O&MJournalDraft.MV.April08.1

RESILIENT DISTRIBUTED COGNITION IN U.S. COAST GUARD FLIGHT CREWS

Michael Valerio, The George Washington University

April 15, 2008

This paper was presented at the Eastern Academy of Management meeting, Washington, DC,

May14, 2008, and for inclusion in the Conference Proceedings. The contributions to the study by

dissertation committee members Andrea Casey and David Schwandt (The George Washington

University) are greatly appreciated.

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RESILIENT DISTRIBUTED COGNITION IN U.S. COAST GUARD FLIGHT CREWS

ABSTRACT

Researchers in the emerging field of high-reliability organizations (HROs) have shown

the importance of resilient distributed cognitions in the prevention, management, and resolution

of organizational catastrophes. However, scholars have yet to agree on how resilient distributed

cognition (RDC) can be characterized, and under what conditions it is activated and then

transferred to others and manifested as highly reliable actions or behaviors. Understanding RDC

cognition in HROs offers the potential promise of avoiding disaster. Our study of a military

HRO, more specifically a Coast Guard C130 Aircraft and Crew engaged in Law Enforcement

(LE) and Search and Rescue (SAR) concluded that resiliency and its subcomponent, reliability,

in organizations can be achieved by learning the language of congregation, that is, a specific

grammar and syntax to organizing. An underlying congregate cognitive map of an organization

is activated through language building that highlights the mechanism behind resilient distributed

cognition and how highly resilient and reliable actions among organizational members is

achievable despite changing membership or diversity of shared beliefs, values and motivations.

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RESILIENT DISTRIBUTED COGNITION IN U.S. COAST GUARD FLIGHT CREWS

Bigley & Roberts (2001) recently argued that Incident Command System (ICS)- based

organizations have the “structure to support constrained improvisation and manage cognitive

behavior of participants necessary for flexible and adaptable response to hazardous and volatile

situations” (p1282). More specifically, due to the highly structured standard operating

procedures, roles and associated training, the ICS structure is a ‘blueprint’ around which an HRO

continuously evolves in a disciplined manner according to prescribed functions and role

switching among participants as facilitated by a formal language of operations (p.1291).

However, we believe that such structural resiliency and operational reliability is a product of the

communications process, not the organizational structure, that is, resilient and thus reliant

communication is due to mastery of the grammar and syntax of congregation (Valerio, 2006).

Weick (1979) has repeatedly reminded us that the organization is not the “separate force or

agent” (p. 34) behind the HRO but the interlocked behaviors of the participants. Nearly three

decades ago Weick (1969) argued “it is not the tangible fixtures in an organization that are

crucial. These merely provide the media through which the (organizing) processes are expressed

(p.16).” We agree with Bigley & Roberts (2001) that successful HRO performance depend upon

“intense communications” but those communications are achieved by understanding a language

of congregation rather than one of structure.

Weick, Sutcliffe & Obstfeld (2005) reaffirmed that sensemaking depends on words and

typifications assembled through “language, talk and communications”; “organizing itself is

embodied in written and spoken texts” (P409), that is, it follows a grammar and syntax of its own

(emphasis ours). Following Weick’s (1969) notion that “organizing is the grammar by which the

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vocabulary of elements in an organization is made meaningful (p.62)”, Czarniawska (2006)

poses that organizing of human interaction “is clearly linguistic: it is a grammar, and the

behaviors must sensibly interlock” (p.1666); however, she concluded that organizational

researchers have failed to describe the actual grammar itself: “But how do they connect cued

events into interlocking structures? What logics, what grammars, what plots are used to build

such connections?” (p1670). Similarly while Eisenberg (2006) reinforces Weick's perspective

that language is both central to the social construction of realities and the role of cognition

(p1693), he too asked: “Where was one to look for the ‘double-interacts’ that were purported to

characterize organizational communication?” (p1697). This study purposefully sought to resolve

this gap in theory by attempting to accurately describe the mechanism of interlocking behavior.

The language of specialized collective action characterized as heedful interrelating

(Weick & Roberts, 1993) and made possible by the language of congregation (Bougon, 1992,

Valerio, 2006) creates a reliable property of the whole system of actors, its technology and

artifacts (Hutchins, 1996a/b; Hutchins and Klausen, 1998; and Suchman, 1996). This language of

congregation is activated by precise congregating labels linked to congregating activities as

mastered through congregating roles among the cognitive maps of the members of the

organization (Bougon, 1992; Valerio, 2006). Weick (1969) had suggested that such

congregation among organizational participants was the product of a “of endless dyads sitting

around the organization, waiting to be plugged into some process, after they will return to their

offices to await new inputs (p.75)”. Evidently, increasing resilient and reliable performance of

organizations occurs when members are socialized to those specific congregating labels, roles,

and activities associated with their highly reliable actions. The fact that these congregating roles

and activities can be described as functions within organizations should not lead researchers to

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confuse the process of organizing for resiliency and high reliability and the associated highly

resilient and reliable actions due to the imposition of structure rather than as a communicative

achievement.

THE RESEARCH AGENDA

This research involved a U.S. Coast Guard C130 Aircraft and crew based in Elizabeth City,

North Carolina conducting maritime law enforcement and search and rescue operations in the

Caribbean Sea in 1999. The research questions that we pursued included:

(1) How do resilient cognitions in a crew or team operate? In other words, how is

requisite variety created and sustained in HROs (Conant & Ashby, 1970; Orton, 1988);

(2) How does a collectivity with ever changing individual membership maintain and

transfer resilient distributed cognition? That is, what processes in organizations create

"heedful interrelating" (Weick & Roberts, 1993) and how doe these processes allow for

the emergence of innovative solutions, specifically "bricolaged" or recombinant-

innovative solutions (D. Chales Galunic & Rodan, 1998; D. Charles Galunic & Weeks,

2002), to unexpected and potentially catastrophic situations (Weick & Sutcliffe, 2001;

Weick, Sutcliffe, & Obstfeld, 1999).

Evidence suggests that resilient cognition, a learned behavior, can be achieved:

1) By defining Resilient Congregating Activities;

(Resilient <---> Learning and Enforcement Mechanism)

2) By creating Resilient Congregating Labels for these Resilient Congregating Activities;

(Resilient <---> Learning and Enforcement Mechanism); and by

3) By creating Cognitive Congregants Roles i.e. one Congregant Cognitive Role = one

idiosyncratic Cognitive Map + At Least Two Resilient Congregating Activitiess.

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Figure 1 illustrates the relationship between resilient congregating activites, resilient

congregating labels and resilient cognitive congregants’ roles.

[INSERT FIGURE I HERE]

Resiliency is achieved by socializing each congregant into a Cognitive Congregant Role.

That is, by learning and enforcing of the Resilient Congregating Action/Activity, and by learning

and enforcing of the Resilient Congregating Labels, that is a Lexicon of Labels.

The problem or interchanging membership and sustainability of resilient distributed

cognition is achieved by introducing or “plugging in” congregate cognitive roles into a new

congregate cognitive map.. A congregate cognitive map and its congregate cognitve roles are

mutually self-defining. A missing congregate cognitive role will be immediately spotted by the

congregant cognitive roles that have an resilient congrating activity in common with the missing

congregant cognitive. Such a blatantly missing congregate cognitive role will call for immediate

correction. Because a congregant cognitive role is an interchangeable for congregate cognitive

maps, it is thus easy to form additional congregations as enough congregants become available

(who have been socialized in existing congregations) to populate a new congregation.

Consequently, random rotation of the congregant congregating roles s into the existing

congregations is a central technique for the over-learning and enforcement of the congregating

roles and activities..

A congregate cognitive map is a syntax/grammar for composing a Congregation. Like

syntax/grammar, a congregate cognitve map is content-free (and both can be diagrammed). One

does not need to know the meaning of the words(cognitive congregating lables) to recognize that

the syntax/grammar(congregate cognitive map) is flawed. In syntax/grammar, a verb links

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subject to object. In a cognitve congregating map (CCM), an reslieint congregating activity

(RCA) is linking a giver to a taker.

With Congregating Activities (CA)s and Congregating Labels (CL) we have

the components of a grammar/syntax to compose a "Congregating Sentence", as follows:

English Grammar: English Sentence --

Subject (sender) --------> Verb (action) --------> Object (receiver)

CCM Grammar: Congregating Sentence --

Sender CL ---------------> CA (action) ----------> Receiver CL

Finally, language use was critical to organizing highly resilient and reliable activities.

