The breakdown of coordinated decision making in distributed systems

The effect of COVID-19 on self-reported safety incidents in aviation: An examination of the heterogeneous effects using causal machine learning

INTRODUCTION

Disruptions to aviation operations occur daily on a micro-level with negligible impacts beyond the inconvenience of rebooking and changing aircrew schedules. The unprecedented disruption in global aviation due to COVID-19 highlighted a need to evaluate emergent safety issues rapidly.

METHOD

This paper uses causal machine learning to examine the heterogeneous effects of COVID-19 on reported aircraft incursions/excursions. The analysis utilized self report data from NASA Aviation Safety Reporting System collected from 2018 to 2020. The report attributes include self identified group characteristics and expert categorization of factors and outcomes. The analysis identified attributes and subgroup characteristics that were most sensitive to COVID-19 in inducing incursions/excursions. The method included the generalized random forest and difference-in-difference techniques to explore causal effects.

RESULTS

The analysis indicates first officers are more prone to experiencing incursion/excursion events during the pandemic. In addition, events categorized with the human factors confusion, distraction, and the causal factor fatigue increased incursion/excursion events.

PRACTICAL APPLICATIONS

Understanding the attributes associated with the likelihood of incursion/excursion events provides policymakers and aviation organizations insights to improve prevention mechanisms for future pandemics or extended periods of reduced aviation operations.

Improving Ad Hoc Medical Team Performance with an Innovative "I START-END" Communication Tool

PURPOSE

To study the effect of a communication tool entitled: "I START-END" (I-Identify; S-Story; T-Task; A-Accomplish/Adjust; R-Resources; T-Timely Updates; E-Exit; N-Next; D-Document and Debrief) in simulated urgent scenarios in non-operating room settings (referred to as "Ad Hoc") with anesthesia residents. The "I START-END" tool was created by incorporating Crisis Resource Management (CRM) principles into a practical and user-friendly format.

METHODS

This was a mixed methods pre/post observational study with 47 anesthesia resident volunteers participating from July 2014 to June 2016. Each resident served as their own control, and participated in three simulated Ad Hoc scenarios. The first simulation served as a baseline. The second simulation occurred 1-2 weeks after I START-END training. The third simulation occurred 3-6 months later. Simulation performance was videotaped and reviewed by trained experts using technical skill checklists and Anesthesia Non-Technical Skills (ANTS) score. Residents filled out questionnaires, pre-simulation, 1-2 weeks after I START-END training and 3-6 months later. Concurrently, resident performance at actual Code Blue events was scored by trained observers using the Mayo High Performance Teamwork Scale.

RESULTS

80-90% of residents stated the tool provided an organized approach to Ad Hoc scenarios - specifically, information helpful to care of the patient was obtained more readily and better resource planning occurred as communication with the team improved. Residents stated they would continue to use the tool and apply it to other clinical settings. Resident video performance scores of technical skills showed significant improvement at the "late" session (3-6 months post exposure to the I START-END). ANTS scores were satisfactory and remained unchanged throughout. There was no difference between residents with and without I START-END training as measured by the Mayo High Performance Teamwork Scale, however, debriefing at Code Blues occurred twice as often when residents had I START-END training.

CONCLUSION

Non-operating room settings are fraught with unfamiliarity that create many challenges. The I START-END tool operationalizes key CRM elements. The tool was well received by residents; it enabled them to speak up more readily, obtain vital information and continually update each other by anticipating, planning, and debriefing in an organized and collaborative way.

Asymmetry of Authority or Information Underlying Insufficient Communication Associated with a Risk of Crashes or Incidents in Passenger Railway Transportation

Similar crashes or incidents may recur as a result of insufficient communication in uncertain and risky situations that potentially threaten safety. The common root causes of insufficient communication across a series of incidents and crashes must be explored in detail to prevent a vicious circle of similar incidents or crashes from occurring. This study summarizes a series of incidents and crashes (derailment due to excessive train speed) at JR West at the West Japan Railway Company (JR West) that are considered to have arisen from insufficient communication. The incidents included (i) resuming train service without confirming the number of passengers on board and leaving passengers behind the station at Higashi-Hiroshima station, (ii) continuing train service in spite of an apparent risk of a crash detected at Okayama station, and (iii) leaving the crack of the train hood as it was at Kokura station. We discuss the causes of insufficient communication (particularly in relation to the sharing of information) among the three branches of staff—the station staff, the conductor and train driver, and the train operation management center—that led to the incidents or crashes. Two factors contributed to the insufficient communication in the series of incidents and crashes: (a) Asymmetry of authority, which hinders the discussion of issues openly and equally among the branches concerned. (b) An unacceptable level of knowledge or information for all branches concerned.

