GIHRE White Book

8/16/2019 GIHRE White Book

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The Better the Team, the Safer the World

Golden Rules of Group Interactionin High Risk Environments:Evidence based suggestions forimproving performance

J. Bryan Sexton (ed.)

Consulting editors

Gudela Grote, ZurichWerner Naef, AucklandOliver Straeter, BruxellesRobert L. Helmreich, Austin, Texas

Gottlieb Daimler and Karl Benz FoundationSwiss Re Centre for Global Dialogue


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The Better the Team, the Safer the World

Golden Rules of Group Interactionin High Risk Environments:Evidence based suggestions forimproving performance

Gottlieb Daimler and Karl Benz FoundationSwiss Re Centre for Global Dialogue

Ladenburg and Rüschlikon, 2004

Swiss ReCentre for Global Dialogue


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Introductory Letter

Gottlieb Daimler and KarlBenz Foundation

The “Golden Rules” in this handbook onGroup Interaction in High Risk Environmentsare the fruit of five years of research in thefields of aviation, medicine and nuclear power.Whilst it is often difficult, or even impossible,to transfer scientific findings direct to everydaysituations, the recommendations set out here

are immediately relevant to employee safetytraining. They can be applied to virtually anyscenario in which teams are required to dealwith challenging or dangerous situations.In our highly technological world, this addsto the team’s own safety, thereby enhancingpublic security as well.

Sponsored by the Gottlieb Daimlerand Karl Benz Foundation, the LadenburgCollegium on “Group Interaction in HighRisk Environments” brought togetherlinguists, psycholinguists, psychologists andspecialists from the fields of aviation, surgery,intensive care and nuclear reactor safety towork on a joint project initiated in 1999.Led by Prof. Rainer Dietrich, HumboldtUniversity in Berlin, they investigated howteams operating in the above areas shouldwork together to deal with crisis situations

to best effect. The participants came fromEurope and the USA.

The Foundation wishes to thank Prof.Rainer Dietrich and all members of theCollegium for their fascinating work and theimportant results it has yielded. Special thanksare due to Dr. Bryan Sexton, who played a vitalpart in preparing this handbook.

The research results could not have been

obtained without the participation and

sponsorship of numerous companies andinstitutions to whom the Foundation is alsoextremely grateful: Computer Simulation andTraining Center in Berlin Schönefeld and itsdirector, Raymund Neuhold, the LufthansaCity Line, the Training Center of the formerSwissair Group, Zurich, the UniversityHospitals of the Humboldt University Berlin,Charité and Klinikum Buch, The Universityof Texas at Austin, the Gundremmingen

Nuclear Power Plant, the University of TexasCenter of Excellence for Patient Safety Researchand Practice and the Director, Eric J. Thomas,MD, the Department of Anesthesiology andCritical Care Medicine at Johns HopkinsUniversity, The Johns Hopkins Quality andSafety Working Group, the UniversityHospital Zurich Department of Anesthesiology,and the Gesellschaft für Anlagen – undReaktorsicherheit mbH (GRS).

Finally, we would like to thank Swiss Re –and its deputy CEO, Rudolf Kellenberger,in particular – for its keen interest in joiningforces with the Foundation to organize theclosing conference in Rüschlikon at the SwissRe Centre for Global Dialogue.

Ladenburg, April 2004

The Board of the Gottlieb Daimlerand Karl Benz Foundation:Prof. Dr. Dr. h.c. mult. Gisbert Freiherrzu Putlitz

Dr.-Ing. Diethard Schade


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Introductory Letter

Swiss Re

At Swiss Re it gives us both a sense of pleasure and commitment to participatein the presentation of the key researchfindings of “Group Interaction in HighRisk Environments”.

Pleasure, because of the involvement of the Swiss Re Centre for Global Dialogue inhosting the final conference of this important

5 year research project. And commitment,because as a global leader in capital andrisk management we must observe thedevelopment of risks in our communities,economy and environment and foster abroader awareness of potential hazards.

For us it is therefore important that theseconcrete research findings on group interactionare relevant far beyond the situations in whichthey were observed. And that this White Book,now allows us to communicate these hard-won insights to our clients and the broaderinsurance community.

In high risk situations the quality of human interaction is critical to the minimizingof human error. To err is indeed human. But asour societies continue to create more complextechnological environments, we must enhanceour interaction and dialogue skills to ensure

that small mistakes do not spiral into majorsystems failures.

Only with this consistent application andtraining of safety related approaches will weavoid or reduce the damage and injury causedthrough poor or negligible behavior.

And progress in the on-going task Swiss Rehas set itself, of supporting the active preventionof hazards and their ensuing harm, thereby

contributing to the creation of a safer world.

Rudolf Kellenberger

Deputy Chief Executive Officer, Swiss Re


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Contents

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Introduction

Section 1Recommendations to Enhance Predictability (Clarify the“what ifs” to improve the predictability of the situation)

1: Ask early for the task later (Inquire early – ask questions earlyin the life of the team)

2: Reduce the need to repeat with a daily goals sheet (Increase

transparency in multi-disciplinary team environments usingdaily goals)

3: Lead in a pinch, cede in a cinch (Encourage leadership behavior inunstructured situations but not in standardized / routine situations)

4: Effective leaders delegate so that they can regulate (During highworkload, the leading team member should manage the situationwhile others manage the technical task)

5: Just say “we / let’s” (use language to foster team perspective)

6: Talk about problems (High performers devote more timeto “problemsolving” communications)

7: For juniors, better to be blatant than to imply (Be explicitin communications if you are inexperienced)

8: Adjust coordination (implicit vs. explicit) as a function

of workload and standardization

9: Make heedful interacting a routine practice

10: Understand the role of standardization in effective teamfunctioning as it relates to policies and procedures (rules)

11: Prepare for the worst – Use briefings to plan for contingencies


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Section 2

Recommendations to Improve Communication(Be attentive to the quantity, style and complexityof verbalization)

12: Maintain an environment of open communication and stay calmduring high workload situations

13: Encourage the new person – Use positive feedback whenan inexperienced team member has to carry out a task

14: Give a verbal nod – While listening, it is important to provideverbal indication of comprehension and reaction

15: Speak simply – use small words, articulate simple thoughts,and ask simple questions

16: Generally speaking, verbalizing is good and more verbalizingis better

17: In multi–lingual settings, high workload communicationis more effective in one’s native language

18: When a non-speaking task must be carried out while verbalizing,keep that task as free from language as possible

19: Use standardized phraseology – especially when speaker andlistener are physically separated

20: RNs talk more like MDs (i.e., concisely) and MDs listen morelike RNs (i.e., attentively)

21: Get better results by taking group interaction aspects of riskassessment into consideration

Summary

Contributors


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Introduction:Golden Rules of Group Interactionin High Risk Environments:Evidence based suggestionsfor improving performance


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Introduction

Lessons learned from theinterdisciplinary investigators

Who we are and why we aremaking recommendationsThe recommendations presented here weredesigned to improve the performance of peoplewho must work together with others in highrisk environments. They were compiled by

a team of interdisciplinary researchers andindustry subject matter experts as part ofa project titled ‘Group Interaction in HighRisk Environments (GIHRE)’. With fundingand support from the Gottlieb Daimler – andKarl Benz-Foundation, GIHRE investigatedand analyzed the behavior of professionalgroups working in such environments.Three distinct settings were investigated:the commercial aviation cockpit, the clinicalareas in modern hospitals (with emphasison intensive care units and operating rooms),and the control room of nuclear power plants.GIHRE investigators were interdisciplinaryand international in origin, bringing a varietyof methodological and conceptual approachesto bear on the study of teams at work in safety-critical settings. The research team as a wholewas comprised of experts from the three

sample-settings (aviation, medicine, nuclearpower plant technology) as well as experts incognitive psychology, experimental psychology,social psychology, psycholinguistics, andlinguistics. The dual goals of GIHRE wereto increase understanding of interactions inthese environments and to develop practicalsuggestions for enhancing performance insuch settings.

Premise for recommendationsWhat follows is not a panacea for what ailsteams at work in safety-critical settings, asit is neither systematic nor a comprehensiveset of recommendations. In fact, we did notset out to create any one of these rules inparticular – rather, through the course ofour work together, we discovered trends inthe data and found results that lent themselvesto providing general suggestions for industry

practitioners. This resulted in a collectionof our “rules of thumb” as a set of evidencebased suggestions from an inter-disciplinaryresearch group tackling the complexitiesof understanding and improving humanperformance when the stakes are high. It isimportant to note that these suggestions stemfrom experimental studies, field observations,correlational studies, and the analyses of qualitative data from 5 years of interdisciplinaryinvestigation into these topics.