The crew navigator/radio operators [NAV/AV (radio)] position acted as “keeper of the

language”, that is, they enforced the “R” in HRO. They controlled the language codes for all

potential labels around which crewmembers congregated their highly resilient and reliable

activities.

There was constant “idle chatter” over the course of the flight; in fact, most of the crew

conversation was social in nature. As a researcher (first author) new to use of headgear and the

monitoring of radio frequencies, the cognitive effort to listen was extremely fatiguing. If this

researcher (first author) “deselected” channels or unplugged his headset, he became more

anxious, that is insecure, and was not able to rest. Unplugging meant total isolation in flight.

This idle chatter seems to serve the purpose signaling: “I am here, I am listening.” And out of

the constant stream of words and phrases, certain keywords can be heard which cue and narrow

attention and trigger actions. Even when other crewmembers were in a state of “rest”, that is,

with their eyes closed and reclined, they wore their headsets with specific channels open. This

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idle chatter was a feature of crewmembers’ cosmological security (Weick, 1993a). The truly

important keywords expected to cue action must necessarily remain rigid and inflexible. It

would seem that these keywords operate within cognitive and cognitive congregate maps as a

largely rigid shared meaning pointing to clearly understand congregating actions; that is words

to serve as a mechanism to detect a wrong label or propagate the use of a novel more useful

label. And while these keywords appear to compose a highly reliable system of meaning, there

are agents i.e. the RAD/NAV positions, which have the authority to introduce change to adapt to

a dynamically changing environment.

The elusive double - interact manifest aspects of the cognitive congregate map (CCM).

For example, there is a “template” for take-offs, landings, vessel search and intercept, or air-

dropping supplies. These templates of action represent various slices of one whole CCM. The

one truly common linkage among all of the crewmembers is the internal communication system

and key words activate these various templates of the CCM. And once activated, like an array of

lights, the various positions with shared actions become activated. Furthermore, longitudinal

comparisons of the individual cognitive maps elicited for the members at the start and at the end

of the 5 day trip showed little or no change in content over time. The ability to switch templates

is a feature of high reliability operations. The template brings up a self-reinforcing cognitive

package that is multi-sensory in nature. The map itself is not the schema, but rather activates the

schema in the head of the interacting individuals.

The CCM in actuality is the map of the territory (Bougon, 1992). It seems to go beyond

the metaphorical level such as Morgan’s (1986) mind metaphors including a psychic prison,

machine, organism and all of the limitations associated with one imprecise metaphor. The CCM

captures all of these metaphors under one real thing. The metaphor we have chosen to best

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represent the CCM is the skin of the squid. Those regions of the skin illuminated are therefore

temporal regions of local centrality (LCoCCM)1 of the CCM where the density of causal

linkages is very strong. More specifically, these LCoCCMs once fully identified can be used to

the highlight crew behaviors (training) necessary to maintain crew resiliency or crew

effectiveness or improved crew cooperation. Each of the LCoCCMs represents different

activations among the CCM and not all crewmembers are active for all congregating actions at a

given time.

C130 HRO Case Study: Context for Organizing Highly Resilient and Reliable Actions

Hurricane Katrina was an organizational catastrophe that will be studied for years.

Relying on the embedded knowledge i.e. geography, typography, facilities, utilities, etc., within

Geographic Information Systems maps, the U.S. Coast Guard was able to rescue thousands of

people during Hurricane Katrina. In our study of U.S. Coast Guard C130 flight crews in 1999,

we found intriguing parallels between the precursor event, Hurricane Floyd (1999), and the artful

construction of air navigation maps of Greensboro, North Carolina and the catastrophic Katrina

event (2006). In the study, we specifically followed the conversation with a radio technician on a

Search and Rescue mission, in which he referred to the improvisational creation of maps during

the flooding of Greensboro, North Carolina, during Hurricane Floyd, September 14-18, 1999.

High-reliability researchers will see parallels to the Katrina and Floyd mapping cases and

Karl Weick's (1995) discussion of the importance of minimal structures in the creation of action.

Weick tells a story about a small Hungarian reconnaissance detachment lost in the Alps who

managed to find their way back to the rest of their army by use of a map of the Pyrenees. A poor

map became the organizing process around which the group was able to notice and extract the

environmental cues necessary to create a more useful course of action that led to their escape. In

1 A term coined by Dr. Michel Bougon

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the Hurricane Floyd case, though, the map was enacted, or "bricolaged," during a series of Coast

Guard sorties. Transcribed from a portion of a crew interview during the development of

individual cognitive maps as prescribed by Bougon (1983), the researcher (R) probes the radio

operator (RAD)’s recollection of the map construction:

RADIO OPERATOR (RAD): Well a recent incident, of course, you know with the

flooding there around the Tarborough Area, like it was mentioned, I think, you were

talking about it on the way down how -- we're not trained for ground, you know, over

ground type situations like that. We do all of our rescues on the high seas and here we

had a situation where it's over land and then--.

RESEARCHER (R): Momentarily, though, it was flooded.

RAD: That's not something that we train for like getting helicopters down there amongst

the power lines, towers, but you don't deal with a whole lot out on the open water other

than, you know, masts on a ship or antennas and whatnot and the middle of the night on

top of that and I just thought that when that alarm went off and they came over the

intercom saying there's 300 people stranded in the Tarborough area, need an evacuation

and they started sending helicopters out that way and then they put the C130 in the air to

kind of maintain the overall on the Commander--.

R: Coordination?

RAD: Well, they had a guy on the ground getting reports from the Sheriff's Department

and Highway Patrol… hey; we got people stuck here, there and whatnot. He would call

up to us and--it almost seemed like the whole mission evolved as it went along. We had

no game plan to speak of getting out there, what exactly are we going to do and it just

seemed like with the people that we had and the discussions that occurred that the plan

just worked itself out and it worked for the most part, it may not have been the best plan,

but we had nothing to refer to. I think Mr. Bills (P)ilot said, the way it evolved, nobody

had -- nobody had any kind of action plan to refer to. What do you do in this situation?

Well, you set up this, that and the other.

R: There was a navigator (NAV) I talked to on a SAR duty night who was in one of the

first crews on the scene and he said all they had was a street map and he said it was

miserable. I mean he couldn't find anything because he had no points of reference.

RAD: We had no charts!

R: And then he said what he did the first night they came in, he put LON (gitude) and

LAT (itude) s all over this street map and he passed it to the next crew.

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RAD: Right, he was there the second day. It was myself and Bart Fellow (NAV), they

had it the first night, you know, we had nothing!

R: OK, so maybe--.

RAD: We had nothing!

R: So what actually evolved as a tool? Was it the street map that they kept modifying?

RAD: Well, I think after that first night, we started looking to see what better resources

they could use, OK, so somebody might have gotten a more detailed chart of that area

from some other way, some other source. But the first night was nothing absolutely. But

it all worked.

This story from our research is a good introduction to the problem that was considered

during this research project. U.S. Coast Guard flight crews have used the C130 aircraft for

nearly 30 years, with a loss rate of < 1% compared with Department of Defense (30%) and other

nations (40%) in non-combat accidents (Bowman, 1999; Canton, 1999; Gero, 1999; Job, 1994)

using the same aircraft over a 45 year period. We believe one key ethnographic finding that

accounts the significant difference between the Coast Guard operations and others mirrors

maintenance policies. Whereas the Department of Defense and other nations have policies that

separate the maintenance of the aircraft from the operation of the aircraft, with a more rigid

specialization of flight crew roles, the Coast Guard has a culture referred to as "fix-and-fly," and

has a tradition of members of the flight crews being cross-trained and capable of moving

between specific flight crew roles over a career, between sorties, and even within an operation.

Our study – like Weick and Roberts' (1996) research on aircraft carriers – involves the

potential interaction of several catastrophic domains: the dangers of natural disasters such as

hurricanes, the dangers of operations at sea, the dangers of aviation operations, and the dangers

of interacting with criminal activities such as drug smuggling and human trafficking.

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In the conversation reported above, the flight crew members in Hurricane Floyd were

well-trained and skillful enough at the navigation role to improvise a solution to a new problem,

which can be framed as a requisite variety solution to the problem. The radio technician often

acted in multiple roles in the flight crew and thus was able to participate in the creation of a

series of increasingly useful maps, which can be framed as a process that created heedful

interrelating to resolve the emergent problem. On a larger scale, the rise of an "unexpected"

problem was resolved through the capacity of members of the "fix-and-fly" culture of the Coast

Guard to take materials at hand and combine them in innovative solutions during a crisis.

