When Problem-Solving Undermines Safety

In Part One, we discussed a 2001 Harvard University study of hospital nursing teams that showed how the prevalence of first-order problem-solving (“fixing and forgetting”) rather than second-order problem-solving (“fixing and reporting”) prevents organizations from learning from their own operational issues. This fixing and forgetting approach leads, in turn, to the perpetuation of hazards by depriving organizations of the opportunity to devise effective solutions and/or safety barriers.¹

Part One also analyzed a serious incident in 2022 involving a Cessna Citation 525 and an Embraer 170 that experienced a loss of separation due to erroneous altitude indications provided by the Cessna’s faulty pitot-static system — an occurrence that illustrates how inadequate problem-solving can preclude risk management and result in dangerous events. After discussing the factors that commonly lead to the adoption of first-order problem-solving, we will now examine how each of them can be mitigated.²

Insufficient Time

Just as the nurses in the study seldom had enough time to report problems or investigate them more thoroughly, aviation professionals may face similar constraints on matters that pertain to flight safety such as airworthiness concerns or operational hurdles.  Tackling the issue of limited time for in-depth analysis and reporting requires rethinking the job descriptions of pilots, flight attendants, dispatchers, mechanics, and other sharp-end staff. 

Nancy Leveson, professor of aeronautics and astronautics at the Massachusetts Institute of Technology, asserts that a safe system is defined as one in which safety is considered from the incipient stage of the design process. She argues that implementing layers of protection once a system is fully developed not only increases its cost and complexity but also creates the need for tradeoffs.³ In a remarkably similar way, job descriptions that are exclusively based on production objectives result in dangerous compromises when new safety responsibilities suddenly begin to be demanded from staff in addition to their existing tasks. The patchwork of goals inevitably created by these afterthoughts culminates in the widespread adoption by frontline workers of first-order problem-solving to the detriment of second-order problem-solving.

Safety must be embedded in people’s roles from the beginning. It should be reflected in their goals and activities and in how their performance is measured, assessed, and appraised. Moreover, just as employees need resources such as training, supplies, and tools to work productively, they also require adequate support to practice effective risk management. The Harvard study illustrates this point by noting, “If workers are to engage in root cause removal, this activity must be an explicit part of their job and enough time allocated for improvement efforts.” For example, managers and supervisors can operationalize this, in part, by asking: How many safety/quality reports do we want to receive each month? How many reports would each employee have to file? How long does it usually take an employee to write a report? Once these factors are understood, they should be incorporated into the time required for tasks such as turnarounds, flight planning, or completing work orders.

The same rationale could have been applied by the Citation jet operator in regard to technical logbook entries. According to the operator’s maintenance controller, the company’s pilots were under “enormous pressure” and would not always heed his recommendations to report faults in the logbook. Additionally, the controller himself was encouraged to not keep the aircraft in maintenance for too long.

For problem-solving, a different strategy is necessary. Given the difficulty in estimating the time required to troubleshoot an issue, the focus should be on enhancing people’s capacity to interrupt their tasks and examine a challenging situation more carefully. Key questions include: How can work be stopped safely for second-order problem-solving to take place, and what resources are required for this? How can workload be redistributed to allow one or more individuals to engage in a deeper analysis of a problem while ensuring operational continuity? 

Poor Teamwork, Low Degree of Psychological Safety

For psychologists Rhona Flin, Paul O’Connor, and Margaret Crichton, authors of the book Safety at the Sharp End: A Guide to Non-Technical Skills, successful teamwork is established when members of a group support each other and exchange critical information. By sharing workload, fostering openness, practicing active listening, and adopting an open and supportive style of communication, teams can achieve exceptional levels of performance.⁴

For teamwork to thrive across multiple levels of an organization, a high degree of psychological safety must exist. Author Amy Edmondson explains that this can be observed when people “feel comfortable sharing concerns and mistakes without fear of embarrassment or retribution. They are confident that they can speak up and won’t be humiliated, ignored, or blamed. They know they can ask questions when they are unsure about something.”⁵

Unfortunately, such an atmosphere did not seem to exist at the French business aviation operation. The BEA report noted that the operator’s crews were “afraid of sanctions,” and some freelance captains were believed to be hesitant to report faults that would ground the aircraft, fearing that they would be denied further flights.