AcknowledgementsThe Gottlieb Daimler and Karl BenzFoundation financially supported thedeliberations of the GIHRE group andthe production of these recommendations.However, it would not have been realizedwithout the generous cooperation of a variety

of institutions, amongst which the ComputerSimulation and Training Center in BerlinSchönefeld and its director Raymund Neuhold,the Lufthansa City Line, the Training Centerof the Swiss Air Group, Zürich, the UniversityHospitals of the Humboldt-University Charité,Zürich, and Buch, The University of Texasat Austin, the Gundremmingen NuclearPower Plant, the University of Texas Center

of Excellence for Patient Safety Research and


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Introduction

Practice (and the Director, Eric J.Thomas, MD, MPH), The Department of Anesthesiology and Critical Care Medicineat Johns Hopkins University, The JohnsHopkins Quality and Safety WorkingGroup, and the University Hospital ZurichDepartment of Anesthesiology. We especiallywish to acknowledge the cooperation of thepilots, power plant operators, nurses andpatients who volunteered for many hours

in the data collection sessions.

Introduction to the focus oninteractions in high risk environmentsIn teams at work under conditions of threatand high workload, interpersonal interactionsare strained and the potential for incorrector incomplete information transfer betweenindividuals increases as task demands increase.As a member of a team, one must “thinkout loud,” in order to share perspectiveand establish a common understandingof the nature the situation. This commonunderstanding amongst team members isoften referred to as a shared mental model of events. In aviation, for example, heedful interactionsamong pilots are used to remainattentive and conscientious of one another andto maintain awareness of how their work fits

into the overall objectives of safe and efficientflight. Effective communication is criticalfor cockpit crewmembers to share a mentalmodel of events relevant to these flightobjectives. This is not to say that effectivecommunication can overcome inadequatetechnical flying proficiency, but rather thecontrary: that good “stick & rudder” skillscan not overcome the adverse effects of poor

communication. Ruffell Smith’s (1979)

landmark full-mission simulator studyshowed that crew performance was moreclosely associated with the quality of crewcommunication than with the technicalproficiency of individual pilots or increasedphysiological arousal as a result of higherenvironmental workload. No differenceswere found between the severity of the errorsmade by effective and ineffective crews, rather,it was the ability of the effective crews to

communicate that kept their errors fromdeveloping into undesirable outcomes.Such findings are not unique to aviation,as similar results have emerged in othersafety-critical systems such as surgicaloperating rooms and medical intensivecare units, where the quality of providerinteractions is associated with patientoutcomes (Young, Charns, Daley, Forbes,Henderson, & Khuri, 1997; Knaus, Draper,Wagner, & Zimmerman, 1986).

The format of the recommendationsIn the pages that follow are 21recommendations from GIHRE to improveteam performance. Each recommendationincludes the justification for its creation,consequence of following the recommendation,the actors to whom the recommendation

applies, and references. The language usedhere is informal, with the intent of reachinga broader audience. The recommendationsgenerally fell into one of two categories –enhancing predictability or improvingcommunication. Recommendations thatenhance predictability help to set expectations,plan for future contingencies, share a commonmental model of the situation, reduce

ambiguities and reduce stress levels within


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Introduction

team members. Recommendations forimproving communication generally deal withthe content, size, structure, and coordinationof utterances.

ReferencesKnaus, W.A., Draper, E.A., Wagner, D.P.& Zimmerman, J.E. (1986). “An evaluationof outcome from intensive care in majormedical centers.” Annals of Internal Medicine

104(3): 410–418.

Ruffell Smith, H. P. (1979). A simulator studyof the interaction of pilot workload with errors,vigilance, an decisions.(NASA TechnicalMemorandum 78482). Moffett Field, CA:NASA–Ames Research Center.

Young, G.J., Charns, M.P., Daley, J., Forbes,M.G., Henderson, W. & Khuri, S.F. (1997).“Best practices for managing surgical services:the role of coordination.” Health Care

Management Review22: 72–81.

Rainer Dietrich with Traci Michelle Childress(eds.), Group Interaction in High RiskEnvironments, Ashgate Publishing:Aldershot, England. (In press, appearancescheduled for 2004)

Referred to as “GIHRE-book”


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Section 1:Enhance Predictability

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Section 1: Enhance Predictability

Recommendation 1: Ask early for the task later(Inquire early – ask questionsearly in the life of the team)

ReasonPrior research has demonstrated that sharedmental models and predictable patternsof behavior are imperative to laying the

groundwork for subsequent effective teamworkand communication. Ginnett (1987) hasshown that initial crewmember interactionsset the tone for the team and can predictsubsequent team performance. In fact, aGIHRE simulator study of 4 flights foundthat the relationships between language useand flight outcome measures were strongestbetween language use in the first flight, andsubsequent (second, third and fourth flights)performance and error measures.

ConsequenceSexton & Helmreich (2002) found that thenumber of questions asked in the initial flightwas positively correlated to performance insubsequent flights. In other words, crewswho asked a lot of questions initially (therebyclarifying uncertainties) had higher subsequent

performance than crews who did not askquestions. Asking questions was not correlatedto performance within the same flight, rather,initial inquiry was correlated to subsequentperformance. It appears to be the case thatclarifying uncertainties is best accomplished in aninitial flight (thereby improving predictability)rather than waiting to ask questions later.

ActorsTraining specialists and team members

ReferencesGinnett, R. C. (1987). First Encounters of theClose Kind: The Formation Process of Airline Flight Crews.Yale University: Doctoral dissertation.

Sexton, J.B. & Helmreich, R.L. (2002).“Using language in the cockpit: Relationships

with workload and performance.” In R.Dietrich (Ed) “Communication in High RiskEnvironments.” Linguistische Berichte Sonderheft 12: 57–74. Buske Verlag: Hamburg.

GIHRE-book chapter: Threat


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Recommendation 2:Reduce the need to repeatwith a daily goals sheet(Increase transparencyin multi-disciplinary teamenvironments using daily goals)

ReasonIn multi-disciplinary settings, cross-

disciplinary awareness and understanding isoften difficult to maintain due to the highworkload and complex systems. For example,in the modern critical care unit, there are staff physicians, residents, respiratory therapists,clinical pharmacists, technicians, bedsidenurses, spiritual care, and others who mustcoordinate and carry out the plan of care foreach patient, daily. Transparency of actionsbetween and within disciplines can requirenumerous discussions with colleagues fromother disciplines who are in various physicallocations with differing degrees of accessibility. To contact individuals separatelyto communicate the plan of care requiresredundancy and leads to lost time.

Consequence Setting public daily goals (see next page) for a given

patient using a goals sheet attached to a clipboard at each bedside can enhance the transparencyof actions and intentions between and withindisciplines for “this patient, in this bed, today.”The daily goals sheet must be signed by theattending physician and kept public to increasetransparency and decrease redundancy 1 and losttime. Daily goals sheets also maintain a publicrecord of thought processes and decision

making by the multi-disciplinary team.

In the implementation study of daily goalsin the critical care unit, less than 10% of residents and nurses understood the goalsof care for the day.

After implementation of the daily goalssheet, over 95% of nurses and residentsunderstood the goals of care for the day, andfurthermore of clinical relevance is that theaverage length of stay decreased by 50%.In a separate demonstration of daily goals

in critical care, Terri Simmonds (personalcommunication, June 2003) found thatpreparation for decision-making was improvedin critical care units after the implementationof daily goals forms (see list “Daily goals).

ActorsCritical care unit directors, training specialistsand team members

ReferencesPronovost P, Berenholtz S, Dorman T,Lipsett PA, Simmonds T, Haraden C. (2003)“Improving communication in the ICU usingdaily goals.” Journal of Critical Care. Jun;18 (2): 71–5.

Sexton, J.B. (2003). “What is the climatelike now: SAQ data from time 2.” Session

Presented at the Institute for HealthcareImprovement Impact Conference, Boston,Massachusetts, June 19, 2003.

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1 Redundancy, which is common in aviation and often lackingin medicine is not a culprit here. We acknowledge thatredundancy is important for safety in high risk environments,however, repeating the same story separately to each multi-disciplinary constituent is not an effective use of time in the

high workload environment of modern medicine.