POSITIONING THE STUDY IN HUMAN AND ORGANIZATIONAL LEARNING

Research Findings on Distributed Cognitions in Loosely Coupled Networks

Weick (1987) suggested that the term organization “implies more orderliness,

coordination, and systemization than is commonly discovered when people look closely at joint

action” (p. 10). An organization, Weick (1993) further stated, is simply a “role structure of

interlocking routines” (p. 633). Weick (1969, 1979) argued that organizational networks can be

depicted graphically through cognitive maps (CMs). Bougon (1992) argues more specifically

that congregate cognitive maps (CCMs) define that organization. The concept of resilient

distributed cognition is derived from research on organizational structuring and organizational

learning.

Organizational Structuring

Organizational structuring has been defined as “a process of generating and recreating

meanings” among the members of an organization (Ranson, Hinings, & Greenwood, 1980p. 4).

Specifically, it is an emergent and unpredictable process shaped by the interplay of “prior social

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relations conditioned by an antecedent structural context” and mediated though the activities of

individuals (Archer, 1995, p. p. 165). Bougon (1992), Schwandt (1995, 1997), and Bradley

(1998) all posit that beneath these action-structures rests a deeper congregate cognitive structure

with its own ontological and emergent properties that frames and shapes (though not necessarily

pre-determines) collective behavior (Archer, 1995).

Rules and resources of social systems (Giddens, 1984) are re social structures, which

become causally efficacious through agency (Archer, 1995). These structures include memory,

norms, roles, leadership policies and procedures, rules, scripts, schemas, and values (Schwandt,

1995, 1997; Schwandt, Casey, & Gorman, 1999). Methodologically, these social structures can

be represented by CCMs depicting thinking and acting collectively in a particular action domain

(Bougon, 1992), such as aerial law enforcement.

Social realists view pre-existing collective cognitive structures as having the potential to

influence behavior, but that behavior is often unpredictable following the emergent nature of

human agency (Archer, 1995). Giddens (1976, 1979, 1984), Goffman (1967, 1974), and Archer

(1995, p. 165) argue that the resources of social collectives are spatial and physical as well as

human. Suchman (1987) demonstrated that physical workspaces are composed of equipment,

action, and spatiotemporal orders produced and informed by the work practices of situated

members. Lave and Wenger (1991) argued that actors, work activity, and the world mutually

constitute each other into "communities of practice" (p. 98). And finally, Suchman (1996),

Hutchins (1996a, 1996b), Hutchins and Klausen (1998) and Goodwin and Goodwin (1998)

demonstrated that workspaces, technology, and activities are mutually constituted in ship

bridges, airline cockpits, and air terminals. Work practice is pivotal to the activations of the

generative social structures of collective action (Archer, 2000).

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Organizational Learning

An adaptive and resilient structure of cognitions in a collectivity is a product of learning

collectively (Balaji S. Chakravarthy & Doz, 1992; Schwandt, 1995, 1997; Spender, 1996; Weick,

1996). Schwandt’s (1997) dynamic social Model of Organizational Learning holds that

“organizational learning,” that is, learning collectively, is a dynamic ability to continuously

generate equilibrating collective mental frameworks vital to organizational resiliency, threat

recognition, and the retention and creation of new knowledge necessary to enact contextual

sensemaking (Schwandt & Marquardt, 2000). Spender (1996) emphasizes that any useful theory

of organization must simultaneously rely on an integrative theory of learning, knowledge and

memory. A genuinely useful operational understanding of resilient distributed cognition would

also explain “collective memory,” learning collectively, collective decision-making, and

collective problem solving (Graesser, Gernsbacher, & Goldman, 1997).

Weick (1979) and Luhmann (1993) argue that the choices involved in the attention and

selection of information entering the collectivity cannot be overemphasized. Collective action

and reflection (Schwandt, 1997) enables the collective action learning required to develop

transferable goal-oriented knowledge competencies, or "interactional competence" (Cicourel,

1972). It is through communicative action that these competencies necessary for resiliency and

continuous learning are diffused throughout the organization (Schwandt, 1997).

Resilient Distributed Cognition

Many researchers have postulated the existence of resilient distributed cognition as a

unique phenomenon (Walsh, Henderson, & Deighton, 1988) often referred to as “shared

representations” or “team models” (Johnson, 2000). However, these researchers have not

reached a consensus concerning how cognitions in a collectivity can be characterized in terms of

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content and structure and under what conditions this collective structure emerges, is activated,

maintained, and shared.

"Distributed cognition," as a descriptor of cognitions within a collective, is defined here

as a socio-cultural process which organizes participants’ acts of perceiving, attending,

classifying, assigning meaning, remembering, and time reckoning (Hutchins, 1996a, 1996b;

Zerubavel, 1997), the outcome of which is the enactment of social practice (Hutchins, 1996a,

1996b). Distributed cognition is thus a process wherein participants organized around a specific

action domain assisted by technology and cultural artifacts, act relatively autonomously while

recognizing their interdependencies to make, exchange and sustain a coincident interpretation of

that environment so they can act collectively with understanding (Boland, Tenkasi, & Te'eni,

1994; Gray, Bougon, & Donnellon, 1985). It is important to keep in mind that while cognition is

an individual sensory phenomenon, distributed cognition occurs when “coincident interpretations

of reality are created, transmitted and sustained (Gray et al., 1985, p. p. 85).

"Coincident meaning” occurs when HRO participants favor one subjective interpretation

over others resulting in coincident expectations and reciprocal actions (p. 88). Such distributed

cognition is dependent on the connections between organizational participants (Weick, 1969,

1979).

"Cognitive Maps" are a visual representation describing the configuration of rules and

resources, or more specifically the concepts and relations associated with organizational

situations through which a person makes sense of his or her environment is known as a cognitive

map (Axelrod, 1976; Baird, 1994; Bougon, 1992; Bougon, Baird, Komocar, & Ross, 1990;

Bougon, Weick, & Binkhorst, 1977; Eden, 1994; Huff, 1990; Kaplan & Kaplan, 1982; Tegarden

& Sheetz, 2003; Weick & Bougon, 1986).

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"Collective Cognitive Maps" (CCMs) are the socio-culturally organized set of participant

cognitions within an action domain where this socio-cultural organizing of knowledge relies

upon a structure of cognitions in a collectivity that recognizes publicly held concepts used to

depict concepts, events and actions (Bougon, 1992). CCMs are collectively shared cognitive

structure that are relied upon to interpret, frame, simplify, and make sense of complex problems

encountered in collective goal accomplishment and threat adaptation (Norem & Cantor, 1992).

The manner in which individual CMs and a collective’s CCM are recursively constructed

and shared is critical to understanding organizational resiliency. Spender suggests that

distributed cognition and organizational learning -- learning collectively -- are two facets of the

same phenomenon (Spender, 1996).

One research tool common to explicating the nature of individual cognition and learning

is the cognitive map and by extension, the tying of individual cognitive maps through

congregating actions (Bougon, 1992) into congregate cognitive maps (CCMs).. The CCM is the

portal to collective sensemaking as a recursive process of distributed cognition and learning

collectively.

A number of researchers (Bougon, 1980, 1983, 1992; Bougon et al., 1990; Eden &

Ackerman, 1998; Eden, Ackermann, & Cropper, 1992; Kaplan & Kaplan, 1982; Spender, 1998;

Weick & Bougon, 1986) have suggested that interlocking role structures or collective structures

(Allport, 1962; Weick, 1969, 1979) can be described empirically through cognitive mapping

methods ultimately yielding a deeper CCM (Bougon, 1992). A CCM is a visual representation

of a collective’s experiences and knowledge in a specific action domain (Bougon, 1992).

Bougon (1992) stated that, structurally, a CCM binds the individual CMs of the social system’s

participants, not by shared meanings regarding perceptions and understandings of the

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environment, but by socially constructed and shared “cryptic” labels. "Cryptic Labels" are

publicly held concepts shaped by uniquely private personal meanings, or coincident meanings

(Donnellon, Gray, & Bougon, 1986).