Edmondson says that building a psychologically safe atmosphere entails three steps: setting the stage, inviting participation, and responding productively.

Setting the Stage: By adequately framing the work that people do, leaders can motivate individuals to speak up and engage in safety-critical discussions. Amid the complexity of air operations, human error and uncertainty are commonplace. Rather than denying these phenomena and blaming individuals who fail to avoid mistakes or are unsuccessful in dealing with ambiguous situations, good leaders accept human fallibility and uncertainty as inherent characteristics of work. By doing this, they help the organization focus on learning from failures and strive to continuously reinforce the “need for voice.”

Inviting Participation: This step involves leaders expressing “situational humility” by acknowledging their own errors and shortcomings, as well as the unknowns surrounding a given task. They also go beyond their “open door” policies and actively seek feedback and input by asking their teams powerful, open-ended questions that are thought-provoking and stimulate curiosity. Lastly, they invite people to participate by creating opportunities for them to do so. Regular group meetings, company forums, safety stand-downs, debriefing sessions, and reporting systems are prime examples of how aviation and other high-risk industries can encourage open communication and generate an atmosphere conducive to employee participation.

Responding Productively: In behavioral science, whether a certain human behavior will repeat itself is determined by the consequences that follow it. That is, negative or unpleasant outcomes cause a behavior to be less likely to recur, as individuals naturally tend to avoid situations or circumstances that threaten their sense of safety — be it physical or psychological. Similarly, how someone is treated after voicing concerns or questions will determine whether they will feel encouraged to speak up again. Thus, it is vital for leaders (as well as other team members) to always respond to constructive and/or well-intended comments in an appreciative, non-judgmental manner — regardless of whether they agree with the other person’s point of view.

Problem-Solving Fulfilment

The 2001 Harvard study demonstrated how, under certain circumstances, high motivation can actually be counterproductive to safety. Remedying this does not mean constraining individuals’ sense of fulfilment, but ensuring that they seek and find motivation in the right set of behaviors. Therefore, it is crucial to understand people’s definitions of purpose, mastery, and autonomy and ensure they align with the organization’s safety values.

A widely acknowledged source of motivation for human beings is their perceived capacity to exert some control over the system of which they are a part and to change things for the better. For nurses and aviation professionals, local, short-term, immediate fixes are often the result of past, frustrated attempts to implement — or at least initiate — system-wide, long-lasting improvements. This underscores the importance of establishing safety management systems or quality management systems that efficiently and effectively translate reported issues into tangible fixes.

Motivation toward adopting second-order problem-solving can also be bolstered by inviting the individuals who experience the issues into the process of devising solutions. Psychologist Scott E. Geller explains that empowering and supporting frontline staff to actively participate in the generation of risk-mitigating measures fosters a sense of ownership and purpose that is essential for a robust safety culture.⁶

Autonomy Without Support

Giving people autonomy to address system issues without providing them with the required support to do so is as harmful to safety as fixing and forgetting practices. As noted in the Harvard study, simply adding more responsibilities to nurses’ roles without offering them additional time and resources to deal with those responsibilities resulted in no improvements in problem-solving. In general, increases in accountability that are not also matched by a corresponding rise in support only generate more anxiety — which ultimately leads to demotivation, loss of job satisfaction, and lower performance. It is therefore paramount that greater demands be accompanied by an increased capacity to manage them.

While granting individuals more autonomy in their work may appear to be a sound management strategy for boosting motivation and creating self-sustaining teams, this approach can have unintended consequences in complex, high-risk systems such as aviation and healthcare. Leveson emphasizes that the intricate relationships between elements in these systems require the existence of multiple levels of oversight and control to ensure that no decision or action taken at any one of them culminates in unwanted events. The same thought is echoed by Professor Andrew Rae, from Griffith University’s Safety Science Innovation Lab in Queensland, Australia, who warns that frontline staff may possess local expertise regarding their tasks but usually lack the broader perspective that is required to identify hazards across multiple work groups and/or elements of the system.⁷ 

Therefore, any increase in autonomy must be carefully assessed in advance. Additionally, any individual or team made more autonomous must be given the necessary tools to be able to easily foresee the systemwide implications of their decisions and actions. This can be achieved by establishing effective communication channels with other teams and levels of the organization.