Functional Leadership in Interteam Contexts: Understanding 'What' in the Context of Why? Where? When? and Who?

Research on team leadership has primarily focused on leadership processes targeted within teams, in support of team objectives. Yet, teams are open systems that interact with other teams to achieve proximal as well as distal goals. This review clarifies that defining 'what' constitutes functionally effective leadership in interteam contexts requires greater precision with regard to where (within teams, across teams) and why (team goals, system goals) leadership processes are enacted, as well as greater consideration of when and among whom leadership processes arise. We begin by synthesizing findings from empirical studies published over the past 30 years that shed light on questions of what, where, why, when, and who related to interteam leadership and end by providing three overarching recommendations for how research should proceed in order to provide a more comprehensive picture of leadership in interteam contexts.

Coordination breakdowns in nuclear power plant control rooms: cause identification and behaviour-sequence analysis

This study aims to identify the causes of coordination breakdowns among control crews and to understand their coordination-behaviour patterns during emergencies in nuclear power plants (NPPs). On the basis of in-depth interviews with 18 control-crew operators, we identified 25 causes of coordination breakdown related to work processes, personnel, and situation and organisation. In addition, we observed 12 control-crew training sessions that dealt with emergencies and conducted lag-sequential analysis. The levels of coordination effectiveness were evaluated using the proportion of coordination breakdowns and the anticipation ratio. We found that higher-performing teams exhibited more non-random coordination behavioural patterns than did lower-performing teams. Coordination-behaviour patterns specific to the higher-performing teams included adaptive workload management (from senior operators) and proactive seeking performance monitoring (from junior operators). The findings of the study enrich our understanding of the critical factors and processes that influence coordination effectiveness of NPP control crews. Practitioner summary: Causes of coordination breakdowns among control crews of NPPs were identified based on in-depth interviews with control-crew operators, and behavioural-pattern analysis of control crews in 12 training sessions were analysed to reveal the patterns that differentiate higher- and lower-performing teams. The findings of the study enrich our understanding of the critical factors and processes that influence the coordination effectiveness of NPP control crews. Abbreviations: NPP: nuclear power plant; RO: reactor operator; TO: turbine operator; CO: coordinator; SRO: senior reactor operator.

Mirror, Mirror: Guided Storytelling and Team Reflexivity’s Influence on Team Mental Models

Because substantial evidence supports team mental model similarity as a positive predictor of team performance, it is important that we help team members to develop a shared understanding of relevant team content. The current study extended the list of team mental model antecedents to include guided storytelling as an effective team intervention. In the first known empirical investigation of planned story usage in teams, we broke new methodological ground by pioneering a team intervention to proactively harness the benefits of narrative. Results revealed that the combination of presenting important information in story format and giving members time to reflect upon their strategies had a positive effect on team mental model similarity. In addition, the positive indirect effect of storytelling on team performance via team mental model similarity was stronger when guided team reflexivity was present than absent. These findings provide encouraging evidence for the continued examination of storytelling and reflexivity in teams.

The Science of Multiteam Systems

Given the complexities of today’s workplace, organizations and agencies are progressively turning toward interdependent systems comprised of teams, or multiteam systems (MTSs), to accomplish multifaceted tasks in challenging environments. Subsequently, MTSs have grown in popularity in group and team research, spanning a breath of disciplines (psychology, organizational behavior, human factors, communication, and medicine). In this review, our goal is to highlight the existing research across a range of disciplines regarding MTSs that serves to answer the question, “What do we know about MTSs?” while also developing a future research agenda aimed at answering the question, “Where does our research need to go to better understand MTSs?” We specifically highlight the current trends, dynamics, and methodological issues in MTSs to further build the foundation for improving MTS effectiveness.