Research streams associated with ethnomethodology, ethnography and linguistics have

demonstrated that the cognitions in a collectivity springs from talk in situ (Boden, 1994;

Garfinkel, 1967; Psathas, 1995; Sacks, 1972, 1995) wherein intersubjectivity is built by the

orderly structuring of turn taking in conversation (Boden, 1994; Leiter, 1980; Sacks, 1972), and

an embodied kinesthetic participation with artifacts and technology (Engestrom & Middleton,

1998; Hutchins, 1996a, 1996b). Organizations then arise “through the laminated sensemaking

activities of members, endlessly negotiated” (Taylor & Van Every, 2000, p. 33) (p. 33).

An effective operational understanding of resilient distributed cognition which addressed

theories of learning collectively and “collective memory” (Spender, 1998) must also link the

cognitive orientations of idiosyncratic participants to social interaction with their mutually

recognized displays of in interactive competence (Cicourel, 1964, 1972, 1981, 1992; Clayman &

Maynard, 1995; Leiter, 1980). While the collective characteristics of memory retention and

information sharing and new knowledge generation are fundamental to such an understanding,

the psychology of individual competencies and how they enter into distributed cognitions cannot

be ignored (Salomon, 1997). Qualitative but discernable differences associated with HRO

resiliency in “collective memory” and learning collectively become embedded in the structure of

cognitions in the collectivity of an HRO. This research specifically explored the structuring of

emergent cognitions in a collectivity realized by the participants of one high-risk HRO, a Coast

Guard C130 aircraft and its crew engaged in a routine LE patrol.

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Collective cognitive structures help explain complex organizational processes (Archer,

1995; Bhaskar, 1979, 1989; Danermark, Ekstrom, Jakobson, & Karlsson, 2002; Sayer, 1992,

2000). Bougon (1992), for example, has suggested that the CCM is (emphasis Bougon’s) the

territory or the social structure of cognitions in a collectivity, that is, an ontological reality

(Sayer, 1992, 2000). Spender (1996) insists that reliance upon individual psychology alone in

collective theory is inappropriate. CCMs as emergent and pre-existing structures, culturally

imposes a sense of order and structurally condition organizing activity (Archer, 1995).

Research Findings on Human and Organizational Sensemaking Processes

Collective communication mechanisms resident within the organization’s congregate

(collective) cognitive structure of collective values, thinking, understanding and acting (Bougon,

1992; Krackhardt, 1987; Schwandt, 1995, 1997; Schwandt et al., 1999; Schwandt & Marquardt,

2000) aer manifested by socially constructed memory, norms, roles, leadership policies and

procedures, rules, scripts, schemas, and values (Schwandt, 1995, 1997; Casey, 1995, 1999). Yet,

researchers have not yet reached consensus concerning the sources of collective cognitive

structure (Johnson, 2000; Klimoski & Mohammed, 1994; LaPorte & Consolini, 1991; Tegarden

& Sheetz, 2003) for such sensemaking processes.

From a sociological perspective, the structure of cognitions in a collectivity is believed to

embody a process that accounts for knowledge generation, learning, and meaning-making within

specific domains of expertise as structured by culture (Cole & Zuckerman, 1975; Hallowell,

1951; Harris, 1994; Schwandt, 1997; Zerubavel, 1997). Researchers (Crossan, Lane, & White,

1999; Gioia, 1986, 1992; March & Olsen, 1975; Neuberg & Newsom, 1993; Vaughan, 1996;

Walsh et al., 1988; Walsh & Ungson, 1991) also broadly suggest that cognitive structure takes

the form of schemas of embedded patterns of social interaction between individuals and their

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environment. And, while few agree as to the nature of that structure (aspects such as the degree

of sociality, or the role of emotion and affect (Bradley & Pribram, 1998; Fineman, 1996; Hume,

1985; McDougall, 1973; Thelen & Smith, 1998; Weick, 1999; Weick & Roberts, 1993) or the

role of a collective unconscious (Cicourel, 1972; Colman, 1975; Freud, 1989; Hopkins, 1997,

1998; Jung, 1990), these structures do exist as ontologically separate realities with casual power

mediated by agency (Archer, 1995; Bhaskar, 1979, 1989, 1998; Layder, 1990, 1998; Popper,

1979). These configurations of culturally shaped social interactions embodied by a deeper

collective cognitive structure are believed to trigger patterns of sensemaking among

organizational participants.

As sensemaking follows a social process of inscribing these patterns (or structuring) of

thinking and acting in a particular action domain into the structure of cognitions in a collectivity,

it is also a process of creating order facilitated by collective cognitive structures capable of

recognizing differences within a complex environment which usually go unnoticed (Klimecki &

Lassleben, 1999). Such order is created through the reduction of equivocality (Weick, 1969,

1979, 1995, 2001), crypticality (Bougon, 1992) or complexity (Luhmann, 1995), depending upon

the strata (individual, collective or institutional) of social reality (Archer, 1995). Furthermore,

that order, cemented by collective concerns for survival or cosmological security (Weick, 1993)

is morally imposed by the collectivity (Clayman & Maynard, 1995; Garfinkel, 1967). Weick

(1995) similarly refers to the “visibility, volition and irrevocability” of public actions that

"commits" participants to each other -- imposing order (p. 157).

Following Garfinkel (1967), Cicourel (1972) argues that this sensemaking activity is

manifested by interpretive procedures that can be accounted for empirically in social interaction:

that is, by how members display their intersubjective orientation to common assumptions and

20

understandings of everyday work activity (Clayman & Maynard, 1995; Leiter, 1980; Moerman,

1988), however “it is impossible to understand fully the nature of social interaction in the

absence of a concern with system factors” (Layder, 1998p. 48) and their interplay with

intersubjectivity and reflexivity (Archer, 1995, 2003).

According to Neuberg and Newsom (1993), cognitive structuring or the “creation and use

of abstract mental representations e.g., schemata prototypes, scripts, attitudes, and stereotypes”

(p. 113), binds previous personal and group experiences with new information and collective

action to create new knowledge supportive of adaptation and resiliency (Schwandt & Marquardt,

2000); such a structuring of cognitions in a collective demands that “certain abilities or

resources”(Bar-Tal, Kishon-Rabin, & Tabak, 1997p. 1158) be available for effective

sensemaking or those socially described cognitive processes used by members to determine the

meaning and significance of situations and events (Weick, 1969, 1979) as new information is

processed through collectively shared memories (Schwandt, 1995, 1997; Schwandt et al., 1999;

Weber, 1995). Consequently, the resiliency of cognitions in a collective may demand unique

configurations of rules and resources necessary for the reduction of equivocality (Weick, 1969,

1979), collective equivocality or “crypticality” (Bougon, 1992), or environmental complexity

(Luhmann, 1995).

Research Findings on Distributed Cognition and Sensemaking Processes in High-

Reliability Organizations

Organizations involved in these devastating accidents, mishaps, or incidents such as the

Three Mile Island incident, the Chernobyl nuclear incident, the Bhopal chemical leak or the

Challenger explosing are but a few examples of high-risk organizations (HROs). HROs are

organizations involved in operations in which the slightest mistake can lead to catastrophe.

HROs operate in very strong cultures marked by custom and tradition that become cognitively

21

focused on performance and obsessed with reliability (Bierly & Spender, 1995). Operating

rooms, cockpits of jet transports, the control rooms of nuclear power plants and C130 aircraft

engaged in maritime law enforcement are all complex settings in which the crews of HROs

interact with each other and technology.

When the organization of a nuclear power plant, a rescue helicopter, an oil tanker, a fire

control command center, or a surgical ward fails to such an extent that a catastrophe ensues,

investigations tend to be searches for features of failure by individual members of the

organization (Richardson, 1994), rather than an investigation of failure trajectories within

interactively complex systems. Stated another way, some individual becomes the “ritual

sacrifice”: an event that allows the organization to “avoid having to learn from the unfortunate

course of events” (Luhmann, 1993, pp. 195-196) or having to decipher the nature of the

interactively complex “structural couplings” between technology, social structure (Luhmann,

1993p. 99) and participants within an action system.

The examples of organizational collapse or failure to adapt to threat, such as Mann Gulch

(Maclean, 1992) or South Canyon (Maclean, 1999), may appear less inexplicable if it is

considered that cognition infused with emotion is neither as rational nor as stable as many

researchers have assumed. Carley and Harrald (1997) suggest that HROs may have to learn one

disaster at a time.

Bougon and his colleagues (1990) suggested that instability in an HRO could result from

the seemingly innocuous addition or removal, by a participant, of a single connection in that

collective’s CCM. Instability in an HRO occurs when an organization can no longer maintain

the effective interlocking role relationship necessary to support collective sensemaking and

decision-making.

