Reiman, T. (2011). Understanding maintenance work in safety-critical organizations – managing the performance variability.

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Understanding maintenance work insafety-critical organisations – managingthe performance variabilityTeemu Reiman aa VTT , PO Box 1000, FIN-02044 VTT, Espoo, FinlandPublished online: 19 May 2010.

To cite this article: Teemu Reiman (2011) Understanding maintenance work in safety-criticalorganisations – managing the performance variability, Theoretical Issues in Ergonomics Science,12:4, 339-366

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Theoretical Issues in Ergonomics ScienceVol. 12, No. 4, July–August 2011, 339–366

Understanding maintenance work in safety-critical

organisations – managing the performance variability

Teemu Reiman*

VTT, PO Box 1000, FIN-02044 VTT, Espoo, Finland

(Received 7 October 2009; final version received 18 February 2010)

Human and organisational performance variability has been identified as a causeof many latent and active failures in maintenance. Seldom has the variabilitybeen considered as an integral and inherent part of the maintenance activity tobe managed by organisational means. The article deals with the challengeof understanding maintenance work in safety-critical organisations. The aim is toreview the current literature on maintenance work and illustrate the organisa-tional research challenges of managing performance variability in maintenance.This article presents six major research challenges in managing performancevariability in maintenance. The article concludes by noting that a holistic theoryon maintenance work is needed to manage the variability and turn it intoa positive force. Maintenance has the potential to produce positive performancevariability and guard against negative instability in complex sociotechnicalsystems.

Keywords: maintenance; human and organisational factors; system safety;performance variability; organisation theory

1. Introduction

1.1. Maintenance work as safety-critical activity

Maintenance is a hazardous activity. In addition to hazards related to process orproduction safety, maintenance work involves occupational safety hazards of variouskinds (physical forces, chemicals, radiation, etc.). Thus, maintenance organisations can beconsidered as safety-critical organisations. This means that safety is a central goal of themaintenance organisation and the organisation has to identify, remove, control andprevent the various hazards associated with its work. Several accident investigationshave uncovered inadequate or faulty maintenance as one of the main contributorsto unanticipated events in various safety-critical domains, including the railway, offshoreoil drilling, chemical, petrochemical, aviation and nuclear industries (Department ofTransport 1989, Pate-Cornell 1993, Marx and Graeber 1994, p. 88, Wright 1994,Reason 1997, Hale et al. 1998, Kletz 2003, Reason and Hobbs 2003, Perin 2005, Baker2007, Sanne 2008a). Thus, maintenance activities can be considered as having a highlysignificant positive or negative impact on the effectiveness of the entire sociotechnicalsystem, including safety.

*Email: [email protected]

ISSN 1463–922X print/ISSN 1464–536X online

� 2011 Taylor & Francis

DOI: 10.1080/14639221003725449

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Maintenance activities have been under various organisational changes andrestructuring initiatives, aiming at, e.g. reduced costs, increased availability of themachines, better knowledge sharing and increased flexibility (Patankar 2005b, Reimanet al. 2006, Pettersen 2008). This development has been going on for years in varioussafety-critical domains. For example, in the aviation domain, the US Federal AviationAdministration has identified a need for better efficiency in aviation maintenance to copewith the ever-growing workloads caused by the increase in the number of passenger milesflown by the airlines. The rise in traffic has not been accompanied by a similar increasein resources, e.g. the number of maintenance technicians. Price-based competitionhas reduced revenues and forced the companies to take various cost-cutting measures,including outsourcing maintenance, leasing instead of buying aircraft and layoffs(Patankar 2005b). In the nuclear industry, ageing plants and equipment (OECD/NEA2000), the ongoing generation turnover (OECD/NEA 2001) and the deregulation of theelectricity market (Bier et al. 2001) have been the main drivers in the recent organisationalchanges (see also IAEA 2001, OECD/NEA 2002). These changes put an even strongeremphasis on understanding the maintenance work and its requirements as well asmanaging the performance variability in maintenance.

This article deals with the challenge of understanding maintenance work insafety-critical organisations and its characteristic sources of performance variability.The aim of this article is to review the current literature on maintenance work insafety-critical organisations and to illustrate, with the help of the literature review andtheoretical work, the organisational research challenges of managing performancevariability in maintenance work.

1.2. Performance variability in maintenance

One of the challenges of maintenance work is that while it is necessary for the technologyin use, it can be a source of latent as well as active failures in the system. In addition, someof the errors are hard to notice. Errors made during preventive maintenance can manifestafter a long time. Quick fixes in failure repairs might do more harm than good in the longrun. Event investigations almost always find actions outside the prescribed boundaries andlabel these human errors or violations (Reason 1997). The foci of studies on humanperformance variability are usually biased towards the negative effects of variability,discounting the potential positive effects (cf. Hollnagel 2004, 2009b, Roth et al. 2006,p. 181, Pettersen 2008, p. 84) or the fact that performance variability is found in all humanwork (Hollnagel 2009b, p. 85), including maintenance. Human performance variabilityis as much a cause of safety as it is a cause of errors and accidents (Hollnagel 2009b).

Maintenance work is characterised by the requirement of acting under uncertainty(cf. Norros 2004, Reiman 2007, Pettersen 2008). The amount of information, dynamicrelations between phenomena and the connections between environmental cues are so vastthat there can never be full certainty of the effects of the maintenance actions or of thevarious phenomena associated with the object of work. It is important to understandthat uncertainty is never caused by an individual alone but is rather related to the objectof work, such as the condition of technical systems in nuclear power plants (NPPs) or thereliability of measurement data in process control. The object of work containsuncertainty; the progress and effects of work can never be fully predicted. This is whyemployees really should feel a suitable amount of uncertainty when dealing with them.Recognising and coping with uncertainty is related to the development of expertise

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(Klemola and Norros 1997, Norros 2004) and decision making, in general. Thus,

maintenance work is by its very nature variable and requires variability also in humanperformance.

In safety-critical organisations, rules and procedures are often considered to be a way

of improving the reliability of the activities of humans and organisations. This notion isbased on the (as such correct) notion that humans are forgetful and prone to error. Rules

and procedures try to control these ‘human’ characteristics. Rules and procedures areconsidered as safety barriers to the troublesome variability of human performance

(cf. Hollnagel 2004, Oedewald and Reiman 2007a). Also, the rule designers often think of

procedures as tools for controlling the worker, not as tools for the worker to control his orher work (Dien 1998, p. 181).

Performance variability has been studied from various perspectives, commonly placed

under the title of human and organisational factors. There are two main approaches tocounteracting and controlling performance variability: the first builds on restricting

and constraining human behaviour through rules and procedures, the second builds on thestrengths, competence and motivation of the personnel. The former approach is based

on the assumption that variability is inherently bad, whereas the latter approachtreats variability as a source of both successes and failures (cf. Hollnagel 2004, 2009b).

These same underlying assumptions can also be found in the maintenance literature.

Next, we will look at the current literature on maintenance work and illustrate the variousapproaches taken towards managing the performance variability in the context of

maintenance.

2. Review of current literature

2.1. Human errors as a source of performance variability

The focal point of concern for research in maintenance work has been on the performance

of individuals. Research has focused on unsafe acts, decision making and errors.Following Reason’s (1990, 1997) groundbreaking studies of human error and maintenance

in nuclear power and aviation, research on human errors in maintenance in various

safety-critical domains has aimed at classifying, predicting and preventing human errorsor minimising their consequences (Marx and Graeber 1994, Laakso et al. 1998, Fleishman

and Buffardi 1999, Isobe et al. 1999, Latorella and Prabhu 2000, Gibson et al. 2001, Pyy2001, Svenson and Salo 2001, Toriizuka 2001, Hobbs and Williamson 2002, 2003, Reason

and Hobbs 2003, Dhillon and Liu 2006). Maintenance errors have been traced as a sourceof several aviation accidents and incidents, and it has been reported that the number of

maintenance-related accidents has been on the increase (McDonald et al. 2000, p. 154,

ATSB 2001, p. 1). All in all, maintenance has been identified as a major source of latentfailures in sociotechnical systems (Reason 1990, 1997).

The aim of many studies has been the identification of the most common types of

errors as well as the most effective countermeasures. For example, Hobbs and Williamson(2003) studied 619 self-reported safety occurrences involving aircraft maintenance.