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-Initial as goals are reviewed-

What needs to be done for patientto be discharged from the ICU?What is patient’s greatest safety riskand how can we decrease risk?Pain Mgt / Sedation(held to follow commands?)Cardiac / volume status; Net goal formidnight; Beta blockade; review EKGsPulmonary/Ventilator (HOB, PUD,DVT, weaning, glucose control); OOBID, Cultures, Drug levels

GI / Nutrition / Bowel regimen

Medications: PO, renal fx, discontinue

Tests / Procedures today

Review scheduled labs

AM labs and CXR?; critical pathway

Consultations

Is the primary service up-to-date?

Has the family been updated?Have social issues been addressed?Can catheters/tubes be removed?

Is this patient receiving DVT/PUD prophylaxis?Anticipated LOS > 3 days: fluconazolePO, LT care plans. LOS > 4 days: epoAre there events or deviations thatneed to be reported? ICUSRS?

Daily Goals. Room Number Date / /

0700-1500 1500-2300 2300-0700

For Weinberg only: ICU status IMC status

Fellow/Attg Initials: _________ © The Johns Hopkins University


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Recommendation 3:Lead in a pinch, cedein a cinch (Encourageleadership behavior inunstructured situationsbut not in standardized

/ routine situations)

Reason

In routine situations, which are typicallyhighly regulated by organizations, peopledo not need a leader to tell them what to do.Depersonalized leadership in the form of standardized operating procedures (SOPs)can substitute for personal leadership.GIHRE Coordination found a negativecorrelation between performance of cockpitcrews and leadership behavior in highlystandardized situations. The more leadershipbehavior was observed the worse theperformance. This notion was also supportedby interview material. Anesthesia teammembers expressed that they like clearleadership behavior if the situation iscomplex, unknown, or high workload, butthey dislike it during routine situations.

Consequence

A leader who does not have to actively engage atechnical task during standard / routine situationsis afforded the opportunity to observe and learn

about the team while SOPs accomplish the role of guiding behavior.This opportunity to observethe team at work and gain a better assessmentof the team and each individual membercan be critical during less routine or higherworkload situations, when the ability to

predict and understand the behaviors of others

is essential. Routine situations also affordteam members the chance to workautonomously and experience their ownefficacy, which are both very importantmotivating factors.

ActorsTeam leaders and training specialists

References

Kerr, S. and Jermier, J. M. (1978).“Substitutes for Leadership: Their Meaningand Measurement.” Organizational Behavior

and Human performance22: 375–403

Zaccaro, S., J., A. Rittman, L., et al. (2001).“Team leadership.” The Leadership Quarterly12: 451–483.

GIHRE-book chapter: Leadership& coordination


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Phase 1 highstandardization



P e r c e n t a g e

Teams performing well Teams performing poorly

# 3 Figure. Percent of leadership behavior present in teams performing well vs. poorly during

flight phases with varying standardization levels.


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Recommendation 4:During high workload,the leading team membershould manage the situationwhile others manage thetechnical task

ReasonThis is a variation of Recommendation 3.

In 1994, The National Transportation SafetyBoard found a disproportionately highpercentage of aviation accidents (over 80%)occur when the captain is the pilot flying.These captains are overloaded with multi-tasking as they try to accomplish both thepilot flying and pilot in command dutiessimultaneously. GIHRE Threat demonstratedthat in complex/high workload situations,the best performing crews have the firstofficer as pilot flying, which fosters anenvironment in which the captain can assessand manage the situation while the firstofficer manages the aircraft handling duties.The data suggest that if a crew encountersa high workload situation when the captain

is pilot flying, it is best to cede control of theaircraft to the first officer. Similarly, in highworkload NPP operations, the shift supervisor

is responsible for decision-making andmaintaining the “big picture,” while technicaltasks are carried out by other operators.

ConsequenceLeaders who fail to delegate during highworkload situations risk overload due to thesimultaneous burden of managing the task,the team and the environment. In aviation,

medicine, or NPP, the notion of leadership

during high workload can be applied toa variety of situations in which it is criticalto have the leader keep the big picture inmind and remain relatively free from thetechnical task at hand. In other words, leadersin high workload situations should delegate taskwork to reduce multitasking and improve decision-making and vigilance.

Actors

Regulators, policy makers, training specialistsand team members

ReferencesNational Transportation Safety Board (1994).

Safety Study: A review of involved-involved, major accidents of U.S. air carriers, 1978 through1990. PB94–917001, NTSB/SS–94/01.Washington, DC: Author.

GIHRE-book chapter: Leadership& coordination; NPP


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Related excerpt to # 4: There is somehistorical precedent for this notion as well,from the annals of submarine battles duringWorld War II.

‘One of Commander Mush Morton’sunorthodox ideas, later adopted to somedegree in the submarine force, was to havehis executive officer make the periscopeobservations, while he, the skipper, ran the

approach and coordinated the informationfrom sound, periscope, plotting parties, andtorpedo director. Thus, so ran his argument,the skipper is not apt to be distracted bywatching the target’s maneuvers, and canmake better decisions.’– Submarine Commander Edward L. Beach,United States Navy (1946)


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Recommendation 5:Just say “we / let’s”(use language to fosterteam perspective)

ReasonThe National Transportation Safety Board(1994) found that 73% of commercialaviation accidents occur on the first day

of a crew pairing (relative to the base ratesof 7–30% of flights that are an initial crewpairing) and that 44% of accidents occur onthe first flight of a crew pairing (base rates3–10%). These results have been interpretedas an indication of crewmember familiaritywith one another, such that the morecrewmembers fly together, the better theywill be able to anticipate and respond toeach others’ actions. Foushee, Lauber, Beatge,& Acomb (1986) found conceptually similarresults, such that fatigued crewmemberswho had previous experience flying togetheroutperformed well-rested crews who hadno previous experience flying together.Crewmember familiarity may manifest itselfas a function of crewmembers referring tothemselves in the first person plural. The firstperson plural (e.g., we, our, us) is frequently

expressed in the form of “let’s,” e.g., “ let’sgetout the landing checklist.”

ConsequenceA GIHRE simulator study demonstrateda pattern of increasing use of the first personplural across the four simulated flights(see # 5 Figure), which may have indicatedan increasing sense of familiarity among the

crewmembers or an increase in their team

perspective. Moreover, the GIHRE study alsofound that the use of first person plural waspositively correlated to performance, andnegatively correlated to the number of errors.In the past, the use of the first person pluralhas been interpreted as a collective or teamperspective by the speaker (McGreevy, 1996;White and Lippitt, 1960). Recent researchby Driskell, Salas, & Johnston (1999) foundthat team perspective was a significant

positive predictor of team performance.In sum, teamwork is about “we” not “me,” and encouraging familiarity enhances predictability,which is associated with better team performance.

ActorsTeam members and training specialists

ReferencesDriskell, J. E., Salas, E., & Johnston, J.(1999). “Does stress lead to a loss of teamperspective?” Group Dynamics: Theory, Research,

and Practice, 3 (4): 291–302.

McGreevy, M. W. (1996). Reporter Concerns in300 Mode-Related Incident Reports from NASA’s

Aviation Safety Reporting System.(NASATechnical Memorandum 110413). MoffettField, CA: NASA-Ames Research Center.

National Transportation Safety Board (1994). Safety Study: A review of involved-involved, major accidents of U.S. air carriers, 1978 through 1990.PB94-917001, NTSB/SS-94/01. Washington,DC: Author.



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First person plural(e.g., we, our, us):

A (routine) B (abnormal) C (routine) D (abnormal)

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Flight Segment

# 5 Figure. First Person Plural by Flight Segment


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Recommendation 6:Talk about problems (Highperformers devote moretime to “problem solving”communications)

ReasonRecently, the commercial aviation industryhas embraced the notion of assessing pilot

ability to manage threats and errors in orderto achieve safe and efficient flight. Problemsolving communications are the verbalmanifestation of threat and error management(Sexton & Helmreich, 2002). Problem solvingcommunications (see # 6 Figure A) are theverbalizations of corrective actions (Predmore,1991), and are a prime example of whatdistinguishes effective performance fromineffective performance. For instance, captainswith outstanding performance used problemsolving utterances seven to eight times moreoften than their poor performing counterparts.Furthermore, there were no differences in howoutstanding captains used problem solvingutterances as a function of workload.Outstanding captains consistently devoteda third of their utterances to problem solving,whether it was a routine or an abnormal flight.

In fact, the more frequent use of problemsolving utterances was not unique tooutstanding captains – outstanding firstofficers and second officers used problemssolving utterances in approximately onethird of their communications overall(see # 6 Figure B opposite).