22

Resiliency is an HRO's ability, despite changing membership, to reconstitute those

effective interlocking role structures. Chakravarthy and Kwun (1989) have described this

process of achieving resiliency as “strategy making” (p. 2). Weick (1995) has suggested that this

interchangeability of personnel necessary for resiliency follows pressures to “develop generic

subjectivity” (p. 170). Generic subjectivity is organized around congregating actions (Bougon,

1992) sustained by talk, mutual expectations and commitment. Commitment is created through

visible, volitional and irrevocable actions by the members of a collectivity (Weick, 1995).

Weick (1996) describes resiliency as an astonishing capacity for retrospective reflection

that not only recreates all of the harrowing performances that lead to failure, but also anticipates

and socially enacts (Weick, 1969, 1979) a definition of environment that conceptually avoids

disaster. Weick (1997) further suggests that learning resiliency is also one of recapturing the

emotion associated with the original vigilant cognitions that were hallmarks of successful HROs.

Left unattended -- that is, not actively reflected upon -- collective performance simply

degenerates into mindless heuristics or repetitive habits of thoughtless action (Spender, 1998).

Chakravarthy and Kwun (1989) also postulate that heuristics retained by only a few participants

working within collectives who do not share them among other HRO participants can neither be

validated nor developed into new knowledge; these few participants may contribute links that if

removed by their departure would destroy the stability of the CCM (Bougon, 1992).

In the fields of strategy, human resources, and organizational behavior, an operational

understanding of how a resilient structure of cognitions, that is RDC, in a collective is created,

sustained and transferred can afford researchers the power to explain theories of collective

performance and the management of environmental complexity (Klimoski & Mohammed, 1994).

Specifically, collective action can be explained by reference to their underlying generative

23

mechanisms and the conditions under which they are activated (Archer, 1995; Danermark et al.,

2002; Sayer, 1992).

The exponential growth in the complexity of high-risk organizational systems (Perrow,

1984) provides an important reason for developing an operational understanding of distributed

cognition. The increasing complexity of HROs puts their collective cognitive capabilities at

greater risk of collapse (Perrow, 1984). Dorner (1997) laments that this growth in system

complexity parallels a growth in the apprehension of failure that ironically acts to make failure

more likely. But we also know that often the root causes behind HRO failure are present within

the system long before the obvious cue is presented (Reason, 1998). Detection of these

technological cues is facilitated by the successful activation of distributed cognition obsessed

with reliability and characterized by what Weick and Roberts (1993) describe as “mindfulness.”

Mindfulness is described “preoccupation with mistakes, reluctance to simplify, sensitivity to

operations, commitment to resilience, and deference to authority" (p. 342).

Further, the economically constrained life extensions of the aging major platforms of

HROs are a risk factor. Beaty (1995) warns that half of today’s air passenger fleet is 50 years old

and what aviation engineers have referred to as BFOs (bits falling off) have increased in

frequency, including the most striking case of the Columbia Shuttle (Starbuck & Farjoun, 2005).

Recent warning signals of potential disaster involving the now 30-year-old, long-range C-130

aircraft fleet have surfaced in the news media (Cihelka, 2000). Such a preoccupation with aging

equipment undermines collective cognitive capability by diverting its attention away from the

focus on the HRO as a system of high reliability actors focused on mission performance as

opposed to equipment malfunction. More specifically, the crew becomes more focused on the

reliability of the aircraft rather than reliability of the mission. This is particularly insidious

24

because it plays on the culture of reliability baiting HROs to hunt for routine maintenance

problems instead of discovering the subtle cues of potential systems failures.***

Sensemaking Processes in High-reliability Organizations

LaPorte and Consolini (1991) have argued that the sensemaking patterns associated with

high-risk HROs are not well understood. Further, Weick, Sutcliffe, and Obstfeld (1999) have

suggested that there are specific processes in HROs associated with stability and resiliency,

including a preoccupation with failure, resistance to simplified interpretations, sensitivity to

operational context, and an under-specification of organizational structure.

Weick (1969, 1979, 1995, 2001) has argued that an organization must include a “mind”

capable enough of making sense of a variety of equivocal inputs. To survive, a resilient HRO (or,

at least those who manage HROs) must develop, share, and transfer the adaptive structuring

processes of the cognitions in a collectivity necessary to continuously make sense of its complex

environment among its changing membership. Resilient collective cognitive structure in an

organization is the product of intentional social learning processes that focus on knowledge

development (B. S. Chakravarthy & Kwun, 1989; Schwandt, 1997; Schwandt et al., 1999;

Schwandt & Marquardt, 2000; Spender, 1996, 1998). This intentionality can be operationalized

through the linking of CMs by strategic design (Eden & Ackermann, 1998) -- achieving

coincident meaning and expectations associated with the congregating actions essential to HRO

mission performance (Bougon, 1992; Gray et al., 1985). The failure of an HRO’s collective

cognitions (Schwandt, 1995, 1997) to make sense of “new information” and collectively

transform it into “goal-referenced” resilient behavior (Deevy, 1995; Weick & Roberts, 1993) can

lead to tragic ends.

Three prevailing factors put HROs at greater risk of breakdown of the structure of

25

cognitions in their collectivity: (a) the ever-increasing complexity of socio-technical

organizations; (b) the economically constrained life extensions of these aging major platforms of

HROs, i.e. ships and planes; and (c) a rapidly increasing reliance on technology. If we are to

take Luhmann’s (1993) sociological theory of risk seriously, a fourth factor, the failure to

consistently maintain a “second-order systems level observer” (one who can recognize

significant differences occurring within a system because of the ability to operate outside the

system i.e. an Inspector General) must be added. Such monitoring also occurs through collective

action and collective reflection (Schwandt, 1997) and the accounting of reflexivity, that is, the

rational features of socially organized and situated work (Cicourel, 1972; Garfinkel, 1967;

Goodwin, 1995; C. Goodwin & Goodwin, 1998; Leiter, 1980)

Perrow (1984) argues that these system complexities, involving the interaction of

economic constraints, people, and technology can overwhelm traditional organizational defenses

embodied by training, supervision, standards, practice, and redundancy. This leads the way to

serious incidents or “normal” accidents. In light of this rapidly escalating risk, how minimally

staffed HROs collectively make sense of these system complexities while operating safely and

effectively despite changing organizational participants is believed to be embedded in the

structure of cognitions in a collectivity and represented by the CCM (Bougon, 1992) of the HRO.

The HRO research, following Perrow's 1984 book, is traditionally sorted by catastrophic

contexts: e.g. fire-fighting, naval, space shuttle, and aviation.

RESEARCH METHODS

The purpose of our current study was to identify and describe the structuring of RDC in a

high-risk HRO in situ by extending Bougon’s (1992) theoretical construct of the CCM to

operational practice, that is, more specifically, to construct the first known CCM of an

26

operational HRO. To date, no researcher had attempted to develop an organization’s CCM, and

more specifically that of an operational HRO.

The HRO under study is the crew of a U.S. Coast Guard C130 aircraft deployed during a

routine law-enforcement patrol subject to any of a number of types of diversions, including

search and rescue (SAR), interdiction of drugs or aliens, fisheries patrols, ice patrols, or oil spill

response. In a recent study of Coast Guard aviation mishaps occurring between 1993 and 1998,

Canton (1999) discovered that Coast Guard C130s engaged in LE have the lowest odds of

mishap. He concluded, “Crews on LE missions looking for violators are more vigilant. This

hyper-vigilance may result in safer flight operations.” (p. 28).

The C130H aircraft HRO, the particular series of aircraft and crew involved in this study

is considered at high risk despite the Coast Guard’s remarkable record of safety, because the

Coast Guard continues to operate it well beyond its service life in extreme environmental

conditions. While a new HRO is believed to evolve during the course of each C130 LE flight

deployment because members of C130 aircrews are interchangeable and the crew membership is

reshuffled for each new deployment, the templates about which the HRO forms rest within the

structure of cognitions in a collective in that HRO than can be explicated via the CCM.

The primary products of examination are individual CMs, a CCM of the focal Coast

Guard C130 aircrew HRO and recorded crew conversations, supported by ethnographic

participant observation. Specifically, Bougon’s (1983) qualitative Self-Q methodology of

individual cause map (distilled CM showing means/ends causal attributions used to make sense

of bracketed environments) construction (Orton, 1996) was employed to construct the CCM

(Bougon, 1992). This study is specifically designed to capture the individual CMs of the

crewmembers and to construct the first CCM of an HRO crew (collectivity) engaged in a routine

27

LE flight.