They categorised error types, outcomes and contributing factors. According to thestudy, the most frequent error was a memory lapse in which a person forgot to perform an

intended action (Hobbs and Williamson 2003, p. 195). Memory lapses were associated

with pressure, fatigue and environmental (e.g. noise, lighting) contributing factors. Whendiscussing their results, they note that ‘it is possible that aircraft maintainers routinely

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perform their assigned tasks in the face of challenges such as fatigue or time pressure’(Hobbs and Williamson 2003, p. 199).

With a similar aim as Hobbs and Williamson (2003), Laakso et al. (1998, see also Pyy2001) reviewed approximately 4400 failure reports from a Finnish NPP from the periodof 1992–1994 and searched for human errors related to maintenance. They were especiallyinterested in human-related common cause failures (CCF)1 and the mechanisms causingthese failures. For single human errors, they (Laakso et al. 1998) identified instrumen-tation and control (84 cases out of a total of 206 single human errors) plus electricalequipment (40 cases) as being more error prone than other kinds of maintenance. Laaksoet al. (1998) identified 14 CCF from the failure reports. The distribution of CCF wassimilar to single errors; they all occurred to either instrumentation or electrical equipment.Also, similar to single human errors and contrary to many other studies (Hobbs andWilliamson 2003, Reason and Hobbs 2003) the most dominant error category was thatof commission. Weaknesses in work planning and in the design and layout of theequipment from the maintainability point of view (cf. Seminara and Parsons 1982)contributed to many of the human errors identified by Laakso et al. (1998). These authorsfurther identified that most errors had stemmed from the refuelling outage periods andplant modifications and that they were discovered only after the outage during poweroperation.

Reason and Hobbs (2003) note that the most common human errors in maintenancein NPPs as well as in the aviation industry are errors of omission: failing to do somethingthat should have been done (see also Reason 1990, Hobbs and Williamson 2003, Patankarand Taylor 2004b). They also note that these errors are commonly associated withreassembly or installation activities. They have categorised the major types of unsafe acts:

. recognition failures, such as misidentification of objects or signals andnon-detection of problem states;

. memory lapses, such as failure in encoding, storing or retrieving information;

. slips of action, such as executing a familiar task wrongly due to absent-mindedness or external distraction or slipping into a familiar course of actionwhen required or intended to perform a less familiar action;

. errors of habit, such as applying bad rules and developing bad routines that haveno immediate negative effect;

. mistaken assumptions, such as applying a good principle or rule-of-thumb in asituation for which it is not appropriate;

. knowledge-based errors, such as problem solving in new situations or unfamiliartasks;

. violations, such as intentional deviations from procedures to save time, getthe job done or due to personal thrill-seeking (Reason and Hobbs 2003,pp. 40–58).

Some of the types of unsafe acts identified by Reason and Hobbs (2003) such as badroutines can be called performance-shaping factors that increase the probability of humanerrors. The conditions and factors influencing human errors have also been extensivelystudied. Suzuki et al. (2008) asked in their article on aviation maintenance relatedincidents, ‘why cannot (the already established) safety procedures prevent human errors’.Their study showed that coordination problems weakened these safety procedures. Theycall for increased sense of responsibility for preventing future coordination failures.Patankar and Taylor (2004a, 2004b) have listed the ‘dirty dozen’ (originally developed byGordon Dupont in 1993 as the key component to the human performance in maintenance

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workshops), or 12 performance-shaping factors that cause human errors in maintenance(Figure 1).

The factors in Figure 1 show that errors are ‘caused’ by qualitatively very differentphenomena, including issues at the individual, group and organisational levels. In orderto shed more light on performance variability in maintenance as well as on how safe orunsafe acts are decided on, studies have tried to identify sources of professionalismin maintenance, including decision-making strategies, rule following and mental models orconceptions concerning the maintenance work.

2.2. Professionalism and decision making as contributing to performance variability

A classic work that sheds light on the technician’s work within an organisational contextis that of Orr (1996). He has conducted ethnography on the work of field servicetechnicians at Xerox. He noted that the technical knowledge and the professional identityof the technicians were strongly dependent on face-to-face encounters between thetechnicians and on the task-related stories (‘war stories’) that they shared (cf. Barley 1996).These stories ‘combine facts about the (copying) machine with the context of specificsituations’ (Orr 1996, p. 127). He (Orr 1996, p. 91) also argues that ‘when technicians talkabout specific machines in their territories (areas of responsibility), it is clear that thesemachines are individuals. Their different histories, different patterns of use, and differentsocial environments have given them each a distinct character for those who know.Given this individuality, the machines may be discussed with as much ellipsis as anymutual acquaintance’. He noted that the technicians consider the machines to be both‘perverse and fascinating’. What really interests the technicians is a failure situation thatthey do not understand (Orr 1996, pp. 95–97). They take pride in being able to cope withthe machines. The technicians must diagnose, repair, maintain and adjust the machinesin an environment that is ‘inherently unpredictable’. Orr (1996, p. 104) notes that ‘in all ofthese activities, and perhaps most critically in diagnosis, the technicians must understandthe machines’. Understanding is central also for anticipating and preparing for futureproblems. Orr points out that the corporation had a different view of the technicians’work, one that emphasised not understanding but rather the following of directivedocumentation (see McDonald et al. (2000), for a similar finding in aviation maintenance).On the other hand, ‘in providing directive documentation, the corporation is assumingresponsibility for solving the machine’s problems, and in the eyes of the corporation,technicians are only responsible for failure to fix a machine if they have not used thedocumentation. However, while the technicians are quite willing to let the corporationassume any blame, their own image of themselves requires that they solve the problemsif at all possible’ (Orr 1996, p. 111).

Lack of resources

Distraction

Pressure

Complacency

Stress Unsafe norms

Fatigue

Lack of knowledge

Lack of awareness

Lack of assertiveness

Lack of communication

Lack of teamwork

Figure 1. The ‘dirty dozen’ elements causing errors in aviation maintenance according to Patankarand Taylor (2004a, b).


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Orr (1996) conducted his study in a non-safety-critical domain. However, somewhatsimilar tensions and ambiguities towards rules have been identified by McDonald (2006)in aviation, Bourrier (1996) and Reiman and Oedewald (2006) in nuclear and Lawton(1998) and Sanne (2008a) in the railway context. Orr’s (1996) findings on the motivationand interests of technicians also parallel those identified by Reiman and Oedewald (2006)in NPP maintenance.

McDonald (2006) summarises the results from a series of European projectsconcerning aircraft maintenance. He notes that the technicians did not follow theprocedures routinely. They often justified their violations by reporting that there were‘better, quicker, even safer ways of doing the task than following the manual to the letter’(McDonald 2006, p. 161, see also McDonald et al. 2000, cf. Dekker 2005, pp. 134–138,Hobbs and Williamson 2003, p. 196). Also, according to McDonald (2006, p. 163), formany aircraft maintenance organisations, ‘there appears to be an unresolved tensionbetween effective planning and the requirement of flexibility to meet the normal variabilityof the operational environment’. He then generalises from a number of surveys in differentorganisations the core professional values of aircraft maintenance personnel. These valuesincluded the following characteristics:

. strong commitment to safety;

. recognising the importance of teamwork and coordination;

. valuing the use of one’s own judgement and not just following rules;

. being confident in one’s own abilities to solve problems;

. having a low estimate of one’s vulnerability to stress;

. being reluctant to challenge the decisions of others.

Taylor and Christensen (1998, pp. 83–84) have defined the characteristics of aprofessional aviation maintenance technician as including competence, centrality, controland commitment regarding flight safety.

McDonald (2006) noted that the above-mentioned professional values in many waysmatched the deficiencies found in the same organisations. Professionalism compensates fororganisational dysfunction. A problem is that the ‘double standard’ of work as formallyspecified and unofficial ways of working is hidden (McDonald 2006). McDonald et al.(2000) and McDonald (2001) argue that evidence from aviation maintenance indicatesthat the current quality and safety management systems do not provide an adequatepicture of the way the work is actually carried out, partly due to this ‘double standard’.