Consequence

Investigations of aircrew transcripts indicated

that there is a substantial difference in theuse of problem solving utterances betweenoutstanding pilots and both average and poorpilots. The best pilots simply talk more abouttheir task-related problems and how to solvethem – the essence of threat and errormanagement. The bottom line is teams that verbalize problems and their management are safer.

Actors

Training specialists and team members

ReferencesPredmore, S. C. (1991). “Microcoding of communications in accident investigation:Crew coordination in United 811 and United232.” In: R. S. Jenson (Ed.): Proceedings of the

Sixth International Symposium of Aviation Psychology: 350–355. Columbus, Ohio:The Ohio State University.

Sexton, J.B. & Helmreich, R.L. (2002).“Using language in the cockpit: Relationshipswith workload and performance.” In R.Dietrich (Ed) “Communication in High RiskEnvironments.” Linguistische Berichte Sonderheft 12: 57–74. Buske Verlag: Hamburg.



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“Problem Solving”communications by position and performance

Problem Solving Utterances:

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CaptainFirst OfficerSecond Officer

LowPerformance

MidPerformance

HighPerformance

# 6 Figure A. Examples of Problem Solving

# 6 Figure B. Problem Solving by Position and Performance

“I don’t want to dump any fuel, in case we might need it.”

“I want to see if that gear works early enough, though.”

“So you might want to determine what they want us to do if weloose ATC communications.”

“Okay, ask him, uh, what kind of weather trends he has got going

there, if it is going down.”


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Recommendation 7:For juniors, better to beblatant than to imply (Beexplicit in communicationsif you are inexperienced)

ReasonExplicit coordination strategies are consciousand overt, whereas implicit coordination can

be defined as coordination through anticipationof the needs of others. Using implicitcoordination, a team member anticipatesthe need for information and assistance fromother team members and proactively providesinformation without waiting for a request.Implicit coordination is a powerful andeconomical method of coordination as italleviates the need to explicitly solicitinformation or help. However, implicitcoordination can be used only in teams havinga common understanding – shared mentalmodel – of the situation. As teams in NPPoperations are fixed shift teams and notconstantly changing – as is the case in aviation– experience from NPP shows the positive sideof implicit communication. The caveat isthat providing information according tothe anticipated need is only useful if the

anticipation is correct. GIHRE found thatimplicit coordination by the first officerin the cockpit (a relatively inexperiencedteam member), correlates negatively withperformance. The more implicit coordinationwas used by the first officer, the worse was theperformance. It is useful to prepare for highworkload situations with a phase of explicitcoordination whereby a shared model can

be acquired in order to reduce subsequent

communication and coordination “costs” duringhigh workload (Orasanu and Fischer, 1992).

ConsequenceIf the inexperienced person uses explicitcoordination he/she can avoid sharinginformation that the other person doesnot need. In this case there are fewermisunderstandings and irritations bysuperfluous or inappropriate information.


ReferencesSerfaty, D., Entin, E., & Johnston, J. (1998).“Team Coordination Training.” In: Cannon-Bowers, J. and Salas E. (Eds.): Making

Decision under Stress.Washington, AmericanPsychological Association : 221–245.

Orasanu, J., and Fischer, U. (1992). “Teamcognition in the cockpit: Linguistic controlof shared problem solving.” Proceedings of theFourteenth Annual Conference of the Cognitive

Science Society,189–194. Hillsdale, NJ: Erlbaum.

Matieu, J., Heffner, T., et al. (2000).“The Influence of Shared Mental Models

on Team Process and Performance.” Journalof Applied Psychology85(No. 2): 273–283.



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Proportion of implicit coordination - first officer

P e r c e n t a g e

Teams performing well Teams performing poorly

# 7 Figure: Percent of implicit coordination by first officer in teams performing well vs. poorly.


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Recommendation 8: Adjust coordination (implicitvs. explicit) as a function ofworkload and standardization

ReasonGIHRE Coordination demonstrated the useof adaptive coordination behavior by bothanesthesia and cockpit teams. These teams

used relatively little explicit coordination(overt communication) during highlystandardized work phases, instead they reliedon centralized coordination in the form of rules. Conversely, during less structured workphases with low standardization, leadershipbehavior, which also can be seen as crucialto coordination success, was dominant duringless structured work phases, with lowstandardization. Implicit coordination andheedful interrelating were mainly used inhigh task load phases, and were economicalways to coordinate, but can be used only byteams who have a common picture – sharedmental model – of the situation.

ConsequencesAdaptive coordination behavior is asignificant contribution to effective teamwork

as emergency situations arise. Teams workingin a routine phase (with little coordinationeffort) need to notice and adapt if somethingthreatening happens. There is a clear need forexplicit coordination, which helps to builda common mental model of the situationand to work out a strategy to cope with it.If the team has a plan for contingencies (e.g.,briefing), it doesn’t necessarily need to spend

any more resources with time-consuming

explicit coordination (overt communication)but rather coordinate implicitly, keepingthe remaining resources free for theproblem solution.


ReferencesKozlowski, S. (1998). “Training and

Developing Adaptive Teams: Theory,Principles, and Research.” In: Cannon-Bowers, J. and Salas E. (Eds.): Makingunder Stress.Washington, AmericanPsychological Association.

Serfaty, D., Entin, E., & Johnston, J. (1998).“Team Coordination Training.” In: Cannon-Bowers, J. and Salas E. (Eds.): Making



26



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Average duration (min.)Task loadStandardizationCommunication units (CU) overallCU standardized communicationCU explicitCU implicitCU leadershipCU Heedful interrelating

Flight phase

1Take-off

3LowHigh840

52%66%34%2%2%

2PreparationClean approach

10LowLow35149%81%19%14%18%

3 Approachand Landing3

HighHigh142928%60%40%3%19%

# 8 Table. Coordination patterns during different flight phases from GIHRE Coordination


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Recommendation 9:Make heedful interactinga routine practice

ReasonIn their study of aircraft carrier crews, Weickand Roberts (1993) observed a phenomenonthey referred to as heedful interrelating , andnoted that higher rates of heedful interacting

were associated with lower rates of errors.In essence, heedful interacting requiresdeliberate efforts to continually considerone’s own actions in relation to the goalsand actions of others. Weick and Robertsexplained that if heedful interacting is“visible, rewarded, modeled, discussed, andpreserved in vivid stories, there is a goodchance that newcomers will learn this styleof responding, will incorporate it into theirdefinition of who they are in the system andwill reaffirm and perhaps even augment thisstyle as they act (p. 367.)” Anesthesia teamsreported their perspective of this behavioras critical to successful team functioning,e.g., continuous monitoring (situationalawareness), thinking aloud, following theprocesses, taking the perspective of otherteam members, taking the perspective of

the decision maker, and looking ahead.

ConsequenceThe team coordinates its actions smoothlyand safely, because it anticipates highworkload situations and prepares itself forthem. Heedful interacting helps to preventindividual members from experiencingoverload, because their fellow team members

notice symptoms of overload in time and help

to share the load. Heedful interacting in highrisk environments enables teams to capitalize onthe redundancies of teams themselves (as opposedto individuals), by optimizing cognitive resources,knowledge, and experiences.


References

Artman, H. (2000): “Team situationassessment and information distribution.”In: Ergonomics, 43: 1111–1128.

Weick, K. E. and K. H. Roberts (1993).“Collective mind in organizations Heedfulinterrelating on flight decks.” Administrative

Science Quarterly38: 357–381.

GIHRE-book chapter: Leadership& coordination.

Grommes, P. & Grote, G. (2001).“Coordination in Action. Comparing twowork situations with high vs. low degreesof formalization.” In: Kühnlein, Newlandsand Rieser (Eds.) Proceedings of the Workshopon Coordination and Action at ESSLLI 01.

Paper 1. Helsinki, Finland.


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Considering and checking the state of others.“Are you ready?” “Do you have a question?”“Can you do it alone?” “Do you agree?”

Considering the future.“We will use autopilot as long as it functions normally.”“We are going to reposition the patient in the operating room,”

Considering external conditions.“We have to check the weather, particularly the wind.”“If the table is too high, lifting the patient will be difficult.”