The unit of analysis is the RDC between people, technology and artifacts in embodied

social interaction (Suchman, 1987; 1996; Hutchins, 1993, 1996a, 1996b; Rogers & Ellis, 1994;

Hutchins & Klausen, 1998; Goodwin & Goodwin, 1998). However, investigation of complex

phenomena such as organizational learning, action, and cognition necessarily involves the

individual, group, and organizational levels of analysis (Cicourel, 1958; Boden, 1994; Rogers &

Ellis, 1994; Brown & Starkey, 2000; Taylor & Van Every, 2000). Bougon (1992) has argued that

all levels of analysis are addressed simultaneously by the CCM, as a system of linking members

through publicly understood (congregating) actions, which bind the organizational participants

into a collectivity.

Assisted by observation and audio-recorded individual and group interviews, and in-flight

crew conversation, the CMs (more specifically dominant cause and influence maps) of each

crewmember and the CCM of the crew were developed. Observations served as a means to

gather data on the nature and relationships of the cryptic labels used in the HRO organizing

process (Bougon, 1992) and to help understand how a structure of cognitions in a collectivity in

an HRO is created and reproduced over time. Proper elicitation of interactional competence

requires an understanding of the socio-technical context (Cicourel, 1972, 1992; Suchman, 1987;

Moerman, 1988; Hutchins, 1993; Boden, 1994) afforded through participant-observation and

interviewing. Crewmembers were interviewed to identify the network of mental labels pertaining

to their collective action domain. At the congregate level, these labels became keywords that

signaled to reciprocal actions between the crewmembers engaged in collective sensemaking and

collective decision-making activities and collective actions or activities.

28

Congregating labels (CLs) either can be found through focused interviews, in the analysis

of crew conversation in situ, the Self-Q Interviews (Bougon, 1983), or through the development

of unique but commonly understood thematic statements which the researcher can attribute to

each participant following the analysis of CMs (Kennedy, 1993). Bougon’s (1980, 1983) and

Bougon et al.’s (1990) Self-Q Interview technique was used to construct individual idiosyncratic

CMs and the HRO CCM. Cognitive mapping elicits individually held assumptions and beliefs

regarding action domains that can facilitate a reduction of equivocality (Lee, Courtney &

O’Keefe, 1992); that is, the CCM adds meaning to equivocal environmental cues allowing the

collectivity to achieve the situational awareness necessary to define and sustain joint action

(Weick, 1969; 1979; Bougon, 1992). Consequently, sharing CM/CCMs should increase

intersubjectivity (Weick & Bougon, 1986; Eden & Ackermann, 1998a, 1998b; Tegarden &

Sheetz, 2003). Such a process is necessary to facilitate the collective self-reflection required for

threat-adaptive learning (Schwandt, 1997).

Research Site

Built in 1938 under the Lend Lease Act, Air Station Elizabeth (AIRSTA) City is the only

Coast Guard air station originally designed and built specifically for the Coast Guard. AIRSTA

Elizabeth City is one of several operational Coast Guard commands co-located on an 800 acre

site along the Albemarle Sound in the city of Elizabeth City, North Carolina.

The C-130H High Reliability Organization

During this study, 226 men and women assigned to the Air Station operated and

maintained five (5) HC-130s (long-range cargo aircraft) and three (3) HH-60 helicopters. The

High Reliability Organization (HRO) studied was the C-130 “H” model, or C-130H aircraft and

its seven member crew. AIRSTA Elizabeth City missions include search and rescue (SAR),

29

enforcement of laws and treaties (LE) including drug and alien interdiction, international ice

patrol operations, training and the maintenance of Aids to Navigation (AToN) for shipping. The

focus of this study centers on the work activities of aircrew operating the C130H aircraft in

support of SAR and LE between the months of September through October of 1999.

With the exception of two air crewmembers, all were married and with children. Not

including the researcher (first author), the average age of the crew was 31.25 years. Average

tenure with the Coast Guard was 6.5 years. Average education was 2.9 years beyond the high

school level (and that includes journeyman work in specialty skills such as electronics, simulator

training and chief petty officer’s academy). Average operating time in the air with the C130H

aircraft was 1015 hours. The average age of the active duty Coast Guard C-130H fleet (1999)

was over 25 years old, among the oldest flying C-130H aircraft in service today.

In 1999, the Air Station C130s flew 5847 hours of flight time amounting to 1136

“sorties”, the majority of which supported LE, SAR and training. The researcher (first author)

observed and participated as a “basic” air crewmember during a Law Enforcement (LE) patrol of

the Caribbean. Despite the excessive hours and age of these aircraft, non-combatant or

peacetime operations of Coast Guard operated C-130s (<1%) is dramatically less than combined

Department of Defense (30%) and other country (40%) operations (Bowman, 1999; Gero, 1999;

Reed, 1999).

Constructing Congregate Cognitive Maps (CCMs)

The Self-Q Interview Process (Bougon, 1982) was used to develop the individual

cognitive maps (CMs) and the Congregate Cognitive Maps (CCMs) of a SAR duty crew (pilot

study) and then of an LE crew performing over the course of a 5-day patrol in the Caribbean.

The action labels tying the individual cognitive maps of the HRO can be established by

30

identifying the shared actions (interacts) among the members in cooperation. These double

interacts (defined as the behavior of one participant being contingent upon the behavior of

another (Weick, 1979) manifest aspects of the CCM. For example, there is a “template” for

take-offs, landings, vessel search and intercept, or air-dropping supplies. These templates of

action represent various slices of one whole CCM. Individual cognitive maps between

crewmembers are linked by “keyword’, rigidly enforced words or word phrases which activate

these various templates of the CCM. And once activated, like an array of lights, the various CAs

and CLs become activated. Furthermore, longitudinal comparisons of the individual cognitive

maps elicited for the members at the start and at the end of the 5 day trip showed little or no

change in content over time. The ability to switch templates is believed to a feature of high

reliability operations. The template brings up a self-reinforcing cognitive package that is multi-

sensory in nature. The map itself is not the schema, but rather activates the schema in the head

of the interacting individuals.

Congregating Actions (CAs) and Congregating Labels (CLs) evolve from being

introduced, utilized/adopted i.e. becoming coincident until they are finally institutionalized

(culturally defined as CG “keywords” i.e. "Search/Presearch Checklist", or "Before Take-Off

Checklist," etc). Part of training for reliability is to adopt a term or phrase and then over-learn

the word or phrase in the context of role-training so that it ultimately becomes institutionalized.

CAs or CLs for this study emerged following Kennedy’s (1993) theme analysis. In the case of

the C130 crew for example, terms become repeated and reinforced by the radio operator, the

keeper of the language. CLs and keywords are not necessarily the same thing. For example, the

term, "Search/Patrol Checklist", is a "keyword" (institutionalized by the Coast Guard); in this

situation, it also happens to be the CL. Hence, a "keyword" (or a part of it) may be a "CL” or it

31

may not, and conversely, a CL may yet have no corresponding (CG-institutionalized) "keyword".

Figure 2, A Partial CCM drawn to illustrate the layout of the congregating of the SAR Duty

Crew. This CCM also shows a Congregating or Organizing Loop (Weick, 1969) going through

the two Congregating Actions and through the two causemaps (correspondence with Bougon

2005).

[INSERT FIGURE 2 HERE]

Data Collection

Data collection took place at the AIRSTA and on board the aircraft while on patrol in the

Caribbean. A combined qualitative methodology relying on the use of several opportunities to

triangulate for meaning and understanding (Tashakkori & Teddlie, 1998; Danermark, et alii,

2002) was used to investigate how the crew of an operational aircraft observed in real time

collectively makes sense of their aerial and marine environment. Such triangulation broadly

embraces the use of compatible methodologies, which operating in isolation; fail to fully

explicate collective behavior. Overall research design was based upon the elicitation of

cognitive maps (Bougon, et alli., 1977; 1990; Bougon, 1974-1995; 1980; 1983; 1992; 1990;

Kennedy, 1993; Baird, 1994; Weber, 1995; Valerio, 2006) supported by ethnography to properly

key the meanings displayed by interactants in conversation and/or validate or meaningfully edit

missing or incomplete segments in recorded data (Moerman, 1988). Cognitive mapping is a

qualitative research approach directed toward understanding, in particular, how individuals in

organizations make sense of events and situations (Jenkins, 1998). The unit of analysis is the

distributed cognition between people, technology and artifacts in embodied social interaction

(Suchman, 1987; 1996; Hutchins, 1993, 1996a, 1996b; Rogers & Ellis, 1994; Hutchins &

Klausen, 1998; Goodwin & Goodwin, 1998).