Reiman (2007) studied maintenance culture at three Nordic NPPs. He carried out threein-depth case studies with his colleagues (Reiman et al. 2005, Reiman and Oedewald 2006).The case studies employed interviews, surveys, seminars, document analysis and groupwork. The study consisted of an analysis of maintenance culture combined with a core taskanalysis (cf. Norros 2004) of the maintenance core task. On the basis of core taskmodelling, the maintenance core task was defined as balancing between three criticaldemands: anticipating the condition of the plant and conducting preventive maintenanceaccordingly, reacting to unexpected technical faults and monitoring and reflecting on theeffects of maintenance actions and the condition of the plant. The overall objective of themaintenance activity was defined as follows: maintaining the operational reliability andthe economic value of the nuclear installation so that its power production can continue aslong as planned. The case plants differed in terms of their emphasis on, the interpretationof and the culturally accepted means of carrying out the demands of the maintenance task.Despite this, they shared similar conceptions about the goals of maintenance and theparamount importance of safety in the maintenance of an NPP. However, sense of control,

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sense of personal responsibility and organisational changes emerged as psychologicallychallenging issues at all the plants. Critical attitudes towards management and the valuesprevalent in the organisation existed at all the plants. The hands-on nature of maintenancework was emphasised as a source of identity at the NPPs. Maintenance work produceda feeling of meaningfulness, especially when there were technical problems to solve orfailure repairs to conduct. Overall, the importance of safety was taken for granted,but there was little reflection on the cultural norms concerning the appropriate means toguarantee it. Reiman (2007) proposes that maintenance work should be considered asknowledge-intensive work and concludes by arguing that the nature and significanceof maintenance work should be better acknowledged by the maintenance workersthemselves and by other parties (e.g. operations and technical groups).

Carroll et al. (1998) have studied decision making in the context of maintenance.They present evidence for the failure to give ‘due consideration for preventivemaintenance’ (cf. Seminara and Parsons 1982, p. 186) in two domains: nuclear andchemical. They show how mental models and implicit assumptions influence decisionmaking. Both industries had trouble developing their programmes of preventivemaintenance. Carroll et al. (1998, pp. 109–110) argue that difficulties in managingmaintenance arise, in part, from limitations in mental models, which they define asindividual, shared and embedded beliefs and understandings. They write: ‘Preventivemaintenance is a prototypical activity that seems to be a low priority in the face ofimmediate demands to keep the machines running at lower cost, and the ultimate effectsof deferred maintenance can be denied, ignored, or blamed on others’ (Carroll et al. 1998,p. 110). They then demonstrate how a company in the chemical industry tried to changefrom a culture of ‘corrective maintenance’ to a culture of ‘preventive maintenance’ witha maintenance game. The mental models, however, proved very hard to change.

These studies have illustrated the complexities of the interaction between thetechnicians and the technical system as well as the challenges facing the personnel inmaking decisions within the social context of the maintenance organisation. The findingsemphasize the need to take into account the social and organisational aspects in order tobetter understand human performance and its variability in maintenance.

2.3. Performance variability in a social context

Rule bending and rule deviations are a typical management challenge in maintenancecontexts. There are some studies that shed light on the social factors affecting rule bending.For example, in the maintenance organisation of an NPP studied by Reiman andOedewald (2006), rules and procedures were a source of tension and ambiguity for thepersonnel. They were afraid of losing their professional identities as skilled craftsmen andbecoming ‘a small cog in a big machine’, but they felt this was the goal of the organisationand also to some extent their daily reality (Reiman and Oedewald 2006). They felt that thestrong tendency to standardise and proceduralise tasks threatened their job motivation,the meaningfulness of the work and their ability to carry out the daily work (cf. Hackmanand Oldham 1980, p. 75, Bourrier 1996, p. 106, Dekker 2005). Sanne (2008a, p. 647) alsopoints out a need in railway maintenance to identify the practices of risk taking and rulebending and the process of how they are produced and reproduced in the social context ofmaintenance.

Often adaptation and interpretation of rules is considered an integral part of thework. Pettersen (2008) has studied the human role in producing safety in aircraft


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line maintenance. His interest was to study the social structure and human agency, andtheir relationship in the production of safety. He provides empirical accounts of how thetechnicians conduct their work and make decisions within the social context in whichthey work. He utilised participant observation, document analysis and interviews in aNorwegian aircraft maintenance company. His analysis emphasised the roles of humanagency – the capacity of the technicians to decide and act – and the unofficial social systemin creating safety. Pettersen argues that the technicians constantly sought to revise theirknowledge and their degree of certainty about it. He illustrates how the technicians bothvalued and distrusted formal descriptions of work (procedures, rules and regulations)as guides for work practice. The technicians adapted their practices and local organisingdepending on the situation at hand. These adaptations were, however, supported by astrong cultural imperative to achieve safety and by the technicians’ awareness of theimperfection and uncertainty of both knowledge and practice. Pettersen (2008, p. 85)notes that ‘technicians’ individual choices and actions take place within the context of ahistorical system where, among other things, maintenance planning, materials supply,a legal institutional framework and safety management systems constitute structuredrelationships of actions that constrain and enable how the technicians can act in ways notregularly accounted for’.

Bourrier (1996, 1999) has compared practices in four maintenance units in Franceand the USA. She spent between 3 and 4 months at each site and conducted a total of300 interviews. She noted differences between the units in, e.g. the coordination of work,the structuring of the tasks and the role of procedures during the annual outages of theplants. Each plant had its own official or unofficial way of following the procedures andacting when the procedures did not cover the work in question. For example, at one of theplants, organisational reliability was based on situational improvisation when no suitableprocedures could be found. Foremen unofficially accepted the practice and trusted theexpertise of their workers and themselves. At another plant, reliability was based onfollowing the procedures strictly; for cases where no procedure existed, the plant hada procedure with which the appropriate procedure could be quickly produced. Accordingto Bourrier, a drawback of this strategy was that it did not support individual decisionmaking on the part of the workers. In conclusion, Bourrier states that ‘local adjustmentsto and re-arrangements of rules and, at times, even rule violations, are not only constantbut necessary for organizations to effectively pursue their goals’ (Bourrier 1996, p. 106).

Sanne (2008b) studied incident reporting and storytelling in railway infrastructuremaintenance. He was interested in the reasons for the low number of reported incidentsand its consequences for organisational learning. He illustrates how different accidentaetiologies shape incident reporting and storytelling. For the railway technicians, anaccident is seen as a ‘breakdown of occupational practices, skills, and values, rather thanas a system breakdown’ (Sanne 2008b, p. 1212). Consequently, this shapes what isconsidered an incident in the technician’s community. On the other hand, incidents thatpose a threat to the technician’s identity as a responsible and careful professional can beframed as insignificant – a one-off event – in terms of learning. Shame, blame and fear ofdisciplinary actions decrease the willingness to submit reports. Some of the technicians hadnever thought about what the organisation as a whole can learn from incidents. Also, themodest and often negative feedback the technicians get from the reports they have madedoes not promote further reporting – or learning. Incidents that do not result in injury arenormalised as ordinary, unproblematic practice, not requiring learning or other correctiveactions. In the occupational aetiology of accidents, the attention warranted by an event isdefined by the severity of its consequences rather than its causes and potential effects.

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Storytelling, in contrast, is a more attractive practice to technicians, since it promotesthe reproduction of occupational communities and provides a means of transferringknowledge to, e.g. newcomers. However, storytelling is usually restricted to local practiceand does not address the systemic causes behind the accidents and incidents. The storiesare also often told as a way to justify and legitimise technicians’ practice rather thanto teach something new.

Studies on the social aspects of maintenance have clarified the role that group-levelfactors play in the maintenance context. They have shown how the social context playsa dialectic role with the formal ways of organising and managing maintenance. Localpractices influence and are influenced by the organisation-level practices, procedures andrules of conduct.

2.4. The influence of the organisation and management of maintenance activitieson performance variability

Pettersen and Aase (2008) have studied safe work practices in aviation line maintenance.They argue that the features of safe practices in aviation maintenance are dependent onslack resources in the organisation. They conducted a qualitative study of the linemaintenance organisation of a Norwegian regional airport with the aim of understandingthe dynamics of safe work practices. They demonstrate how the line techniciansemphasised the importance of practical competence, e.g. in defining the ‘normal’ operativestate of a component or a technical system. The formal maintenance documentationsystem had ‘grey areas’, where experience, practical skills, support from colleagues andtrial-and-error strategies were required in troubleshooting and problem solving.Level-headedness and humility about one’s own skills and knowledge were consideredas desirable traits by the technicians. Further, as the technicians were under a constantpressure to get airplanes operational within planned schedules, they had institutionaliseda way of slowing things down in order to create slack in the otherwise tightly coupledsystem. Recent changes in the organisation further reduced slack and transformed, e.g.communication practices between technicians and pilots. Pettersen and Aase (2008)conclude that slack in organisations (e.g. in the form of time, knowledge, competenceand tangible assets) can be viewed as structural preconditions for the existence andeffectiveness of several forms of safe practices. They caution against treating slack solely asa waste to be rid of in the organisation.