Temporal Discounting

Human beings tend to give more weight to immediate rewards than longer-term ones. When local fixes yield instant results, the importance of engaging in in-depth analyses and reporting usually wanes, and the execution of these tasks becomes contingent on convenience, meaning that they are only carried out when they are seen as opportune.

Alas, since temporal discounting is a deeply ingrained aspect of human behavior, it cannot be easily mitigated. The answer thus lies in creating attractive rewards for second-order problem-solving that are as timely and certain as the ones stemming from first-order problem-solving. For instance, some aviation operators are known to give instant financial compensation to individuals who submit safety reports. 

However, immediate rewards do not need to be monetary or material only. Behaviors such as seeking help to overcome a challenge or inviting others to analyze an uncertain or ambiguous situation, for example, can be excellent sources of instant rewards, as long as the people who show up to assist respond productively to those requests. Responses that promote psychological safety (those that demonstrate gratitude for, and commend a person’s decision to seek assistance or invite others to participate in a discussion) serve as positive reinforcement that will help curb a culture of fixing and forgetting. 

For psychologist James Reason, “[l]ocal fixes may lead to the concealment of system problems from managers and others with the power and duty to effect more lasting global improvements.” In today’s highly complex systems, monitoring how individuals overcome operational challenges is critical for safety. The normalization by frontline workers of recurring issues or situations in which “nothing bad happened” hinders organizational learning and initiates a dangerous drift toward a riskier state. Without enough time for second-order problem-solving, a high degree of psychological safety, adequate support and resources, and the right incentives, individuals are likely to adopt a “fix and forget” mentality.⁸

While the strategies to mitigate the several contributing factors to the prevalence of first-order problem-solving vary, all of them are rooted in the same goal: making it easy for people to do the right thing. Only through what behavioral science calls “access” — resources that facilitate the performance of a behavior — can we effectively ensure that the daily frontline responses to operational hurdles support effective risk management and generate the required organizational resilience to avert disasters.

Image: © rathke | iStockphoto

Lucca Carrasco Filippo is a flight safety specialist and a former commercial helicopter pilot. He holds a degree in aeronautical sciences and multiple qualifications in safety management systems, human factors and incident investigation.

Notes

1. Tucker, A.L.; Edmondson, A C.; Spear, S. (2002a). “When Problem Solving Prevents Organizational Learning.” Journal of Organizational Change Management Volume 15 (Issue 2): 122–137. 
2. BEA Bureau d’Enquêtes et d’Analyses (BEA). (2023). “Serious Incident Between the Cessna Citation 525 CJ Registered F-HGPG Operated by Valljet and the Embraer 170 Registered F-HBXG Operated by HOP! on 12 January 2022 RE Route South of Auxerre (Yonne). 
3. Leveson, N.G. “Engineering a Safer World: Systems Thinking Applied to Safety.” Cambridge, Massachusetts, U.S.: MIT Press, 2012.
4. Flin, R.; O’Connor, P. “Safety at the Sharp End: A Guide to Non-Technical Skills.” Boca Raton, Florida, U.S.: CRC Press, 2017.
5. Edmondson, A. C. “The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth.” Hoboken, New Jersey, U.S.: Wiley & Sons, Inc., 2019.
6. Geller, E. S. “The Psychology of Safety Handbook.” Boca Raton, Florida, U.S.: CRC Press, 2016.
7. Rae, A.; Provan, D. (n.d.). Ep.87 “What Exactly Is Systems Thinking? The Safety of Work.” https://safetyofwork.com/episodes/ep87-what-exactly-is-systems-thinking
8. Reason, J. “Managing the Risks of Organizational Accidents.” In Routledge eBooks (1st ed.). Ashgate Publishing Limited, 1997.