# 9 Figure. Transcript examples of interactions categorized as heedful interacting


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Recommendation 10:Understand the role ofstandardization in effectiveteam functioning as it relates topolicies and procedures (rules)

ReasonOne of the most important functions of behavioral rules (standard operating procedures

or SOPs) is to increase the predictability of behavior and adherence to norms. In safety-critical settings, rules help to set parametersand expectations in coordinating the behaviorof individuals in teams, especially when teammembers do not know each other. Usingstructured interviews, GIHRE “Coordination”found that anesthesia teams find rulesparticularly helpful in extremely ambiguousemergency situations that are not standardized.However, rules can also be restrictive if theyare too rigid and concrete, as they can inhibitthe search for and discovery of solutions inunexpected situations. One example of thismight be the 1998 crash of SwissAir flight111, where an inflight fire led to a crashand the loss of all passengers. Accidentinvestigators found that the pilots, overloadedwith checklists and procedures, were unable

to locate and eliminate the source of the fireor to expedite plans for an emergency landing.

There are different kinds of rules:describing concrete actions – action rules;describing processes to fulfill a task – processrules; describing the goals to be achieved –goal rules. Action rules are used mostcommonly, however, process rules and goalrules provide for the possibility of more

innovative solutions because they are more

flexible. NPPs provide an example of thisflexibility. Operations in NPP are highlyregulated, but operators are often called uponto respond to situations or events that are notspecifically prescribed in a procedure (Dien,1998). Operators are required to balancetheir decisions between strict adherence toprocedures and checking the validity of theprocedures in a given context. They understandthat strict adherence to procedures does not

necessarily guarantee safety, and can even bedetrimental to safety if applied in the wrongcontext. Ideally, a procedure would allow fora corridor of freedom for possible actions of auser. Such procedures should state conditionsrequired for the application of proceduresand conditions to be maintained during thesituation (e.g., critical parameter of the systemor patient that needs to be maintained).Nuclear operations introduced “symptombased procedures” to cope with the trade-off between application of rules and freedom fordecision. Symptom based procedures are basedon critical parameters of the plant which haveto be maintained independently from thecause of the critical situation.

ConsequenceUsing the right amount and type of rules results

in a flexible system, where the actors have supportif they need it but they can remain creative if new

solutions are required.Also, too much relianceon rules and diffusion of responsibility isavoided with rules that keep people thinkingby not specifying actions in too much detail.

ActorsRule makers, safety specialists, training

specialists and team members


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ReferencesDien, Y. (1998). “Safety and application of procedures, or ‘how do ‘they’ have to useoperating procedures in nuclear powerplants?.” Safety Science29: 179–187.

Hale, A. R. and P. Swusste (1998). “Safetyrules: procedural freedom or actionconstraint?” Safety Science29: 163–177.

Grote, G. (1997). Autonomie und Kontrolle–Zur Gestaltung automatisierter und risikoreicher Systeme.Zürich, vdf Hochschulverlag.

GIHRE-book chapter: Structures; NPP


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Section 2: Improve Communication

Recommendation 11:Prepare for the worst:Use briefings to planfor contingencies

ReasonBriefings have been demonstrated as aneffective means by which leaders can planfor contingencies, establish norms, discuss

threats, and build the team all at the sametime. There are two critical components of briefings: technical and interpersonal. In thetechnical component, it is important for theleader (be it a captain, surgical attending orNPP shift manager) to cover the technicaldetails of what will take place, set expectationsand plan for contingencies. Regarding theinterpersonal component, which is often afunction of howthe technical component isarticulated, the leader must open channelsof communication, empower team membersto speak up and participate, and formallyestablish the team environment. In commercialaviation, it is not uncommon to hear a captaintell the crew “I only got 3 hours of sleep lastnight and am feeling off today, please keepand eye on me and don’t let me do anything

stupid .” The phrase “don’t let me do anything

stupid” goes a long way to engage teammembers in the process and empower themto participate 2. The delicate balancing actof the leader in a briefing is to displaycompetence while disavowing perfection.

ConsequenceIn technologically advanced and psychologicallycomplex environments such as the operating room,

intensive care unit, or cockpit – there is a clear and

present need for knowing the threats and possible

contingencies, establishing norms, and having a formal opportunity to build the team. In commercial aviation, we know that briefing content is a powerful predictor of subsequent performance(Ginnett, 1987; Sexton & Helmreich, 2000).GIHRE-Aviation has demonstrated that sub-optimal briefing is a leading deficiency of simulator crews that consistently perform poorly across three

simulation scenarios.High performing crews

displayed very good planning and contingencymanagement and showed good situationalawareness. In contrast poor performingcrews had inadequate planning andinsufficient situational awareness – theydid not evaluate their plans as requiredby the changing situation.

Contingency planning (part of thetechnical component of briefing) was apredominant behavior in crews that dealtsuccessfully with technical problems.In medicine, there is anecdotal evidencethat operating room briefings (approximately90 second discussion just prior to skin incision)are proving to be valuable. Operating roombriefings allow the multidisciplinary teamperforming a surgical procedure to createshared mental model of the situation, planfor contingencies, and open up channels

of communication between physicians andnurses, as well as between anesthesia andsurgery personnel. These operating roombriefings have been associated with reductionsin nurse turnover rates, reductions in perceivedworkload, and increases in nurse input (JamesDeFontes, MD – personal communicationApril 2003).


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ActorsSafety specialists, training specialists, medicalschool faculty and team members

ReferencesGIHRE-book chapter: Structures

GIHRE-book chapter: Aviation

Ginnett, R. C. (1987). First Encounters

of the Close Kind: The Formation Processof Airline Flight Crews. Yale University:Doctoral dissertation.

Sexton, J.B., & Helmreich, R.L. (2000).Analyzing cockpit communications:The links between language, performance,error, and workload.” Human Performancein Extreme Environments5 (1), 63–68.

2 It is interesting to note that after several hundred observationsin surgical operating rooms and critical care units we have never

heard the phrase "don’t let me do anything stupid," in medicine.


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Recommendation 12:Maintain an environmentof open communicationand stay calm during highworkload situations

ReasonCreating the appropriate environment inwhich teamwork will be effective is essential

to increasing predictability and reducingstress during high workload. Findings fromGIHRE “Threat” demonstrate the importanceof establishing and maintaining anenvironment of open communication.Such “Team Environment” behaviors weredocumented in non-jeopardy observationsof over 3,000 flights and were among themost clearly observable and frequentlyobserved behaviors across all phases of flight(GIHRE book chapter – Threat). TeamEnvironment was defined as: “Environmentfor open communications established and/or maintained (e.g., crew members listenwith patience, do not interrupt or ‘talk over,’do not rush through the briefings, make eyecontact as appropriate.)” In high workloadsituations, the relationship between TeamEnvironment and other variables such as

overall performance, technical proficiency,and indices of error increases. For teamsperforming under stress, it is important tostay calm collectively and to develop copingstrategies. Coping and remaining calm doesnot equate to silence on the part of a teammember. Rather, GIHRE data indicate thateffective strategies include more verbalization,verbalizations that relate to problem solving,

speaking in the first person plural, and

adjusting the extent of explicit and implicitcoordination to the experience level andfamiliarity of team members. GIHRE“Coordination” found that anesthesia teamsreport that they cannot work efficiently inan atmosphere where the team leader projectsoverload, as it brings additional pressure intothe situation and blocks task fulfillment.Professional NPP operators also pointed outthe performance implications of maintaining

an environment of open communicationin high workload as it relates to sharingmental models and finding appropriatesolutions to problems.

Consequence Setting the stage for subsequent teamwork is anexercise in delayed gratification, but it is critical toopen and supportive interactions, and it is anexcellent buffer against the deleterious effects of highworkload. In the case of the team leader, it iscritical to remain calm as workload increases,because the leader’s behavior is a model forteam members and it creates a team normthat helps other team members cope withstress. As workload increases, there are threatsof: attention becoming too narrowly focused(tunnel vision), interactions being reduced,and information being shared less. Such

conditions are harmful to effective decision-making and can be offset by a leader whoprojects calm and a previously establishedenvironment where input is valued.


References

Tannenbaum, S., I., K. A. Smith-Jentsch,


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et al. (1998). “Training team leaders tofacilitate team learning and performance.” In:Cannon-Bowers, J. and Salas E. (Eds.): Making


Zaccaro, S., J., A. Rittman, L., et al. (2001).“Team leadership.” The Leadership Quarterly12: 451–483.