Herrera and Hovden (2008) have studied leading (proactive as opposed to reactive)indicators applied to aviation maintenance. Their aim was to understand leadingindicators in the framework of resilience engineering and their ability to provideinformation on changes in risk. They argue that leading indicators should provide a signalof unintended system interactions and focus on the normal operation of the system insteadof failures. They give some examples of leading indicators: ‘the resources available, thecapacity to identify circumstances beyond the experience (of the maintenance personnel),the possibility to reflect-on-action, openness, communication, the current technical stateof the aircraft, maintenance oversight, and implementation of preventive maintenance’.

Bier et al. (2001) have studied the effect of deregulation on safety in the US aviationand rail industries and the UK nuclear power industry. They raised the issue that cuttingcorners in maintenance in these industries is a troubling trend from the safety point ofview. Another growing issue after deregulation was mergers and acquisitions. Bier et al.point out that organisations cannot always accurately predict the (safety) impacts of


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restructuring and downsizing. The safety impacts of organisational changes have beensurprisingly little studied in maintenance or other safety-critical fields (Reiman et al. 2006).Ramanujam (2003, p. 614) argues that the ‘current explanations of the organizationalorigins of accidents understate, or even ignore, the role of organisational change’.According to the few studies that have been made, some common issues of concernin organisational changes include vague responsibilities about safety matters during thetransition period from one organisational form to another, loss of competence,deteriorating morale and employee motivation, deteriorating relations between employeesand managers, and stress or excessive workload among the personnel (Bier et al. 2001,Kecklund 2004, Reiman et al. 2006, Pettersen and Aase 2008, Herrera et al. 2009). Herreraet al. (2009) express in their study on changes in aviation a worry on the safety effectsof increased subcontracting of maintenance activities at airline operators. They recom-mend that before outsourcing the companies should conduct risk analyses to considerwhat parts of the maintenance function and what competence is needed to keep in-house inorder to ensure safety.

Pettersen and Aase (2008) studied the role of change and restructuring in the linemaintenance organisation of a Norwegian regional airport. The technical organisation,including its line maintenance department, was merged with a larger airline’stechnical organisation, which functioned as a business unit separate from the airline.They write:

Before parts of the technical organisation were sold and all technical functions were ‘underthe same roof’, all personnel and resources could be directed towards line maintenance(i.e. first-line operations) if needed. Enabled by the social structure and culture of theorganisation . . . these resources functioned as reservoirs of knowledge, competence andresources that could be used by line maintenance in their efforts towards creating safepractices. As soon as parts of the organisation were sold, for example the engine repair shop,structural ‘walls’ were built taking away slack and dwindling the knowledge and competenceboundaries of the line maintenance department. These changes do not directly produceaccident risk, but change the dynamics of operational practice.

They also noted changes in the information flow, opportunities for learning, communi-cation between technicians and pilots and the amount of training (especially refreshercourses) offered. This means that change efforts alter the ways in which safety is achieved.The line technicians expressed their concern about losing operational experience andknowledge in the new organisation.

Reiman et al. (2006) have studied the safety effects of recently implemented changesin four Nordic NPP maintenance organisations. Their analysis of selected changes showedthat all of these changes faced plenty of obstacles and had unforeseen or unintendedconsequences or side-effects on organisational practices and culture. Cost reduction,enhancement of the efficiency of maintenance activities and maintaining and developingcompetence were identified as goals of all of the reviewed changes. In addition to thesegoals, the interviewees came up with many other secondary or implicit goals. Many ofthese dealt with cultural issues such as communication, status, personnel issues andstagnation (‘waking up’ the organisation). Some of these goals were explicit, some implicit,but they all affected the way the change was carried out and eventually the outcomes of thechange process. Despite the prevalence of ‘soft’ goals, few organisational and personneldevelopment methods were used in these cases. Change management was approachedfrom a very technical standpoint, and Reiman et al. (2006) concluded that a more dynamicframework, including the consideration of human and organisational factors, is neededfor assuring safety during change in safety-critical organisations.

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Studies on the organisation and management of maintenance activities have illustratedthe effect of the organisational structural solutions and especially, change in thosesolutions to the performance variability. Change creates instability in the organisation andexposes the organisation to the negative effects of performance variability. These effectsare exacerbated if there is ambiguity among the personnel about the organisational goalsor priorities.

2.5. Goal conflicts creating conditions for performance variability

Due to the characteristics of the work (close contact with machinery or a running process,exceptional work conditions, time pressures, etc.), maintenance operations are challengingin terms of occupational safety. Maintenance activities can thus be viewed as posing a riskto humans (Lind 2008, p. 928). Occupational safety has been studied, for example,in aviation maintenance by Neitzel et al. (2008), in railway maintenance by Sanne (2008a)and Farrington-Darby et al. (2005) and in Finnish industrial maintenance, in general,by Lind (2008). Research on occupational safety in maintenance often draws on some ofthe theoretical approaches presented above – often on the human error view. Occupationalsafety studies that consider the relation of occupational safety to the other goals of thesystem are reviewed in this section.

Mercier (1988, pp. 86–87) characterises the maintenance work of an NPP as follows:‘It is rare for so many non-repetitive tasks to be concentrated in an industrial environmentthat is so very hostile to human activity. The forces in this environment are considerable.Temperatures, pressures, the multitude of fluids, mechanical power, omnipresentelectricity, even the sheer weight of the equipment . . . all culminate to make maintenanceactions potentially dangerous and to weigh against success. The ‘‘nuclear’’ hazard and theassociated radiation protection restraints are simply one more risk, but a risk that is oftenquite minimal compared to the others’. In all safety-critical domains, there are variousoccupational risks that affect the way work is carried out and that have to be balancedwith the other goals of the organisation, such as efficiency, economics and system orproduction safety.

Reason and Hobbs (2003, p. 59) argue that different forms of human errors areassociated with incidents threatening the safety of operation and with incidents threateningworker safety. Thus, different remedies are needed to address both types of outcomes.According to Reason and Hobbs, the three most common types of errors threateningoperation safety are (in descending order) memory lapses, violations and knowledge-basederrors. Worker safety is threatened especially by slips of action and violations. Lind (2008,pp. 929–930) found in her study of accident reports that the most importantlatent conditions in fatal or non-fatal occupational accidents in industrial maintenancewere defects in planning or managing the work and defective work instructions(cf. Reason 1997).

Sanne (2008a) conducted ethnography of railway infrastructure maintenance inSweden. He studied how the maintenance personnel framed occupational risk-taking.Sanne (2008a, p. 645) notes that the railway technicians have a double-order relationshipto risk: ‘their job of achieving public safety and protecting the public from risk necessarilyexposes them to occupational hazards’. In addition, they ‘must trade train safety againstother ends, such as punctuality, time limits, economic constraints, and their own safety’(Sanne 2008a, p. 646). Sanne argues that the technicians took occupational responsibilityfor transportation safety hazards since their tasks are safety-critical. They further


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considered that it is important to understand the safety consequences of one’s actions in

a tightly coupled and complex railway context. He illustrates how the technicians beara sense of responsibility for each other’s safety. Occupational risks are constructed as

manageable with reference to technicians’ competence and to mutual responsibility and

trust in the team. Sanne (2008a, p. 652) writes that ‘interdependence in a team and fatalconsequences imply that to be a responsible railway technician, one must be able to take

care of oneself and ensure team safety, irrespective of formal roles and responsibilities’.

On the other hand, the technicians’ occupational responsibility also entails responsibilitytowards passengers. An attitude or collective aim of ‘making it work’ existed in the

technicians’ community, and it biased their actions, encouraging them to do what isneeded under given circumstances, even if this entails ‘rule bending and risk taking’

(Sanne 2008a, p. 653). They are sacrificing their own health and safety to assure the safety

of others. Sanne concludes his analysis by noting that technicians take occupational risksto compensate for inadequate planning, time or resources: matters that should have been

handled by the corporation. Thus, risk taking is an expression of responsibility, skill and

control, and it is not conceived as ‘risk taking’ for the sake of thrills or adventure.Patankar (2005a, 2005b) presents an overview of ethical challenges in aviation

maintenance in a case study of ethical challenges faced by six mechanics working for a

major airline company in the USA. He distinguished several characteristics that inspiredone of the mechanics, ‘Joe’, to raise safety issues and violations: personal confidence in his

skills, professional pride, support from peers and an understanding that the general public

is his real boss; that he is working to guarantee their safety. Patankar identifies three mainethical challenges in aviation maintenance: (1) ‘data smoothing’, where data is falsified

so that it is within certain allowable limits, (2) ‘pencil-whipping’, which means signing fora job that has not been performed and (3) ‘not knowing when to act’, which refers to the

inevitability of numerous procedural violations in aviation maintenance on part of all the

parties involved. Patankar (2005a, 2005b) then considers the transition of mechanics intomanagers and raises the issue of why some managers who are familiar with the regulations

still put their mechanics into higher risk situations. He proposes that the reason is that

when a mechanic becomes a manager, his goals change from being primarily heldaccountable for safety to being held accountable for on-time performance. For the

managers, the major ethical challenge is thus the issue of safety versus financial survival.

