlng and llsLenlng Lo Lhe people around Lhem. Cne fundamenLal Lool Lo
develop an open mlnd ls Lhe ladder of lnference." (Argyrls and Schon, 1974), popularlzed by eLer Senge ln
Lhe llfLh ulsclpllne." Some of Lhe bellefs LhaL can prevenL groups from seelng and uslng valuable
lnformaLlon are:
! My bellefs are Lhe LruLh
! 1he LruLh ls obvlous
! My bellefs are based on Lrue daLa
! 1he daLa l selecL ls Lhe lmporLanL daLa

llgure 1

1he Ladder of lnference, llgure 1, can ald ln breaklng Lhrough Lhese obsLacles by explalnlng how pre-
exlsLlng bellefs block or llmlL Lhe ablllLy Lo see reallLy. 1he progresslon of Lhe Ladder shows how people move
from observaLlon Lo acLlon. AL Lhe boLLom of Lhe ladder, reallLy ls lnlLlally percelved as keol uoto &
xpetleoce, such as LhaL capLured by a movle camera. 1he human mlnd Lhen selecLs a seL of 5electeJ uoto &
2010 8osa AnLonla Carrlllo, MSCu 4/3/12 12
xpetleoce Lo whlch lL pays aLLenLlon. 1o Lhls 5electeJ uoto & xpetleoce lL afflxes Meooloq, develops
Assomptloos, and comes Lo cooclosloos, whlch become 8ellefs. 8ellefs Lhen form Lhe basls of Actloos, whlch
creaLe addlLlonal keol uoto & xpetleoce. 1he movemenL up Lhls ladder ls unconsclous and auLomaLlc. lL
happens ln an lnsLanL. Cne of Lhe lnherenL problems wlLh Lhls process ls LhaL experlence ofLen causes one Lo
see whaL one expecLs Lo see as shown ln flgure 2, Seelng ls 8ellevlng."

llgure 2.





ln Lhe second flgure, R&%(&02 lnfluence Lhe /&%&?)&. 8,), S A'$&4(&-?& Lhe mlnd pays aLLenLlon Lo
causlng an lnLernal relnforclng loop ls esLabllshed whlch shorL clrculLs reallLy. 1he Lendency ls Lo selecL daLa
Lo supporL Lhe exlsLlng bellefs. Cnce Lhls loop ls ln place, lL ls very dlfflculL Lo lnLroduce new lnLerpreLaLlons of
Lhe daLa.
1hls dynamlc of seelng ls bellevlng" ls dramaLlcally lllusLraLed ln negaLlve relaLlonshlps beLween
unlon and managemenL. Cnce Lhe bellef LhaL Lhey" can'L be LrusLed ls ensconced ln Lhe culLure, lL ls very
dlfflculL Lo lnLroduce collaboraLlve approaches Lo safeLy. Small mlscommunlcaLlons become beLrayals" and
grounds for sLopplng progress. llgure 3, Cycle of MlsLrusL, lllusLraLes Lhe negaLlve effecL of Lhe ladder of
lnference can have on breaklng down LrusL. MlsLrusL ls lnlLlaLed when people asslgn negaLlve meanlng Lo an
evenL or behavlor. lf Lhe assumpLlons are noL verlfled, Lhe mlsLrusL could be mlsgulded.
1here are many examples of how Lhls cycle can negaLlvely lmpacL Lhe accepLance of safeLy
lmprovemenL efforLs (Carrlllo 2002). 1here are also examples of how leaders have broken Lhls cycle by calllng
people LogeLher Lo re-examlne Lhelr assumpLlons, explore new meanlngs, and experlmenL wlLh LrusL ln small
ways LhaL bullL new bellefs abouL Lhe lnLegrlLy of boLh unlon and managemenL leaders (Carrlllo 2002, 2004).

2010 8osa AnLonla Carrlllo, MSCu 4/3/12 13
llgure 3. Cycle of MlsLrusL


1&?"##&-.,)("-2 0"4 T2& "0 )<& U,..&4
Managers and employees can learn Lo use Lhe Ladder of lnference Lo quesLlon Lhelr bellefs and
assumpLlons. 1hls, accordlng Lo Welck and oLhers, ls whaL dlsLlngulshes hlgh performance organlzaLlons LhaL
succeed ln complex, hazardous envlronmenLs. laclllLaLors can conslder Lhe followlng acLlons as sLraLegles for
reduclng Lhe barrlers LhaL mlscommunlcaLlon can presenL and for uslng conversaLlon Lo leverage whaL ls
worklng well.
! Pold workshops on Lhe Ladder of lnference. locus on llsLenlng, quesLlonlng, and problem
solvlng. lnLroduce lL Lo Leams, commlLLees, and all levels of managemenL.
! CreaLe Llme and space for conversaLlons Lo lmprove all aspecL of Lhe work. Make safeLy an
lmporLanL Loplc.
! LvaluaLe exlsLlng sLrucLures such as safeLy Leams and commlLLees. ls Lhere Llme alloLLed for
sensemaklng or has Lhe conversaLlon become roLe.
! Where are Lhe real conversaLlons Laklng place? Can Lhey be leveraged?
! Look for opporLunlLles Lo address people's frusLraLlons. Where ls Lhere confuslon abouL
prlorlLles, amblgulLy?