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Recommendation 13:Encourage the new person –Use positive feedback when aninexperienced team memberhas to carry out a task

ReasonIf the first officer has the active role (pilotflying) in the cockpit, the captain should

verbalize positive feedback if performancemerits. High performance in cockpit crewswas associated with high rates of positivefeedback from the captain to the first officer(GIHRE book chapter: Leadership andcoordination). Captains, by verbalizing theapproval of first officer actions throughpositive feedback, are able to demonstratetheir situational awareness, encourage theirfellow team member, and voice their approvalof the current course of action. In this sense,positive reinforcement helps to reduceambiguity about a shared mental modelof the situation as well as to reduce thestress level of the first officer. In addition,structured interview data from anesthesiateams led GIHRE Coordination to believethat there are many missed opportunitiesfor positive feedback during and after task

completion (e.g., spinal anesthesia or aresuscitation) to junior team membersin medicine.

ConsequencePositive feedback during a difficult taskcan help to build confidence in juniorteam members, reduce stress, and to clarifyambiguities. Feedback after the task is

completed, sometimes in the form of a

debriefing, is generally a very useful tool tobuild a common understanding of a situationin a formal procedure that lends itself topedagogical opportunities. GIHRE has founda strong interest in and desire for feedbackin the teams under investigation, with themajority of individuals reporting that theydo not receive appropriate feedback (GIHREbook chapter: Threat).


ReferencesSwezey, R., W. and E. Salas (1992).“Guidelines for use in team-trainingdevelopment.” Teams: Their training and

performance. R. Swezey, W. and E. Salas.Norwood, NJ, Ablex : 219–245.

Kozlowski, S. (1998). “Training andDeveloping Adaptive Teams: Theory,Principles, and Research.” In: Cannon-Bowers, J. and Salas E. (Eds.): Making

Decision under Stress.Washington, AmericanPsychological Association.




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Recommendation 14:Give a verbal nod – Whilelistening, it is important toprovide verbal indication ofcomprehension and reaction

ReasonFailure to provide an active response to aspeaker results in ambiguity that clouds the

shared mental model of the situation, andfrustrates the efforts of the speaker tocommunicate. As an example, a GIHREsimulator study (GIHRE book chapter:Behavioral Markers), found that a first officerwho was busy with radio communicationafter an engine failure in flight, missed thecaptain’s command to run the single enginechecklist. When the captain repeated thecommand three minutes later, the aircraft wasbelow 500 feet and descending – which is toolate to run the checklist. Verbal indications of comprehension that close the communicationloop can prevent such situations. Similarly,the NPP simulation study showed that a lackof verbal reaction does not necessarily meanthat the addressee has failed to receive theinformation from the speaker, but the lackof the verbal reaction causes repeated and

unnecessary verbalizations that increase riskdue to delay and lack of feedback.

ConsequenceClosing the communication loop witha verbalization as simple as an “uh-huh,”or an “mmhmm,” or a “…right,” providesa minimal form of feedback to the speaker.In situations where new information is being

introduced, the listener can go a step further

than the verbal nod by repeating a piece ofthe original message to indicate receipt of thatmessage. It is important to either give explicitfeedback or to make it explicitly clear whenone cannot respond (thereby explicitly closingthe loop). If a verbal reaction from the listeneris not forthcoming, the speaker shouldexplicitly request an indication of comprehension. In fact, GIHRE found thateffective teams show proportionally more

speech acts of type “make sure” and ingeneral more indications of ensuring thatcommunication went well, like “confirm”,“acknowledge” and “reaffirm” speech acts.The GIHRE “Microstructure of Cognition”group found that as workload increases,latency of response increases, and thatreceptiveness worsens under conditionsof increased workload. Verbal nods decreasethe ambiguity.


GIHRE-book chapter: Behavioral markers

GIHRE-book chapter: Language andcommunicative behavior

GIHRE-book chapter: Microstructureof cognition

GIHRE-book chapter: NPP PO


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# 14 Figure. Giving the “verbal nod.”


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Recommendation 15:Speak simply – usesmall words, articulatesimple thoughts, andask simple questions

ReasonUsing a simulator study and computer-basedtext analyses, GIHRE Threat found that the

use of large words (defined as six letters ormore) was negativelyrelated to performancevariables and communication skill, while beingpositively related to rates of error (Sexton andHelmreich, 2000). One interpretation is thatthe ability to communicate effectively includesthe ability to apply a simple and succinctvocabulary. Conceivably, those individualswho expend the cognitive resources necessaryto speak more elaborately (using biggerwords) do so at the expense of decreasedsituational awareness or team perspective.Related to this notion of speaking simplyare the results from experimental laboratorytechniques used by the GIHRE LanguageProcessing. They found that as workingmemory was taxed, the risk of an erroneousmessage increased, but that the results differedas a function of the degree of complexity in

the question being asked. Yes/no-questionsclearly differed from wh-questions (wh-questions begin with “what”, “when” etc.)in semantic structure. In broad terms yes/no-questions are verification tasks. In theirsimplest form they allow the speaker to requesta judgment on the truth of a proposition.Therefore the answer is either “yes” for trueor “no” for false propositions. In contrast, wh-

questions take an incomplete proposition and

intend an addressee to utter the elementthat makes a complete and true proposition.

ConsequenceResults from GIHRE investigators indicatethat frequent use of simple words (fewerthan 6 letters long) was associated with saferoutcomes. Note that using simple wordsis not the same thing as verbalizing less – infact there is a substantial negative relationship

between average word length and averagenumber of words spoken (i.e., talking more isassociated with using shorter words). Dietrich,Grommes and Neuper (in press) found thatapproximately 90% of all questions froma set of aviation simulator transcripts wereyes/no and wh-questions. Yes/no-questionswere used more frequently (70 %) thanwh-questions (30 %). Under conditionsof increased memory load, answering wh-questions was more prone to error and also tooklonger than answering yes/no questions.

ActorsTeam members, and training specialists

ReferencesSexton, J.B., & Helmreich, R.L. (2000).“Analyzing cockpit communications:

The links between language, performance,error, and workload.” Human Performancein Extreme Environments5 (1), 63–68.

GIHRE-book chapter: Language processing



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# 15 Figure. Keeping individual utterances short and sweet

“veni, vidi, vici”: I came, I saw, I conquered. (Thelaconic dispatch in which Julius Ceasar announcedto the Senate his victory over Pharnaces.)


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Recommendation 16:Generally speaking,verbalizing is good andmore verbalizing is better

ReasonA fundamental aspect of communicationis quantity, or how much is verbalized by thespeaker. What makes for a safer communication

style, brevity or verbosity? Recommendation15 suggests that speaking simply is good forperformance, but this is not the same thingas “not speaking very much at all.” High ratesof verbalization foster familiarity among teammembers and reduce ambiguities surroundingwhat individual team members are thinkingor feeling. Simply stated, verbalization duringgroup interaction is essential for establishingand maintaining the shared mental model of the situation in safety-critical settings. Priorresearch has found (Foushee and Manos, 1981)that better performing crews communicatedmore overall. This relationship betweenperformance and quantity of verbalcommunication was also documented in aBell Aeronautics Company study in 1962(Siskel and Flexman) and replicated inFoushee, Lauber et al. (1986).

ConsequencesIn studies of language use in the cockpitby GIHRE Threat, a metric as simple asthe number of words spokenwas associated withhigher performance and lower rates of error.In other words, when it comes to cockpitcommunication generally – it appears tobe the case that more is better. Pilots spoke

more during high workload flights than

during routine workload flights, and captainsspoke more than first officers and secondofficers (see # 16 figure). Individualscommunicate more during periods of highworkload due to the inherent multi-taskinginvolved in flight deck management. On arelated note, verbalization is quite observableas far as behaviors go, and an ongoingobservational study of teamwork and errorduring neonatal resuscitations is demonstrating

that the behavior “information sharing” wasobservable in 100% of 132 resuscitations asof this writing (Eric Thomas, MD – Personalcommunication November, 2003).


ReferencesFoushee, H. C., Lauber, J. K. Beatge, M. M.,& Acomb, D. B. (1986): Crew Performance as

a function of exposure to high density, short-haul duty cycles. (NASA Technical Memorandum88322). Moffet Field, CA: NASA-AmesResearch Center.

Foushee, H. C. & Manos, K. L. (1981):“Information transfer within the cockpit:Problems in intracockpit communications.”

In: C. E. Billings & E. S. Cheaney (Eds.):Information transfer problems in the aviation

system(NASA TP–1875). Moffet Field,CA: NASA-Ames Research Center.

Siskel, M. & Flexman, R. (1962): Study of effectiveness of a flight simulator for training complex

aircrew skills.Bell Aeronautics Company.