Patankar (2005b) points out how the ethical challenges in maintenance are exacerbated bythe economic and social challenges of the industry as a whole. These economic challenges

have led airlines, e.g. to outsource maintenance activities and lease airplanes instead ofbuying them. The mechanics perceived that the industry is focusing more on cost-cutting

and profits than safety, and felt that this decreased their job satisfaction. Patankar (2005b)

recognised four common themes among the mechanics he interviewed: (1) passion foraviation, (2) commitment to safety, (3) role models and defining moments and (4) ‘square

peg in a round hole’, in other words a sense of disconnection between the maintenance

workforce and the company. Patankar (2005b, p. 47) writes: ‘Ultimately, the aboveindividuals are committed to safety because of a strong sense of social responsibility

entrusted in them by the virtue of their profession’. He also shows the importance of rolemodels and stories in the character development of the mechanics. The different

orientations of the supervisors and the mechanics are illustrated by a quote from one

technician:

I had a supervisor tell me once, that the airplanes come in for a ‘check and service’. I explainedto them, no they do not, they come in for ‘inspect and repair’. There is a major difference

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there. . . . I have very serious problems with that thought process (of avoiding repairs), theairplane is in, it’s down, it’s there to be repaired, and sent back out in as good a fashion aspossible. . . . (Patankar 2005b, p. 52)

The dual objectives of maintenance in ensuring safety and maintaining operationsor schedules and the general tension between safety and efficiency have been identified inmany studies (see, e.g. Endsley and Robertson 2000, Dekker 2005, Kettunen et al. 2007,Gomes et al. 2009).

Professionalism, including competence, personal responsibility and capacity forsituational judgement or adaptation, emerges as an important dimension in balancingthe different organisational goals. Thus, maintenance personnel seem to consider thecapability for performance variability an integral aspect of professionalism. However, it isnot clear what constitutes professionalism in a maintenance context and by what meansit can be achieved and developed.

2.6. Competence management and training as controlling for performance variability

Maintenance requires a multitude of skills and a wide range of knowledge. Still,maintenance is often considered as mostly manual labour. Perin (2005) shows in heranalysis of event handling in the nuclear industry how the industry’s culture of controlis very engineering driven, emphasising probabilities, measures and risk estimates. Thisculture largely discounts qualitative and experiential knowledge. These collective waysof thinking influence, e.g. how the power plants convert ambiguity into certainty andseparate judgement from reason (Perin 2005, p. 225). She also emphasises the importanceof maintenance in designing and operating an NPP and agrees on the findings of, e.g.Barley (1996) and Oedewald and Reiman (2003) on the unique knowledge of techniciansand on their work as being more similar to knowledge work or engineering work thanis commonly accepted. Technicians’ knowledge is more contextual than engineers’ ordesigners’ knowledge, and it is based on real-time experience of equipment and its use.Also Samurcay and Vidal-Gomel (2002, p. 159) have stressed the fact that (electrical)maintenance work requires both technical knowledge derived from engineering scienceand pragmatic knowledge including an understanding of the overall work process in theorganisation.

Endsley and Robertson (2000) have applied the concept of situation awareness (SA) toaircraft maintenance teams. They define SA as a three-level phenomenon; level 1 SAmeans being aware of the aircraft system one is working on. Level 2 SA involves thetechnicians’ comprehension of the significance of observed system states. Level 3 SAdenotes the ability to project the state of the system in the near future. Technician withlevel 3 SA would be able to project what effect a particular defect might have on theperformance of the aircraft in the future. Endsley and Robertson (2000) performed taskanalysis to determine the specific SA requirements in the aircraft maintenance arena.They also conducted an SA resource analysis to identify the resources used in themaintenance environment to achieve the identified SA requirements. The results indicatedthat the largest problem for team SA exists when there are gaps due to, e.g. mismatchedgoals, lack of information or lack of understanding between organisations or individuals.Based on the results, a team SA training programme was developed for the airline.Training needs were found in five areas: shared mental models, verbalisation of decisions,shift meetings, feedback and general SA training. Endsley and Robertson (2000) concludeby noting that providing personnel with knowledge is important but not sufficient for the


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achievement of SA. Maintenance personnel must also have the skills and abilities requiredto effectively communicate that knowledge, and they require the ability to recognisewhat information needs to be exchanged among and between team members (Endsley andRobertson 2000, p. 323).

Oedewald and Reiman (2007b) have studied the theoretical knowledge of maintenancenewcomers and experienced personnel in a longitudinal study of a Nordic NPPmaintenance organisation. The aim of their study was to evaluate the effectiveness ofa training programme for newcomers and to identify the general training needs inmaintenance. A measure of conceptual knowledge was developed in cooperation withtechnical experts and trainers from the case organisation. The measure contained75 multiple-choice questions in nine knowledge areas: mechanical and electrical engineer-ing, I&C, radiochemistry, technical specifications, process control, design basis of theplant, maintenance planning and maintenance procedures. The conceptual knowledgeof all 10 new workers was measured three times during the 3-year project, and they wereinterviewed twice during the project. In addition, 43 experienced maintenance workers(mean tenure 16.5 years) completed the conceptual knowledge questionnaire (Oedewaldand Reiman 2007b). The results showed that the newcomers’ overall scores improvedduring the first 2 years of work. However, some basic concepts, such as redundancy, weredifficult for many respondents. In the experienced worker sample, the overall scores variedsubstantially and did not correlate with tenure. Questions concerning process control andelectrical engineering were frequently answered incorrectly. Basic concepts were notself-evident for the experienced group either. Furthermore, the experienced workers tendedto be optimistic about their knowledge concerning, e.g. the process control area, since theydid not often answer with the option ‘I do not know’ and got plenty of minus pointsfor choosing the wrong answers. Oedewald and Reiman (2007b) argue that personalorientation towards the work is important for the development of expertise (cf. Sandberg2000, Norros 2004). Those newcomers who scored extraordinarily well in the third test hada slightly different orientation towards maintenance work from the beginning. Accordingto the study, the high-scoring newcomers seemed to be more aware of the uncertaintiesinherent in complex systems and in the interviews, they emphasised the importance ofhaving an overall picture of the plant. Other studies in various safety-critical domains havealso shown that recognising uncertainties in the technology and risks in the activitiesfacilitates learning (Norros 2004).

Crew resource management (CRM) has been applied successfully also in maintenancedomains. The goals of CRM (or maintenance resource management, MRM) traininginclude improving communication skills and teamwork, facilitating the use of humanperformance tools (pre-job briefing, post-job briefing, etc.) and increasing awarenessof human performance issues such as norms, fatigue, communication and their safetyeffects (Reason and Hobbs 2003, pp. 114–116, Patankar and Taylor 2004a). In aviationmaintenance, the US Federal Aviation Administration (FAA 2000) has defined the overallgoal of MRM as ‘to integrate the technical skills of maintenance personnel withinterpersonal skills and basic human factors knowledge in order to improve communi-cation effectiveness and safety in aircraft maintenance operations’. Endsley and Robertson(2000) consider MRM training as the necessary background knowledge for SA training.

In the context of aviation maintenance, Patankar and Taylor (2004b, p. 23) argue thatsuccessful MRM programmes require that organisations be willing and able to ‘providespecific feedback to safety-related recommendations, establish secure and effectiveself-reporting systems, provide a simplified and effective process to update/changemaintenance procedures, reward safety-compliant behaviours, and above all practice

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(high) ethical standards’. They have developed a MRM/technical operations questionnairefor self-evaluation when developing maintenance activities (Taylor and Thomas 2003,Patankar and Taylor 2004b). Their results show the positive effect of MRM training on,for example, stress awareness and value of assertiveness (speaking up on safety issues).They also found significant differences in scores between the occupational categorieswithin maintenance (Patankar and Taylor 2004b, pp. 98–116).

Studies on competence management and training have shown the multifaceted natureof professionalism in maintenance. They also have provided compelling evidence on thesignificance of investing in the development of maintenance competence as a way ofmanaging the negative effects of performance variability.