Welck (2009) also offers seven prlnclples of sensemaklng.
MF C#$%(?,)("-2 "0 !"#$%&'()* (- 6,-,B(-B /,0&)* !:%):4&
1he purpose of research ls Lo seek a wlder perspecLlve from whlch Lo undersLand complex problems
ln a way LhaL allows new soluLlons Lo emerge. 1hus, Lhe researcher conLemplaLes noL only whaL has gone
wrong, buL also where Lhlngs have apparenLly gone well Lo Lry Lo dlscover any underlylng prlnclples LhaL
mlghL exlsL Lo explaln success or fallure. lL ls hoped LhaL Lhrough undersLandlng Lhese prlnclples oLhers wlll
be able Lo lnfluence llke effecLs.
1hls arLlcle has been argulng LhaL Lhe maln lmpllcaLlon of complexlLy and lLs relaLed Lheorles on Lhe
role of relaLlonshlps ln organlzaLlonal performance ls Lhe way lL refocuses aLLenLlon away from managemenL
conLrolllng whaL organlzaLlonal members should be dolng Lo learnlng from whaL Lhey are already and have
always been dolng. lf Lhere ls a recommendaLlon for leadershlp, lL ls Lo pay more aLLenLlon Lo how
managemenL ls relaLlng and managlng lLs relaLlonshlps. 1he generaLlon of producLlve conversaLlon should be
consldered as one of Lhe foundaLlons of lnLervenLlon efforLs.
2010 8osa AnLonla Carrlllo, MSCu 4/3/12 14
lollowlng Lhls recommendaLlon may be dlfflculL. 8ulldlng relaLlonshlps ls generally vlewed ln Lhe
sphere of emoLlons and feellngs whlle buslness culLure values loglc, Lechnologlcal flxes, and measuremenL.
Powever, complexlLy Lheory presenLs evldence LhaL Lhere ls loglc aL work LhaL ls far dlfferenL from cause and
effecL. Small acLlons can produce large unlnLended resulLs (good and bad). 1hese lnLeracLlons Lake place
consLanLly and Lhe only way Lo lnfluence Lhem ls Lo be lnvolved ln Lhe sensemaklng process before, durlng or
afLer Lhe work ls compleLed. lL ls a never-endlng process because sensemaklng evolves wlLh every new facLor
or condlLlon LhaL appears. 1hls conversaLlon ls Lhe acL of relaLlonshlp bulldlng. 1hus, when organlzaLlonal
members engage ln meanlngful conversaLlons, everyLhlng changes.
1he skllls necessary for reaplng Lhe beneflLs of complexlLy dynamlcs and guldlng Lhem Lo some exLenL
ls Lhe capaclLy for self reflecLlon, acknowledglng one's conLrlbuLlon Lo exlsLlng condlLlons, sklll ln faclllLaLlng
consLrucLlve sensemaklng conversaLlons, and Lhe ablllLy Lo capLure and feedback Lhe knowledge and
lnformaLlon surfaclng ln conversaLlons. erhaps Lhe greaLesL value of complexlLy Lheory ls Lo quesLlon
assumpLlons of how Lhe world works so LhaL managers and safeLy professlonals can come up wlLh new, more
successful ways Lo solve complex problems.
Are any of Lhe Lools and lnLervenLlons descrlbed here brand new? 1hey mlghL be Lo a young
professlonal. WhaL ls new, are Lhe underlylng assumpLlons abouL how organlzaLlons work, and how Lhlngs
geL done. LssenLlally, lL's good-bye conLrol and command. 1he ldea LhaL managers can conLrol and predlcL
ouLcomes brlngs wlLh lL a seL of aLLlLudes LhaL close down Lhe cruclal communlcaLlon LhaL can alerL one Lo an
unexpecLed or unseen danger or opporLunlLy. Whlle, movlng from conLrol Lo LrusL unleashes sLarLllngly hlgh
levels of producLlvlLy and creaLlvlLy.
Managlng polarlLy, consclous faclllLaLlon of sensemaklng, harnesslng pracLlcal drlfL requlres a
LransformaLlon ln one's behavlor and way of Lhlnklng. Llvlng ln amblgulLy and helplng oLhers manage lL ls an
exerclse ln courage. llrsL, Lhe leader connecLs wlLh people. WlLhouL Lhls connecLlon, a leader cannoL creaLe
Lhe LrusL and credlblllLy Lo galn followershlp. 1hls LrusL ls galned by communlcaLlng Lhe messages, l respecL
you," ?ou are valued." CrganlzaLlons cannoL expecL managers Lo develop Lhese compeLencles wlLhouL
lnvesLlng ln Lhelr educaLlon on a conLlnuous basls. nor can Lhey expecL managers Lo faclllLaLe Lhls ampllfled
level of communlcaLlon wlLhouL Lhe proper resources (Llme and personnel). LducaLlon and engagemenL are
Lhe mosL powerful Lools an organlzaLlon has Lo lnsLlLuLlonallze sensemaklng as a consLrucLlve pracLlce Lo
bulld safeLy awareness. 1o do Lhls, fronL llne leaders need Lhe compleLe supporL of mlddle managemenL who
ln Lurn needs Lhe supporL of senlor leadershlp. WlLhouL organlzaLlonal supporL, Lhe lndlvldual leader can sLlll
make a dlfference wlLhln hls/her sphere of lnfluence. Powever, when complexlLy managemenL prlnclples
become a parL of Lhe way leaders run an enLlre organlzaLlon, Lhe poLenLlal for greaLness and an accldenL free
workplace ls exponenLlal.

R(;%("B4,$<*

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