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N u m

b e r o f w o r

d s s p o

k e n

0

200

400

600

800

1000

1200

1400

1600

A (routine) B (abnormal) C (routine) D (abnormal)

CaptainFirst OfficerSecond Officer

Number of words spoken by cockpit position and segment:

# 16 Figure. Number of Words Spoken by Cockpit Position and Flight Segment


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Recommendation 17:In multi-lingual settings,high workload communicationis more effective in one’snative language

ReasonEnglish is internationally recognized asthe industry-standard language of aviation.

While this is convenient for a handful of countries, it often places pilots from nationsthat are not native speakers of English ata significant disadvantage. For example,some airlines require 100% of cockpitcommunication to take place in English,such that pilots can be reprimanded forspeaking in their native language. Moreover,mixed nationality cockpits are becomingmuch more commonplace, in which someof the crew is a native speaker of Englishwhile others are not. Crews with membershaving varying degrees of English proficiencyare challenged with problems of translation,interpretation of content, and most importantlywith regard to GIHRE, failure to stay on thesame page and maintain comprehension ofthe shared mental model of the situation.There is evidence from incidents and accidents

whereby misunderstandings of verbal messagesby second language speakers have led tounfortunate outcomes (Cushing, 1994).Unpublished data from a study conductedby University of Texas researchers with aEuropean carrier indicated that crews whoreverted to their native language were betterperformers in a taxing simulation scenario.As findings from GIHRE “Microstructure”

support, even in highly proficient second

language speakers 3, comprehension is slowedand more error prone relative to nativespeakers. This is indicated by a delay ofan electronic signal from the brain that ismeasured using a continuous EEG (this signalis called an N400 component ). Researchers agreethat the N400 component means the brainis at work processing language. As shown in# 17 Figure, language processing was delayedby 200 milliseconds in second-language

speakers relative to native speakers, throughoutall experimental conditions. The situationmay not be as significant in early acquisitionbilingual speakers.

ConsequenceThere is a general delay of messagecomprehension when the listener is not anative speaker of the language of the message.This scenario, whereby the listener has adifferent native language from the speakeris usually the case in multinational teamsand for pilots from non-English speakingcountries. In high workload situations, pilotsshould make decisions and problem solve intheir native language whenever it is feasibleto do so (i.e., as long as the rest of the crewunderstands the native language).

ActorsRegulators, Team members, andtraining specialists

ReferencesCushing (1994). Fatal words: Communicationclashes and aircraft crashes.Chicago.

GIHRE-book chapter: Microstructure


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Hohlfeld, A., Mierke, K., Sommer, W.(in press). “Is Word Perception in a Second-Language more Vulnerable than in one’sNative Language? Evidence from BrainPotentials in a Dual Task Setting.” Brain

and Language.

3 The situation may be less severe in early acquisitionbilingual speakers.

N 4 0 0 l a t e n c y a t

P z

( m s )

compatible

1000

800

600

400100 400 700

L1L2

# 17 Figure. Delay of N400 component in second-language speakers (L2) relative to nativespeakers (L1) in a language perception task that occurred at the same time as (SOA) the

performance of an additional task.


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Recommendation 18:When a non-speaking taskmust be carried out whileverbalizing, keep that task asfree from language as possible

ReasonOverlapping and simultaneous tasks impedethe perception and understanding of verbal

messages. The impediment is markedly morepronounced when the additional task alsoinvolves language processing such as reading.Language-related processes draw from limitedresources that have to be shared whensimultaneous language tasks compete.It is reasonable to assume that a similarsituation holds true when informationhas to be translated into internal language-like representations.

ConsequencesIn a situation where verbal communicationis essential, additional tasks should be keptas free as possible from language-like processessuch as reading written messages or digitaldisplays. Instead, information should bepresented using self-explanatory symbolsor signs such as arrows, which point into

the direction of action or analogue insteadof digital displays to avoid language-relatedtranslation processes. As shown in # 18Figure, there is less interference betweenlanguage perception and the visual processingof a “non-linguistic” square than withprocessing of the “linguistic” letter.As described in Rule 16 semantic processingduring language perception is indicated

by the N400 component, a brain signal

provided by a continuous EEG.


ReferencesSpence, C. & Read, L. (2003). “Speechshadowing while driving: On the difficultyof splitting attentions between eye and ear.”

Psychological Science14 (3), 251– 256.

GIHRE-book chapter: Microstructure

Hohlfeld, A., Sangals, J., Sommer, W. (acc.,pending rev.). “Effects of Additional Tasks onLanguage Perception: An ERP investigation.”

Journal of Experimental Psychology: Learning, Memory, and Cognition.


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N 4 0 0 l a t e n c y

( m s )

900

700

500

300 100 700

lettersquare

# 18 Figure. While speaking, reaction times were slower for processing letters as compared

to processing shapes (measured in milliseconds).

SOA (ms )


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Recommendation 19:Use standardizedphraseology – especiallywhen speaker and listenerare physically separated

ReasonIn the Nuclear Power Plant operationalhandbooks it is typically stated that

communication should be audible and clear,so that all shift members can understand it.Furthermore it is stated that the speakershould confirm whether the message wasunderstood (e.g., by requesting feedback fromthe shift supervisor). Though not systematic,some plants have worked out communicationguidelines for words that should be avoidedduring communication, as they had previouslyled to misunderstandings. Nevertheless,there is no regulation in place for a standardphraseology. Standard phraseologies arecommon in aviation, submarine operations,and air traffic management.

ConsequenceStandardized terms can prevent communicationbreakdowns under conditions of increasedtask load in communication settings where

speakers and listeners are physically separated.Conversely, informal speaking can containmultiple ambiguous linguistic meanings thatcan lead to misunderstandings. Linguisticmeanings that are used more commonly areprocessed more rapidly and with fewer errors.The use of standardized phraseology iscorrelated with the risk of producingincoherent verbal contributions under

conditions of non-standard high task load.

Experimental evidence demonstrates thatstandardized question formats can speedup answer preparation in the listener.Standardization of communication compensatesfor the vulnerability of the message beingincompletely delivered through redundancyand disambiguation. In short, standardizationof the phraseology for information exchangeis a safety measure that minimizes the riskof message deterioration. Communication

at a distance is hindered by split attention,local distance between speakers, lack ofvisual contact, electroacoustic devices of communication, and a decrease in familiaritybetween communicators.


GIHRE-book chapter: NPP POGIHRE-book chapter: Language Processing


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# 19 Figure. Using Standard Phraseology


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Recommendation 20:RNs talk more like MDs (i.e.,concisely) and MDs listenmore like RNs (i.e., attentively)

ReasonPhysicians are trained to expect andcommunicate in headlinesor clinical bulletpoints of patient condition, whereas nurses

are trained to expect and communicate the storyof the patient. Due to the inherenttraining and status differences betweenphysicians and nurses the opportunitiesfor information transfer to breakdown arecommon. A compromise of communicationstyles is needed to improve the delivery andreceipt of information in these hierarchicalinteractions. Nurses need to convey essentialinformation for physicians more conciselythan the traditional “here is the story of thispatient,” while physicians need to elicit andlisten more carefully to the concerns andunique perspectives of the nurses becausephysicians often fail to notice when breakdownsin information transfer occur (see # 20 Figure).Evidence for these potentially conflictingstyles of information transfer betweenphysicians and nurses was found in the

questionnaire data from the GIHRE bookchapter: Threat. Specifically, items regardingcollaboration between physicians and nursesand breakdowns in communication providedevidence, as did open ended comments madeduring focus groups and through thequestionnaires. Also, recent evidence fromthe UT Center of Excellence for Patient SafetyResearch and Practice indicates that nurses

who report better communication with

physicians report lower rates of nurse turnover.

ConsequencesNurses are trained to give the narrative ofthe patient in a detailed and contextualizedaccount. When communicating to physicians(who must then make decisions about thedelivery of care), there are oftentimes manyopportunities for the physicians to tune outparts of the story, as they wait for the more

clinically relevant input upon which to basetheir decision-making. The result is thatclinically relevant information can be lostin the exchange, due to the delivery style of nurses and the listening style of the physicians.