3. Contributions of current research

3.1. Performance variability in maintenance work

Maintenance work is characterised by variability. This inherent variability includesvariability in tasks, work conditions, condition of the equipment, environmentalrequirements, resources and time constraints. Some characteristic sources of performancevariability have been identified in the various maintenance studies (cf. Reason and Hobbs2003, Patankar and Taylor 2004b, Reiman 2007, Pettersen 2008, see also Figure 1). Theseinclude:

. the changing nature of the task depending on the specific inspection findings,available resources including tools, spare parts and personnel, as well as timeconstraints;

. the difficulty of predicting the time and other resource requirements of the varioustasks;

. The object of maintenance actions can be in operation, shut down/out of use orbroken, with each state imposing different demands for maintenance;

. effects of many maintenance actions are delayed, making it hard to develop one’swork practices based on feedback from the object of work;

. wide range and mix of required skills and competencies due to the great varietyin the tasks and activities necessary for reliable operations;

. maintenance of a safety-critical system involves many rules and regulations, thequality of which can vary;

. challenges in coordinating complex work and communicating relevantinformation;

. conflicting demands of safety and efficiency;

. use of informal procedures, black booklets or non-usage of procedures;

. workplace norms that sanction unofficial practices;

. personal beliefs (such as illusions of control and invulnerability, the falseconsensus belief that ‘everyone else does it’, belief that management promotes rulebreaking in the name of efficiency);

. innovation and inventiveness of the maintenance personnel to adapt to thesituation at hand;

. personal preferences and individual freedom over work styles and habits and

. fatigue and stress.

The significance of maintenance for safe and reliable operation has been shown instudies of maintenance errors and their consequences. Furthermore, organisational issues


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have been shown to be important for explaining performance variability in themaintenance context. However, current research on maintenance work is fragmented interms of its focus; individual studies are seldom put into the larger context of safety scienceor maintenance human factors.

3.2. Need for a theory to understand performance in maintenance context

Previous studies have tried to explain the performance variability mainly by looking at thenegative outcomes of the variability (errors), social factors affecting the variability(Pettersen 2008, Sanne 2008b), the knowledge and psychological (mental) characteristicsof the maintenance personnel (Endsley and Robertson 2000, Patankar 2005a, 2005b,Oedewald and Reiman 2007b, Rouse 1979) or the organisational functions such as safetymanagement or effects of outsourcing (Bier et al. 2001, Taylor and Thomas 2003,Patankar and Taylor 2004b, Reiman et al. 2006, Herrera and Hovden 2008, Suzuki et al.2008). Many studies have combined two or more of the above-mentioned dimensions (Orr1996, Bourrier 1999, McDonald 2006, Reiman 2007, Pettersen and Aase 2008). Next, wewill look at the research challenges in combining these various foci into a holistic view onmaintenance work in safety-critical organisations.

Patankar and Taylor’s (2004a, 2004b) list in Figure 1 is focused on the dimensionscreating negative performance variability in maintenance. A similar list could be devisedon the elements creating positive variability in the maintenance organisation. Figure 2presents a preliminary outline of a ‘pure dozen’ success factors in maintenance.

Figure 2 illustrates the multilevel nature of the challenges of effective maintenancework. For example, motivation is an individual-level dimension (having to do with themental states and models of the personnel), whereas norms belong to the social level andwork design to the organisational level. The dimensions in Figure 2 are not exhaustivein terms of describing a high reliability maintenance organisation, and they probablypartly overlap. In addition, the dimensions as such do not explain the mechanisms orprocess by which, for example, norms, communication or complacency are created in theorganisation. Some indications of the mechanisms and various social processes can befound in the literature, and these are dealt with in the next section.

The organisational challenges of maintenance stem from the nature of the maintenancecore task and its inherent variability. In order to understand the performance variabilityin maintenance, the maintenance core task and its demands in various domains have to beunderstood first. The core task of maintenance and the inherent hazards of the technologythat is maintained have to be taken into account (Reiman 2007).

Figure 3 presents a conceptualisation of the key content themes and researchchallenges of maintenance work in safety-critical domains. The content themes are basedon the analysis of the current literature and the theoretical framework of key

Flexible organization and slack resources

Social permission to carry work thoroughly

Self-criticism and reflection

Motivation and mental resources

Norms supporting safety

Vigilance and energy

Adequate task and safety knowledge

Situation awareness

Assertive attitude to safety issues

Clear communication Functioning teamwork and cooperation

Good task and work design

Figure 2. Positive elements affecting maintenance, corresponding to and opposed to the ‘dirtydozen’ identified by Patankar and Taylor (2004b) arranged in order from individual to social toorganisational factors.

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organisational dimensions proposed by Reiman and Oedewald (2007). Figure 3 illustratesthe phenomena underlying the success factors of Figure 2, such as mental states(vigilance), social processes (norms supporting safety) and organisational functions(flexible organisation). The figure also includes technological hazards and the maintenancecore task as influencing elements, as well as performance variability as the main elementof concern in studies of human and organisational factors in maintenance to date.

The content themes of past research are categorised into four main organisationaldimensions in Figure 3: mental states and models, organisational functions, socialprocesses and performance variability. When considering safety and effectiveness ofmaintenance, the technological hazards as well as the core task of the maintenancefunction have to be taken into account in addition to the four dimensions. Next, theresearch challenges are elaborated based on Figure 3.

4. Research challenges in maintenance organisations

4.1. Role of the individual in the maintenance function

More research is needed to better understand and conceptualise the role of individualand social factors (the role of human agency, cf. Pettersen 2008) in performance variabilityof the maintenance activities. This concerns questions such as individual assertivenessconcerning safety issues or the role of social networks and informal connections in dailywork. When assertive safety behaviour is against the norms of the workplace, what factorsdefine how the employee will act? How strong of a coupling exists between the officialsystem and the informal social organisation? How do the gaps in these two ‘systems’ affectsafety? Furthermore, research should address the tensions and differences in prioritiesand conceptions between maintenance and other functions of the company. Especially, thesignificance of the differences to system safety as well as the well-being of the maintenance

Effectiveness and performance

variability

Mental states and mental models

Organisational functions

Social processes

Maintenance core task

3. Tools for the management of maintenance activities

1. Role of individual factors in maintenance6. Leading indicators for

effective maintenance

5. Holistic evaluation methods for maintenance

organisations

2. Effect of social processes on performance

4. Maintenance core task and its

requirements

Technological hazards

Figure 3. The main dimensions of organizational factors and the associated research challengescritical to safety of maintenance.


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personnel should be addressed, along with ways of developing a joint understanding ofsystem goals and priorities.

The current literature on human factors in maintenance has identified severalpsychological phenomena of importance for the effectiveness of the maintenance activities.Studies have illustrated the challenges of job motivation and its sources (Orr 1996,Reiman and Oedewald 2006), sense of personal responsibility (Kelly 2005, Patankar2005a, 2005b, Sanne 2008a), safety awareness and mindfulness (Endsley and Robertson2000, Reiman 2007), as well as adequate mental models of the core task (Carroll et al.1998). Especially, the contextual development of such characteristics as competence,responsibility and professionalism should be clarified in future research. Furthermore, theeffect of these characteristics on situational judgement (e.g. in terms of rule bending, goalprioritisation or specific maintenance actions) within the social context of maintenance is atopic for empirical investigations. Research should also specify the social and individualmechanisms of the formation of responsibility and competence, and their contents.For example, what is the relation of risk taking to the feeling of responsibility(Sanne 2008a), or the relation of theoretical understanding to the actual performanceof the work (Oedewald and Reiman 2007b)?

The corrosion incident at Davis–Besse in 2002 is an example of an incident that couldhave been prevented by responsible and mindful maintenance personnel. For example,maintenance personnel regularly found rust particles clogging air-conditioning and waterfilters. Maintenance had to change the air filters every 2 days for 2 years, whereasthe industry norm was to change the filters once a month (Perin 2005, p. 216). Thisaccumulation of rust was a weak signal of wider problems that could have been detectedhad people questioned the reasons why the filters were being replaced (Weick and Sutcliffe2007, p. 46). However, rust accumulation was not a failure that people felt was significantenough to warrant a strong response (Weick and Sutcliffe 2007, p. 48).