The juggling paradigm: a novel social neuroscience approach to identify neuropsychophysiological markers of team mental models

Since the discovery of the mirror neuron system in the 1980s, little, if any, research has been devoted to the study of interactive motor tasks (Goldman, 2012). Scientists interested in the neuropsychophysiological markers of joint motor action have relied on observation paradigms and passive tasks rather than dynamic paradigms and interactive tasks (Konvalinka and Roepstorff, 2012). Within this research scenario, we introduce a novel research paradigm that uses cooperative juggling as a platform to capture peripheral (e.g., skin conductance, breathing and heart rates, electromyographic signals) and central neuropsychophysiological (e.g., functional connectivity within and between brains) markers underlying the notion of team mental models (TMM). We discuss the epistemological and theoretical grounds of a cooperative juggling paradigm, and propose testable hypotheses on neuropsychophysiological markers underlying TMM. Furthermore, we present key methodological concerns that may influence peripheral responses as well as single and hyperbrain network configurations during joint motor action. Preliminary findings of the paradigm are highlighted. We conclude by delineating avenues for future research.

Breakdowns in coordinated decision making at and above the incident management team level: an analysis of three large scale Australian wildfires

Emergency situations are by their nature difficult to manage and success in such situations is often highly dependent on effective team coordination. Breakdowns in team coordination can lead to significant disruption to an operational response. Breakdowns in coordination were explored in three large-scale bushfires in Australia: the Kilmore East fire, the Wangary fire, and the Canberra Firestorm. Data from these fires were analysed using a top-down and bottom-up qualitative analysis technique. Forty-four breakdowns in coordinated decision making were identified, which yielded 83 disconnects grouped into three main categories: operational, informational and evaluative. Disconnects were specific instances where differences in understanding existed between team members. The reasons why disconnects occurred were largely consistent across the three sets of data. In some cases multiple disconnects occurred in a temporal manner, which suggested some evidence of disconnects creating states that were conducive to the occurrence of further disconnects. In terms of resolution, evaluative disconnects were nearly always resolved however operational and informational disconnects were rarely resolved effectively. The exploratory data analysis and discussion presented here represents the first systematic research to provide information about the reasons why breakdowns occur in emergency management and presents an account of how team processes can act to disrupt coordination and the operational response.

The cognitive underpinnings of adaptive team performance in ill-defined task situations

As the nature of work changes due to technology, organizational restructuring, and globalization, complex tasks have emerged that necessitate the use of teams. Oftentimes, teams complete tasks that have more than one plausible solution or engage in performance episodes under uncertain circumstances. Therefore, teams are called upon to be highly adaptable to these ill-defined tasks by responding to continuous changes in the task environment. We propose that dimensions of team cognition (i.e., shared mental models and transactive memory systems) help drive adaptation. In recognition of the additional cognitive demands placed upon teams who must be highly adaptable, we believe much can be gained from taking a closer look at the facets of team-level cognitive variables. The current effort aims to provide a more comprehensive explanation of emergent cognitive states, and how they interact to drive adaptive team performance, especially within the context of ill-defined problems.

Perspective: examining communication as macrocognition in STS

OBJECTIVE

There are significant points of alignment between a macrocognitive frame of teamwork and a communication perspective. This commentary explores these touch points in regard to use of teams in sociotechnical systems (STS).

BACKGROUND

The macrocognitive framework emphasizes a team's shared mental models whereas a communication frame emphasizes that shared meaning among team members is more frequently implicitly than explicitly recorded in their messages. Both acknowledge that communication (in macrocognition) or messages (in communication) serve as an index of team members' goal-directed behavior. The two approaches differ in the role of communication: as information exchange in macrocognition as compared with verbal and nonverbal symbols composing messages for which senders and receivers co-construct meaning.

METHOD

This commentary uses relevant literature to explicate the communication position.

RESULTS

From a communication perspective, individuals are simultaneously sending and receiving messages, communication is continual and processual, and meaning construction is dependent on relationship awareness and development among communication partners as well as the context.

CONCLUSION

The authors posit that meaning cannot be constructed solely from messages, nor can meaning be constructed by one person. Furthermore, sharing information is not the same as communicating.

APPLICATION

Architects and users of STS should be interested in designing systems that improve team communication-a goal that is interdependent with understanding how communication fails in the use of such systems. Drilling down to the fundamental properties of communication is essential to understanding how and why meaning is created among team members (and subsequent action).