ActorsTeam members, faculty members of medicaland nursing schools, and training specialists

ReferencesThomas EJ, Sexton JB, Helmreich RL.(2003). “Discrepant attitudes about teamworkamong critical care nurses and physicians.”Critical Care Medicine31 (3)

Sexton JB, Thomas EJ, Helmreich RL.(2000). “Error, stress, and teamworkin medicine and aviation: cross sectional

surveys.” BMJ 320: 745–749



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# 20 Figure. Discrepant perceptions of teamwork between MDs and RNs

0

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90

100

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f r e s p o n

d e n

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d e q u a

t e t e a m w o r

k

54%

90%

RN rates ICU Physician ICU Physician rates RN

ICU Physicians andICU Collaboration


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Recommendation 21:Get better results bytaking group interactionaspects of risk assessmentinto consideration

ReasonInsurance is a challenge in industry segmentswith low-probability, high-consequence losses

(nuclear, aviation, hospital and refineries).As premium rates are in the per mill range,it takes many years for an insurer to breakeven after having had to pay out a significantloss. In this highly volatile environment, riskselection – meaning the insurance of onlygood operators – seems to be the only wayfor insurers to survive.

In the past, risk assessments focusedon whether the technical equipment usedto handle safety-critical work processes wasappropriate. Back then, the buzzword was“HPR” plants (Highly Protected Risk) withextensive technical loss prevention. However(with the exception of 11 September), thelargest man-made loss ever was an explosionin a petrochemical plant in Texas, whichcould not be attributed to a failure in technicalloss prevention, but to “soft” factors such

as procedures and staff’s adherence to them.As a result, the risk assessment focus wasextended to encompass organizational elementsof formal safety management procedures.While both perspectives are still very usefulwhen distinguishing between good and badrisk management, there are a growing numberof companies which, despite enforcing quitehigh standards from both aspects, still remain

at risk. It was found that these companies can

be best identified by evaluating how they dealwith the daily safety aspect on the shop floorand by examining the management beliefsand norms that are shared by those responsiblefor safety. We analyzed some large losses inthe refining/petrochemical segment using

James Reason’s “layers of protection” (LOP,or the “Swiss cheese”) model. This approachconcentrates on the way latent failurescombine along a trajectory of opportunity,

permitting an incident to occur. We foundthe following distribution of the 67 latentfailures identified: 33% hardware; 37%software (procedures, training etc); and 30%“liveware” (group interaction, human error,change management, etc).

ConsequencesFocusing on technical and formalorganizational procedures helps us identifysome of the companies at risk. At the sametime, global standards for both technicalequipment and process safety managementprovide a more uniform framework for riskmanagement, although they may disguisesafety problems in plants where beliefs andnorms dictate the day-to-day behavior of theworkforce. Such companies must be identifiedif we are to gain a sufficiently thorough

understanding of plant operations to enableus to make an adequate assessment of risk.

ActorsRisk managers, risk surveyors,inspectors, operators.

ReferencesMüller, Stefan & Grote, Gudela. Safety culture

– a reflection of risk awareness.Swiss Re, 1998.


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Reason, James. Human Error . Cambridge,Cambridge Univ. Press, 1990.Grote, G & Zirngast, E.G. Change Management

Audit Program, Change MAP. Proceeding of CCPS Conference, Toronto, 2001.


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The greater the insight,the sharper the foresightThe insurers’ perspective oninteractive safety management

Swiss Re has a long tradition in analyzingloss histories to develop risk assessmentinstruments. Experience has shown that man-made catastrophes often have less to do with

mechanical breakdown, material fatigue oreven with fate than they do with humaninteraction errors, inadequate management of complex systems and safety culture in general.When Swiss Re’s Risk Engineering startedits “Human Error Project” in the early 90’s –in collaboration with hospital physicians,work psychologists and airline pilots –it acknowledged that to always blame theindividual operator for causing fatal accidentswas too simple an equation. Thus, the teamsought to identify the systematic risks inherentto the interaction of hard, soft and live-ware.Today, the knowledge which this researchyielded is regularly applied in the riskassessment and underwriting of highlyexposed industrial risks.

Developing an instrument to enable aclear assessment of complex risks nevertheless

remains an ongoing task. It is an illusionto think that the interaction among man,machine and process can be reduced to asimple linear construct which is easilyunderstood by all active participants.

To assess the reliability of interactingsystems, one must know how those sub-systems and components communicate withone another within the parameters of their

unique communication culture – a complex

task in its own right.The culture of a corporation is hardly

rigid; changes – both visible and invisible –do occur. Yet changes in safety culture oftengo undetected. The corporation’s safetybehavior can differ from one location toanother, depending on economic aspects,management attitudes and the unique setof corporate values. That behavior is acomplicated interactive system, one influenced

by soft factors and governed by unwrittenrules to a large extent. The safety culture ofa global corporation is not likely to have a riskand safety index that allows a relevant rating;too many aspects and immeasurable soft factorswould have to be taken into account to geta sound “aerial view”. Further, fluctuationsin the economic cycle influence the safetyculture of a corporation and the safetyconsciousness and behavior of its managementand staff, both positively and negatively.Whereas cost restrictions in a recession phasemay have a negative impact on safety-relatedinvestments, the self-expressive, autonomy-seeking approach prevalent in boom phasesmay lead to overconfident behavior in whichsafety parameters are neglected. Or, in timeswhen production plants are running atuneconomically low capacity, savings in

manpower and maintenance costs may causecritical situations regarding safety in high-hazard process plants, while in boomingmarkets, operators may be tempted to tryand extract more from a power system thanit was originally designed to put out. Finally,while there are always those who knowaboutpotentially unsafe acts or situations, theymay or may not do anything to counter them.

There are, of course, many reasons why this

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is so. When explicitly part of a corporateculture, as in the “no risk – no fun” approach,those reasons are easier to detect than if theyare part of the unwritten rules of the game.

Such hidden shortcomings usually goundetected in routine safety audits, in whichindividual processes are analyzed and individualoperators are questioned. Particularly in caseswhen unsafe activity becomes establishedas a deliberate standard procedure, neither

management nor auditors are likely to hearthe whole story. So the safety auditor shouldroutinely ask himself two questions: first, doesthe safety culture allow for unsafe shortcutsand second, what might motivate – or offerbenefit to – somebody who were to take them?

Answers can only be found if adherenceto operating and communication processes iscontrollable, and will only prove useful if theydivulge information about the corporate codeof conduct and safety rules in everyday practice.

Given large corporate clients’ enormousrisk potentials and their huge demands forcover, insuring them has almost become abusiness in its own right. Risk pricing is notonly based on statistics and loss history, butlargely on potential losses, thus – as insurerscall it – on the risk quality – understood tobe a measure for the loss propensity within

a given safety culture .For this reason, insurers of high risk

operations are well advised to closely examinecorporate safety culture and its underlyingsafety management systems. The changefrom the linear cause-consequence relationshipmodel to the complex interactive way of approaching risks has induced a paradigmshift in risk analysis – branching out from

the physical process plant to the corporation

and to its specific environment. As regardsresponsibility for saf operation, the lineextends from the individual operator to themanagement processes and on to culturalfactors. The traditional quantitative riskassessment approach – based on figures fromthe past – is enhanced with a qualitativecomponent of analysis to offer a future-oriented indication of risk.

To conclude, the better we foresee the

potentially weak link in a safe operation, themore effectively its failure can be prevented.And from the insurer’s point of view, thebalance saved from each large loss avoidedwill more than cover the cost of risk andsafety research.

Marcel BürgeHead of Risk Engineering and Training,

Swiss Re


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Contributors

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Contributors

GIHRE Contributors

Traci Michelle ChildressTraci Michelle Childress studied HumanStudies and Creative Writing at WarrenWilson College. She works as a freelancewriter, translator and editor. She has donegraduate work at the SALT Center for Fielddocumentary studies in Portland, MA in theUSA. She participated in the organization

of the U.S “Asheville Poetry Festival, 1997”as a writer and editor of related texts andpublications that accompanied the festival,and she has also done oral history workon Activism in Appalachia in the USA.This work is a part of the oral history archivesat the University of North Carolina at ChapelHill. Currently, she continues work as afreelance editor and writer while also workingas co-coordinator for the GIHRE project atthe Humboldt University in Berlin, Germany.She is also pursuing a Master’s in Health Artsand Sciences at Goddard College.

Rainer DietrichRainer Dietrich, born 1944, is currentlyProfessor of Psycholinguistics at theHumboldt-University of Berlin. His mainresearch interests are in the field of language

production and second language acquisition.He heads the psycholinguistic experimentallab of the faculty of Arts II and has conducteda number of experiments on languageprocessing. The specific objective of the latteris the structure of the production system andthe time course of utterance production underconditions of workload.

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