Maintenance personnel are motivated by the complexities and problems of thetechnical system, the safety consequences of their work and the chances to completesignificant repairs (Orr 1996, Endsley and Robertson 2000, p. 314, Reiman 2007).Even personal risk-taking in the name of system safety or getting the job done is oftenconsidered motivating (Sanne 2008a). The motivating aspect of the problems and faultsituations is a paradox in the sense that one of the goals of maintenance is to avoidproblems and keep the technology running reliably. This can be dangerous if the technicalsystem exhibits a lot of glitches and faults. IAEA (2005, p. 6) warns that ‘constant repairstend to create a firefighter mentality among the workers, which is further bolstered by boththe feeling of satisfaction after the repairs are successfully completed and ‘‘rewards’’ orpraise following a job well done. These feelings contrast starkly with the otherwisemundane and systematic approach of preventive maintenance’ (cf. Carroll et al. 1998,p. 102) Routine work also poses challenges for the maintenance personnel: it decreasesmotivation (Hackman and Oldham 1980, Carroll et al. 1998, p. 117) and can lead to lowerquality or increased slips and lapses due to inattention. Too much routine can be avoidedby organisational practices, e.g. by the division of the tasks and job rotation. Maintenancepersonnel strongly identify themselves as craftsmen. Attending to the machinery, forexample, when conducting fault repairs, is a crucial source of job motivation.The motivating aspect of fault repairs partly stems from the fact that they are directly(and visibly) related to the overall goal of the organisation: maintaining operations.Hackman and Oldham (1980, p. 75) point out that ‘(t)he irony is that in many suchsignificant jobs, precisely because the task is so important, management designs andsupervises the work to ensure error-free performance, and destroys employee

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motivation . . . in the process’. On the other hand, the maintenance personnel acknowledgethe impossibility of proceduralising all the aspects of the maintenance work and theinadequacy of the procedures to cope with the realities and surprises of daily work(cf. Hirschhorn 1993, p. 140, Bourrier 1996, Orr 1996, Carroll et al. 1998, Dien 1998,Dekker 2005, Reiman 2007). The maintenance personnel seem to consider a key part ofone’s professionalism to be the knowledge of how to interpret, apply and neglect theprocedures in a manner that work can be carried out as thoroughly and as efficientlyas needed (cf. Hollnagel 2004, 2009b). Succeeding with this adaptive and variable wayof working requires a good knowledge of the task and its hazards.

An experienced maintenance team might manage daily tasks without a perfectunderstanding of the fault mechanisms and details of the working methods. This is due tothe fact that their gradually formed tacit knowledge works well enough in most situations.In spite of that, several event investigations have illustrated how the weaknesses of theexisting knowledge surface when established routines are challenged by unusualdisturbances or events (Hopkins 2000, Kletz 2003, Feldman 2004). One means of tacklingthis problem is to analyse the maintenance personnel’s conceptions and mental models oftheir task. Norros (2004) has argued based on her studies in various safety-critical domainsthat reflective as opposed to procedural orientation towards work facilitates learning.The reflective orientation is also more flexible (i.e. variable) and adaptive to the situationat hand than the procedural orientation. Organisational processes such as training,learning practices and leadership should encourage this reflective orientation.

4.2. Social processes in maintenance

The second research challenge is related to the effects of social processes (e.g. formationof norms, social identity) on performance variability in maintenance. In terms of socialprocesses, more information is needed on the ways technicians develop their practices andlearn from their daily work within the social structures of their company (Pettersen 2008,Sanne 2008b). For example, how do the various safety management systems affectfield-level practices? How do the social identities of the maintenance personnel incorporatemodels of errors, accidents and professionalism? What are the potential safetyconsequences of strong professional identities that are based on local practice andindividual responsibility (Sanne 2008b) versus those based on collective responsibility andstructured practice (Reiman 2007)? Do these solutions depend on the nature of the coretask or the cultural features and history of the organisation? Both quantitativequestionnaire studies and qualitative case studies have a role in clarifying the contentsand effects of the various individual, social and organisational level dimensions.

Maintenance workers need to adapt to local circumstances and sometimes contradic-tory goals, and work with the skills, resources, tools and time that they have. Normsand local practices develop, and subcultures form based on technical disciplines, hierarchyand physical location. The bending of rules or ‘innovative’ utilisation of tools is used tocompensate for organisational deficiencies and to accomplish goals deemed professionallyimportant. In many cases, minor adjustments to local procedures do not constitutenegligence but are done with good intentions (to get the job done, to save money). Thework and the organisational processes can be such that employees have to bend the rulesin order to get the work done. All this happens in a social context, where maintenancepersonnel jointly construct their view on the work and their image of the maintenanceprofession, and both conceptions create and shape their practices. Pettersen et al. (in press)


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remind that informal practices are as much part of the maintenance system as the formalorganisational structure.

Social processes and informal practices of the maintenance communities can lead to thenormalisation of small deviations and incidents as ordinary aspects of the work(Sanne 2008b). Normalisation of deviance means a process where small changes – newbehaviours, technical anomalies or variations that are slight deviations from the normalcourse of events – gradually become the norm, providing a basis for accepting additionaldeviance (Vaughan 1996). Normalisation of deviance produces disregard and misinter-pretation – neutralisation – of potential danger signals. A signal of potential danger isinformation that deviates from expectations, contradicting the existing worldview(Vaughan 1996, p. 243). Since many maintenance actions and practices have effects thatcarry over a long time period, the normalisation of deviance is a particularly significantsocial process in the maintenance domain.

4.3. Management of the maintenance organisation

Many studies have shown that the achievement of effective and reliable maintenanceis dependent on good management of the maintenance organisations. Management doesnot mean solely upper-level managers, but all activities geared towards ensuring that theorganisation is capable of functioning effectively. Maintenance organisations need to beable to anticipate and plan for both expected events as well as unexpected disturbances.Organisations have to be able to respond in a flexible manner to breakdowns and changesin tasks, and they need to be able to update their knowledge of the sociotechnical systemthat they are simultaneously part of as well as maintaining.

Two of the major challenges facing maintenance organisations are the almost constantprocess of societal change and the various restructuring initiatives launched within thecompanies owning the maintenance organisations (Kecklund 2004, Reiman et al. 2006).These are reflected in the maintenance organisations as organisational changes. Changeshave generally been perceived as stressful and causing uncertainty among the workers(Reiman et al. 2006). McDonald (2001, p. 223) warns that organisations that are based onunofficial practices are especially vulnerable to changes (in technology, organisations andpersonnel). Maintenance belongs to that category. Changes in maintenance have usuallybeen heavily technology driven (cf. Clegg and Walsh 2004). Human factors have beenconsidered only when problems occur, e.g. the personnel show ‘change resistance’ or donot otherwise act as planned by the change agents (Reiman et al. 2006). Changemanagement is an organisational function that would benefit from a more explicit focuson human and organisational factors. Research should aim at providing tools andmethods to accomplish this.

Training is one of the instruments for creating an awareness of hazards as well assufficient skills for carrying out the work in a safe manner. An ongoing generationalchange in the workforce calls for tools to analyse the existing know-how of the personnelso that effective training programmes can be created. Maintenance work in safety-criticalorganisations is not a routine-like activity that could be carried out just by following theprocedures. It requires different types of skills and knowledge. Practical craftsman skills,overall understanding of the functioning of and couplings between the systems as well astechnical knowledge about the materials and equipments are needed in maintenance work.Thus, in addition to the tacit knowledge about maintenance practices and specific tasks,understanding of the theoretical basis of technical phenomena and work processes are

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essential contents of the know-how of the personnel (Perin 2005, Oedewald andReiman 2007b).

Learning from near misses, failures and events is important for the continuousimprovement of maintenance activities. This involves certain challenges. First, reportingof events is often inadequate. Second, even if events are reported, there are difficultiesin analysing the significance of events in terms of what they tell about the effectiveness ofmaintenance activities. Third, even if analysed correctly, getting the results back into thefield presents its own challenges. Consequently, maintenance activities remain rootedin local history and local adaptations, without necessarily taking the entire organisationor the experience of other parties into account.

Another approach to competence management is to seek to decrease the probabilityof the occurrence of human errors with various human performance management anderror prevention tools (Reason and Hobbs 2003, Patankar and Taylor 2004a). Reason andHobbs (2003, p. 95) list a number of error management techniques in maintenance,including training, work planning, job cards, licence-to-work systems, licensing andcertification, audits, procedures, disciplinary procedures, human resource managementand total quality management. They note that these techniques have not been effectivein preventing a steady rise in maintenance-related errors during the past decade. Theycomment on the techniques that ‘their limitations include being piecemeal rather thanprincipled, reactive rather than proactive, and fashion-driven rather than theory-driven’.