32

A portable Sony (ICM-5000EV) tape recording unit plugged into the aircraft internal

communication system (ICS) was used to record crew conversation. Personal follow on

interviews with the participants probing “labels” in their cognitive maps were also

recorded. Due to the presence of classified electronic equipment on board the aircraft,

videotaping was prohibited. Limited photography with a SLR 35mm camera was allowed.

Instrumentation

For the interview phase of this study, the Self-Q interviewing technique (Bougon, 1983;

Bougon et alli, 1990; Kennedy, 1993; Baird, 1994; Weber, 1995) was used. This instrument

consists of four interviews of 40 to 90 minutes each. For this study, personal and group Self-Q

Interviews were conducted (a) with participants of a SAR HRO (the pilot study), and with an LE

HRO (the actual dissertation study).

[INSERT TABLE I HERE]

The interviews and observations of the intact crew’s interactions took place during the 5-

day LE deployment in August of 1999. These interviews and observations focused on the

development and maintenance of the distributed cognitions in the HRO

collective. These interviews served three objectives: (1) Documenting the characteristics of the

structure of distributed cognitions in an HRO collective; (2) Exploring and evaluating averted

"near misses" or aviation incidents to understand how catastrophes were avoided; and (3)

Developing an ethnographic account of the C130 HRO. The entire data generation and

collection process is summarized by Table 1, Summary of Data Generation Procedures.

Additional sources for the exploration of scenarios of potential near misses as

documented by the Aviation Safety Reporting System (ASRS, 2000) self-reporting database on

33

similar C-130 aircraft, was used to add an institutional context to the everyday activities of

aircrews as well as help with some gray areas in the ethnographic interviews.

Analysis

Table I also demonstrated that data collection and analysis is a qualitative iterative

process that required detailed analysis of all 5 days of cockpit recordings of crew interactions.

The researcher (first author) followed Kennedy’s (1993) thematic analysis based on the

meanings of the labels as determined by semi-structured interviewing and ethnographic

observation (Moerman, 1988).

The output from the CMA computer-based analysis of the Self-Q Interview data

(Bougon, 1974-2005) was used to prepare first the individual and then the congregate three

cognitive maps. Semi-structured group and individual interviews were used to amplify Self-Q

data, collect demographic and past performance and experience information.

Collective cognitive structure emerges when two requirement are met (Weick, 1979;

Kennedy, 1993):

(1) Two similar notions be present in both cognitive maps; and

(2) A double-interact between two participant’s maps.

Double-interacts are essential to establishing interdependence among the participants

(Kennedy, 1993. Interdependency is the term which best describes how “the actions of

participants in different roles and with different responsibilities fit (Kennedy, 1993, p. 166) into

an interlocking role pattern for collective goal action and ultimately collective goal attainment.

Following Weick and Bougon (1986), Kennedy (1993) used three criteria to identify mutual

interdependency among cognitive maps:

Criterion 1. The content of two labels has common relevance for both participants.

34

Criterion 2. The direction of the relationships as indicated by the arrows connecting the

two linking labels is in the same.

Criterion 3. Two or more labels of both participants are casually related to provide what

is required to enable each participant to fulfill mutual role tasks and expectations.

Theme statements which characterize dominant role behavior then emerge as the pattern

of potential independencies are identified. Theme statements for the LW Crew are shown in

Table II.

[INSERT TABLE II HERE]

Finally, Table 3 demonstrates that while a single CCM exists for the LE Crew, at least

twelve (12) variations of that CCM or localized congregations (Local Centralities of the CCM)

emerged as linked by at least twelve congregating actions and three congregating labels which

also happened to institutionalized Coast Guard keywords/phrases.

[INSERT TABLE III HERE]

Assumptions of the Study

The primary assumption of the current study was that collective cognitive structures, that

is, structures of cognitions in a collectivity both exist and influence collective action. This is a

social realist assumption (Archer, 1995). Organizational participants are socialized into these

collective cognitive structures and often take them for granted (Cicourel, 1972; 1981;

Krackhardt, 1987; 1992).; however, and while these cognitive structures as represented by the

congregate cognitive map of the HRO (Bougon, 1992) are not the same thing as tangible what

researchers typically label as organizational structures as manifested by organizational charts and

35

the like, they are real, if not properly understood. Social realism assumes that (1) the world

exists independently of knowledge, (2) that knowledge is fallible and theory-laden, even if it is

idiosyncratic and in the minds of individuals (Hume, 1985), (3) the world is differentiated and

stratified by events, objects and structures which possess emergent powers and that such

mechanisms are ontologically separate and analyzable, (4) that social phenomena are concept-

dependent requiring both explanation and interpretation, that is, that unlike the natural sciences,

social science possesses hermeneutic conditions, (5) that knowledge is linguistic or expressible

linguistically, and (6) social explanation is critical of commonsense understandings of events and

the generalizability of social mechanisms (Archer, 1995) (Sayer, 1984/1992; Layder, 1990;

Danermark, et alli, 1997/2002).

From the social realist perspective, structure and agency are ontologically distinct strata

of reality, each having its own causally efficacious powers and not reducible to each other

(Archer, 1995). These cognitive structures, it was assumed, can be described through

configurations of rules, human resources, and material resources. Further, these knowledge

structures or “typifications” (Schultz, 1964, 1971) can be visually represented via CCMs

(Bougon, 1992). Cognitive interpretive frameworks associated with sensemaking are assumed to

be both produced and reproduced by organizational structures such as leadership, roles, policies

and directives, collective norms (Goffman, 1967; Parsons, 1951; Giddens, 1984; Archer, 1995;

Schwandt, 1997) standards generated by communities of (aviation) practice (Lave, 1988) (Lave

& Wenger, 1991), and member "background expectancies" (Garfinkel, 1967, p. 37).

CCMs encompass collectively stored beliefs, knowledge, and experiences (collective

action domain) that enable and constrain perception, interpretation, and action (Jelinek, Smircich,

& Hirsch, 1983; Giddens, 1984; Gioia, 1986). As such, it was also posited that an HRO’s

36

distributed cognitive or sensemaking abilities, as well as the dynamics of learning and transfer

(Weick, 1993b)(1997), can be captured and analyzed by congregate cognitive mapping (Bougon,

1992; Eden & Ackermann, 1998b). Expanding on the Schultz’ ( 1964, 1971) concept of the

reciprocity of perspective, the heedful interlocking, double-interacts associated with HRRAs

manifested by the CCM is a reciprocity of cognitions (actions) focused on purposeful and

heedful behavior in the high reliability domain.

Finally, the use of language, words, and dialogue offers evidence of the structuring of

cognition and action (Pierce, 1955; Vygotsky, 1997; Riegel, 1973; Sayer, 1992; Layder, 1990;

Weick, 1995; 1996b; 1999 and Pennebaker & Francis, 1999). The cryptic words or labels in the

CCM may point to the “the knowing system” (Pinker, 2000 of organizing for high reliability and

the assembly rules behind the double-interacts which interlock congregant behaviors (Weick,

1969; 1979; Bougon, 1992) may point to the “knowing how system” (Pinker, 2000) of

accomplishing HRRAs. Social constructions of reality as “thought by organizational thinkers”

(Weick, 1979, p. 2) are made possible through structures of cognitions in collectivities that are

recursively created between language and cognition (Riegel, 1973; Cicourel, 1964, 1972; 1981;

Layder, 1990). As such, this sensemaking or RDC can be highlighted through the screening of

linguistic cues for utterances, speech acts or talk tied to specific contexts and action domains

(Cicourel, 1964, 1972; 1981; Predmore, 1991; Bougon, 1992; Symer, 1998). Furthermore, “talk

creates its own logic, turn by turn. At the same time, everyday interaction creates the contexts

and interprets the contingencies out of which next actions spring” (Boden, 1994, p. 215). This is,

in fact, the linguistic organizing of human interaction (Czarniawska (2006) which affords “a

glimpse of the psychic unity of humankind (Pinker, 2000, p. 239). There is a grammar to this

37

organizing, that is a “rule system… which are combinatorial and recursive that allow us to reason

about an unlimited range of cases, often far from our experience (Pinker, 2000, p.285)”.