Safety management systems are an integrated formal way of managing organisationsand their safety. Many safety management systems are based on a rational or anon-contextual image of an organisation (Reiman and Oedewald 2007). The role ofmanagement in supervising and directing organisational behaviour is emphasised. Waringand Glendon (1998, p. 175) criticise safety management systems that are based on anoverly rational image of the organisation and argue that they may be only partly effectivewhile creating an illusion that the risks have been fully controlled (see also Waring 1996,p. 46, Dekker 2005, p. 2, Perin 2005). The reality of organisational life is usually verydifferent from the ideal set out in formal documents and systems. For example, in thecontext of aviation maintenance, McDonald et al. (2000) and McDonald (2001) argue thatevidence indicates that the current quality and safety management systems seldom providean adequate picture of the way the work is actually carried out. The social structure andthe inherent performance variability need to be taken into account. The role of safetymanagement systems and human performance tools in steering the work in maintenanceand controlling unwanted performance variability is an important topic for futureresearch.

4.4. The core task of maintenance

The maintenance function is critical for the safety of any complex sociotechnical system.Weick et al. (1999, p. 93) have aptly observed that ‘maintenance people come into contactwith the largest number of failures, at earlier stages of development, and have an ongoingsense of the vulnerabilities in the technology, sloppiness in the operations, gaps in theprocedures, and sequences by which one error triggers another’. Maintenance is a keyfunction for a resilient organisation to use the term coined by Hollnagel et al. (2006) todenote the intrinsic ability of an organisation (system) to ‘maintain or regain a dynam-ically stable state, which allows it to continue operations after a major mishap and/or inthe presence of a continuous stress’ (Hollnagel 2006, p. 16). Hollnagel (2006) argues that


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the challenges to system safety come from instability which can be a result of, e.g. thenecessary adaptations or adjustments having consequences beyond the local and intendedeffects. This is exactly where maintenance comes into play, as an adaptive force as well asthe last line of defence against the unseen effects of organisational instability.

The role of maintenance in increasing the resilience of the sociotechnical system is asomewhat neglected aspect in research (cf. Reiman 2007). Maintenance is supposed tohave a crucial role in creating safety and resilience in the sociotechnical system as well asin the negative sense, creating vulnerabilities and having a strong tendency towardsexhibiting performance variability. Maintenance personnel have hands-on experience withthe plant equipment and know its condition best. The maintenance function is able toperceive new vulnerabilities in their development stages.

In the opinion of the author, being resilient means being aware of the boundariesof safe activity, being able to recognise how the organisation is currently creating safety,monitoring whether or not one’s model of safety and hazards is adequate and steering theorganisational processes in the necessary manner. These processes include recovery fromincidents or even accidents. The ability and willingness of the organisation to carry out itscore task is thus at the essence of resilience. Maintenance plays an integral role in this.The challenge is in further specifying the core task of maintenance and its relation to theoverall task of the organisation, and in defining more specific criteria for a resilientmaintenance organisation. For example, how do the core tasks of aviation maintenanceand NPP maintenance differ, and how are the differences reflected in the maintenancecultures? How much of this difference is explained by technological differences and howmuch by historical reasons or differences in regulations? Research should also tackle theoutside influences on the maintenance task, such as deregulation or price competition.For example, if a government-owned organisation, e.g. an NPP or a shipping company,is turned into a private enterprise, does the task of the maintenance function also changeor have some new requirements?

4.5. Evaluation methods for maintenance organisations

The methods for evaluation should provide the organisations with information on howthey currently perceive and respond to their core task. It is not sufficient to rely on generalcriteria such as safety attitudes or participative leadership. In addition to these, the task ofthe organisation and the constraints and requirements that this task sets for maintenancehave to be taken into account. Organisational evaluation is one way of reflecting on theability of the organisation to carry out its task properly. This ability includes that theorganisation is able to monitor its current state, anticipate possible deviations, react toexpected or unexpected perturbations and learn from weak signals and past incidents(cf. Weick and Sutcliffe 2007, Hollnagel 2009a, Reiman and Oedewald 2009).

Future research should aim at developing methods and approaches for evaluatingthe functioning of the maintenance organisations holistically, taking into account theindividual, social and organisational elements. This includes understanding and explainingthe different trade-offs in maintenance work, for example between efficiency andthoroughness (Hollnagel 2004), occupational safety and system safety (Sanne 2008a),rule following versus rule bending (Bourrier 1999), certainty and uncertainty (Reiman2007) and individual and collective action (Pettersen 2008).

The development of methods for the evaluation of maintenance organisations isconnected to the debate on the integration of human and organisational aspects into safety

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auditing and technical safety assessments (cf. Le Coze 2005, Reiman and Oedewald 2007,Mohaghegh et al. 2009). Work is needed in defining the significant features of complexsociotechnical systems in terms of understanding their safety and effectiveness. Thisresearch should draw also on the recent developments in the organisation scienceparadigm.

4.6. Leading indicators of the maintenance function

It has been recognised that incident rates and other ‘lagging’ indicators such as personalinjuries do not provide an adequate picture of the ‘health’ of the system in relation tomajor accidents (HSE 2006, Herrera et al. 2009). If one wants to evaluate the effectivenessof development initiatives as well as the functioning of the current maintenanceorganisation, reliable indicators are needed. Based on an understanding of the socialcontext and core task of maintenance, future research should identify the relevant leadingindicators for developing the safety and effectiveness of maintenance activities. Theseindicators should be able to direct the development initiatives and provide indicationsof whether the organisation is improving or not. These indicators can be used in afeed-forward manner (cf. Hollnagel 2008) to adjust the functioning of the maintenanceorganisation before its performance deteriorates.

5. Conclusions

Maintenance has too often been considered as mostly manual labour requiring little or nomental work. This correlates also to maintenance quite often being at the bottom of thehierarchy (in comparison to, e.g. technical support and operations) in terms of respect,influence and authority in organisations (Mercier 1988, p. 14, Perin 2005, p. 75, cf.Hopkins 2005, p. 85). Mercier (1988, p. 14), for example, argues that NPP maintenancework suffers from a ‘dirty hands’ image. Perin (2005, p. 262) states that ‘given thesignificance of maintenance activities to risk reduction in all high hazard industries, in thistwenty-first century a ‘‘dirty hands’’ image marks a cultural lag of ‘‘gigantic’’ proportions’.An emphasis on the manual labour requirement of maintenance is prevalent also inside themaintenance organisations themselves (Reiman 2007).

Research on maintenance has focused mainly on human errors and individual-levelissues, even though social and organisational factors have received increasing attention inrecent years. Still, studies of normal work, practices and cultures of maintenance have beenscarce. Research and development in the maintenance context should acknowledge thatmaintenance is a function that not only produces safety, but also gives rise to latentfailures. Maintenance personnel and the activity of the maintenance function can help theentire organisation to be better aware of the boundaries of safe activity, the conditionof the technical equipment and the effectiveness of current practices and conceptions increating safety. In addition to its preparatory and anticipatory role, maintenance plays acritical role in recovering from expected breakdowns and unexpected system perturba-tions. A holistic theory on maintenance work is needed to manage the variability and turnit into a positive force. At its best, maintenance produces positive performance variabilityin terms of needed adjustments and adaptations to the condition of the technicalinfrastructure and guards against negative instability in terms of equipment perturbations,safety system breakdowns, slow degradation of technical infrastructure and the otherchanging vulnerabilities of the technology in use.


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Acknowledgements

The author is grateful to the two anonymous reviewers for providing useful comments andsuggestions to an earlier version of the article. The work has been funded by the Finnish nationalnuclear safety research programme (SAFIR2010) and VTT.

Note

1. Common cause failures (CCF) are failure causes or mechanisms that may apparently result orhave resulted in multiple functionally critical failures in redundant components in real demandsituations (they are unable to fulfil correctly their required function) (Laakso et al. 1998, p. 10).In relation to human error this means that a repeated human action affects several redundanttrains of a safety system or several safety systems immediately or in a longer time span.

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About the author

Teemu Reiman received his PhD in 2007 in psychology from the University of Helsinki. Hisdissertation focused on evaluation of organisational culture at maintenance units of Nordic nuclearpower plants. Currently he holds the position of senior research scientist at VTT Technical ResearchCentre of Finland. His current work is concentrated on understanding performance of complexsociotechnical systems and improving system safety in various safety-critical domains includingnuclear and healthcare.

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Reiman, T. (2011). Understanding maintenance work in safety-critical organizations – managing the performance variability.

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