Delimitations of the Study

The study was delimited to a single HRO, which was specifically examined to investigate

how, that HRO made sense of its daily operational environment. As such, conclusions drawn in

this study are particularistic rather than generalizable (Miles & Huberman, 1994). The purpose is

to explain rather than predict (Sayer, 1992). The primary sources of data were a case study of an

HRO, interviews with the HRO’s participants, observation of these participants, cockpit

recordings of these participants’ on-the-job conversations, and available mishap records

involving similar types of aircraft. The study was also bounded by a discrete five-day time period

and by a unique aviation culture operating within a larger traditional naval organization, the

United States Coast Guard. Finally, the study was conducted by an “insider,” that is, a

researcher whose organizational perspective was informed by a 27-year career in the U.S. Coast

Guard, the same organization that supported the interpretive perspective of natural inquiry in the

current study (Schultz, 1995). The biases of the present researcher are somewhat tempered by

the fact that this researcher is not part of the unique aviator subculture and has never been

formally “indoctrinated” into that subculture.

Limitations of the Study

The study was delimited to U.S. Coast Guard air crewmembers during a routine five-day

LE patrol. To afford a richer understanding of how a unique aviation subculture structures

cognitive capability, an operational C130 aircraft was observed during a routine LE patrol

38

specifically towards eliciting collective cognitive structuring processes. This purposeful

sampling limits the generalizability of the findings, which may not be transferable to commercial

or non-aviation HROs (Sayer, 1984/1992; Eisenhardt, 1989; Miles & Huberman, 1994). The

causal powers of these collective cognitive structures are generalizable only to the extent that the

contexts of these structures are similar as they are necessarily embedded within a cultural context

(Sayer, 1984/1992). And, Lincoln and Guba (1985) claim that no subjective methodology or

interpretation can completely eliminate “misconstruction” and distortion on the part of the

researcher, whether this distortion is “perceptual,” “selective,” or “retrospective” (pp. 298-294).

SIGNIFICANCE OF THE STUDY

The current study has significance from both practical and theoretical perspectives. From

a practical perspective, this study enriches our understanding of how an HRO makes sense of and

collectively avoids potentially disastrous situations. Weick (1993a) stated that the emergence of

collective senselessness (or “absent-mindedness” (Beaty, 1995) or “mindlessness” (Spender,

1998)) is tied to the manner in which a collective is organized and how the meaning frameworks

of the collective’s participants are constructed, sustained, and reproduced. By observing crew

interactional behavior and capturing their thinking and action relationships (CCM) over a five

day period, this study may offer insight into how the fragile networks that often comprise critical,

high-reliability, or otherwise accident-prone organizations can manage failure, enhance

resilience, and detect and avoid disaster.

From a theory of action perspective (Parsons, 1951), in other words, one which

recognizes that resilient HROs “adapt to their environments through changes that emanate from

both performance and learning actions” (Schwandt, 1997, p. 341), the results of this study may

offer insight into the mechanism or structure of cognitions in a collectivity through which an

39

operational and testable construct of RDC for HROs may be pursued. As argued in this paper, we

are pursing a theory of RDC that is linguistic in nature but embedded within a larger theory of

organizational communication (Eisenberg, 2006).

40

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46

FIGURES AND TABLES

Figure 1, A Congregate Cognitive Map Showing Congregating Labels (CLs) and

Congregating Activities (CAs)

47

Figure 2, A Partial CCM drawn to illustrate the layout of the congregating of the SAR Duty

Crew.

48

Procedure Description of Activity Data Generated

Phase One Semi-Structured Group

Interview

Conduct semi-structured interviews of SAR

and LE crewmembers specifically engaging

in discourse about mission role, experiences

and associated stories.

Interview Transcript

Group Format Self-Q

Interview

The Self-Q Interview was used to encourage

the participants to describe their mission role

performance in practice.

Set of Labels for each participant

with respect to performing SAR or

LE

Phase Two 1. Preparation/statement

identification

Analysis of interview transcripts and Self-Q

questions, to prepare a set of declarative

statements about the mission/role

performance of each participant.

For each participant, sets of index

cards, each with a declarative

statement or phrase which reflected

the specific participant’s role

performance.

2. Structured Interview.

Content review, importance

and influence sorting.

During the second Self-Q interview, a

structured sequence of sorts accomplished by

the participant to determine content

comprehensiveness, importance, and

influence rankings of the declarative

statements (the labels).

Ten cryptic "labels", that

are perceived by a participants as

most important in his mission/role

performance with respective to

either the prosecution of SAR or

LE.

3. Completion of MB-

Matrix/Relationship

Questionnaire.

The completion of a participant-specific

questionnaire in which each label (in his

CM) was examined in relation to every other

label in terms of the existence of an influence

link, the direction and magnitude of co

variation, and equivocality. Participants

completed this questionnaire during the

second interview within 1 to 3 days after the

second interview (independently).

After coding (i.e., a strong positive

link = 21, a moderate positive link =

2, no link = 0), an MB-Matrix with

11 rows and 11 columns reflecting

the participant’s perceptions of the

nature of the direct relationships

between the major labels (of his

CM) of interest.

Semi-structured Fifth but non

Self-Q Interview, clarification

of ten most important labels

The coded labels were reviewed with each

participant independently to explore the

meanings of words and phrases behind the

labels and to collect personal experiences and

stories related to mission performance as

well as demographic information.

Interview Transcripts

Phase Three 1. Construction of Participant

Cognitive Maps.

One output file of the CMA analysis program

(Bougon, 1974—2005) was used as input to

the Decision Explorer (DE) Program to

generate graphical displays of cognitive

maps.

Graphical Cause and Influence Maps

for each participant showing labels,

relationships, causality flows,

indegree and outdegree values, and

map shape/organization.

2. Participant Validation of

participant cognitive maps, the

Fourth Self-Q Interview.

Each participant was shown all cognitive

maps of the crew. Participants correctly identified their

own maps from the collectivity of

maps Participants correctly

identified their own maps from the

full collection of maps.

Table I. Summary of Data Generation Procedures

49

Participant* Theme Statement (Constructed by the Researcher)

P Fly the Plane. Focus on getting the plane to the mission site.

CP Validate the Mission Site. Ensure the plane gets to the right mission site.

FE1 Manage Teamwork. Ensure everyone works together to fly the plane.

FE2 Maintain the Plane. Manage the aircraft endurance.

NAV/RAD1 Anticipate SAR. Search/Scan environment for suspicious activity.

NAV/RAD2 Guide the Plane. Plot the course. Define the location of the plane.

DM Anticipate and for Suspicious Activity.

LM Search/Scan for Suspicious Activity.

BA Learn the Job.

*Participant/Role: Pilot (P), Co-Pilot (CP); Flight Engineer (FE); Navigator/Radio Operator

(NAV/RAD); Drop Master (DM); Load Master (LM); Basic Aircrew (BA).

Table II, LE Crew Theme Statements

50

Possible Congregations

*(LCoCCMs)

(Congregate Roles )

Common Relevance

(Frequency of Shared

Label Use)

Possible

Congregating

Actions

(Researcher’s

Interpretation of

Labels Convergence)

Congregating Label

(Official Keywords or

Public Labels used

among

crewmembers)

P/CP/NAVRAD2 location flight planning Flight Phase: Cruise

“Operational Descent

Checklist”

“Search/Patrol

Checklist”

“Presearch/Patrol

Checklist”

P/FE2/NAVRAD1 lodging/supplies sustainment

P/CP/NAVRAD1 weather flying

P/CP/FE1/NAVRAD1/NAVRAD2

/LM/DM

mission scenario mission planning

P/CP/FE1/NAVRAD1/NAVRAD2 a/c (aircraft) readiness a/c performance

monitoring

P/FE1/FE2/NAVRAD2/DM a/c readiness repair operations

P/CP/LM required fuel fuel monitoring

P/NAVRAD2/LM a/c control unit tasking management

CP/NAVRAD2 alternate airports contingency planning

FE1/NAVRAD2/LM crew fatigue safety monitoring

FE1/FE2/NAVRAD1/LM cooperation crew facilitation

NAVRAD2/DM/BA personal learning On-the-Job training

*Local Centrality of the CCM – congregations or participants with labels strongly linked around

specific LCoA (clusters of CAs/Activities/Tasks).

Table 3. Possible Crewmember Congregations (LCoCCMs) Once Common Relevance

(Criterion 1), Causal Directionality (Criterion 2) and Mutual Interdependencies (Criterion

3) are identified.