High Reliability Theory and the Dutch Defence Organisation

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High Reliability Theory and the Dutch Defence

Organisation

Course: Master Thesis Crisis and Security Management 2017-2018 Instructor: Dr. Gabriele Landucci

Second Reader: Dr. Wout Broekema Name: Jeroen Heijmans

Student number: S1371592 Word count: 17.668

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Abstract

The Dutch Defence organisation struggles with the need to innovate, whilst also coming from a decade of strong budget cuts. With little room for changes rooted in heavily financial investment, this study explores

how High Reliability Theory (HRT) might offer guidance of increasing the reliability of the Dutch Defence Organisation, thus improving the organisational performance without strong budget increases. The study devices a framework of nine greater issues that can hamper the reliability of the Dutch Defence organisation, based on HRT principles established by the field. It finds that implementing organisational

and cultural change can solve certain issues. Other issues prove to be problematic as they severely undermine reliability, but need strong financial investment to be eradicated. This study not only shows potential improvement for the Dutch Defence organisation, but also that HRT can be used as an active

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1 Introduction

"The 'can-do mentality' is still there, but we cannot stretch it any further" (IGK, 2016, p.7). This quote has been a reoccurring theme within many military evaluations, repeated by both soldiers as well as high-ranking commanders. People working for the Dutch Defence organisation express a high level of loyalty and a willingness to go the extra mile, but with a decade of budget cuts, re-organisations, and decreased military facilities (DIS, 2013) the limit of what can be done with good work ethics alone seems to be reached. Meanwhile, it was only in 2016 that the 'Strategic Knowledge and Innovations Agenda 2016-2020' (SKIA) specified a number of goals the military should strive for, if they want to remain a capable force in the world of today. The report stressed the need for change and innovation within the Defence organisation, if it wants to be able to keep up internationally, and respond effectively to the every changing and complex world of today. A large part of the SKIA focuses on technologic development and innovation in the Dutch Defence organisation. This results in a strained relationship between military budget and capability, which can only be solved in the political sphere. However, the report also outlines the need for better and efficient management and increased flexibility of the Dutch Defence organisation (SKIA, 2016, p.12). It is therefore that this study explores ways in which 'High Reliability Theory' (HRT) can improve the functioning of the Defence organisation. Through HRT it is possible to investigate how certain organisations are able to function in a complex and dangerous environment without making costly errors. It would enable the Dutch military to organize in such a way that it would be better able to keep up internationally, and face the challenges of uncertainty brought by high-paced global change. Flexibility, resilience and efficiency all are

important themes, which in general increase the reliability of an organisation, creating a 'High Reliability Organisation' (HRO). Becoming an HRO is more connected with the organisational dynamics and internal culture than with technology and resources per se. Therefore, this study argues that HRT is a good starting point for improving the Dutch Defence organisation.

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circumstances, usually with high stakes, and it cannot afford any mistakes nor learn by trial-by-error. It seems that any defence organisation, like a country's military, should be regarded as such an organisation. Their field of operation is often highly complex, both on a technical as well on the political and ethical field, they are responsible for lives (both of their soldiers as non-combatants), and it cannot learn by trial by error. Weick outlines a distinction here between being an organisation that deploys specific techniques to increase reliability, hence functioning as an HRO, and circumstances in which an organisation operates that ask of the organisation to be reliable. This study will assess to what extent the Dutch Defence organisation faces issues that they could address by adopting HRO principles to be able to make some of the positive changes as mentioned by the SKIA, as well as to become a better organisation in general.

Goal of thesis

The goal of this study is to use High Reliability Theory (HRT), both as a framework to identify issues within the Dutch Defence organisation, and as an inspiration for solutions that might enable to Defence organisation to become more reliable. The research

question that guides this study is: How can High Reliability Theory be used to find issues that undermine an organisation's reliability, and inspire solutions that counter these issues and thus increase an organisation's reliability? This question reflects the twofold purpose of this research: assessing the issues that undermine reliability and finding solutions that can fix the issues and increase reliability. Since it is an explorative study that uses HRT in a fashion where it finds issues and solutions, the question follows a 'how' format. The methods section will go into detail on how this study uses a framework that operationalizes basic HRT principles in order to use HRT as an analytical tool for identifying problems and solutions.

Societal value

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creating sustainable change. The study will also identify certain issues that undermine the capacity of the Defence organisation in general, and their ability to act like an HRO in specific, which are not solvable without heavy investment.

Academic relevance

There are three aspects in which this research is academically relevant. 1. The study broadens the applicability of HRT into the military field, where it is rarely used. Thus, it broadens the general array of topics coverable by this theory. 2. Many HRT and HRO studies are focused on investigating why an organisation is reliable. In the context of this study, it will be used to offer guidance for improvement, enriching the theoretical use. The study proposes an extension of the theory, moving from merely investigating to actively analysing and inspiring solutions. It argues that further research could follow this format that enables HRT to become a practical tool of analysis for organisations to increase reliability. 3. In certain principles, a clear connection is made with Risk

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2 Theoretical Framework

There are multiple theories about how organisations can increase their safety, should prevent crisis and adapt to an increasingly complex world. Some theories such as resilience theory or safety culture theory concern with how organisations can prevent certain safety issues, or other negative events from happening, where theories such as the Normal Accident Theory (NAT) largely focuses on why accidents happen. In this

theoretical framework the field of organisational theory regarding safety and accident prevention will be shortly reviewed, by explaining the largest theories on this topic: resilience and safety culture. It will then funnel the attention to High Reliability Theory (HRT), discussing its main components, during which some comparisment and contrast will be created with NAT. This chapter ends with a provision of a basic overview of risk management, and why this theoretical field should be more strongly connected with HRT.

Organisational Resilience

Resilience theory found its origins around the 1950s, in the field of childhood psychology, and offered explanations why certain children in stressful circumstances were better able to develop competences than others (Vernon, 2004). In the decades thereafter it quickly expanded itself to other theoretical fields such as engeneering, ecology and health; merging with other theoretical notions. Many scholars, suchs as Sheffi (2004), tied resilience to business and organisational fields as an concept that could increase business continuity and organisational performance.

The following quote by Woods is best able to provide understanding of resilience in an organisational setting: "[Resilience is] how well can a system handle disruption and variations that fall outside of the base mechanism/model" (Woods, 2012, p.21).

According to Woods, resilience was determined by four component: buffering capacity - how many disruptions a system can withstands, flexibility - how quickly a system restores from disruption, margin - how close a system operates at performance boundaries, and tolerance - how the system behaves near boundaries, will it decline in performance or suddenly collapse? It becomes common to see resilience as a necessity to the

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in an increasingly complex world (Salt & Walker, 2006). Despite the perception that resilience becomes increasingly important, there is debate within the use of the concept as a way of handling crisis and continuity, as the question arises whether resilience should focus on restoring to the status quo or adapting to a new one (Wenger, 2017).

Safety Culture

Where Resilience in the organisational setting has a strong focus on the system, safety culture primarily concerns itself with the people in the organisation. Cox and Cox define it as the "attitudes, beliefs, perceptions and values that employees share in relation to safety in the workplace" (1991, p.94). While there are some core characteristics related to safety culture, such as attention for safety by the management, safety systems in place and pressure on the work floor (Flin, et all., 2000), the common notion is that what defines and makes up the safety culture is very much context dependend (Cox & Flin, 1998).

The importance of safety culture became increasingly recognized after the Chernobyl accident, as the Chernobyl evaluation report suggested that certain technological failures were rooted in the organisational culture (Flin, et all., 2000). The safety culture influences the concern and attention people have for safety, and thereby largely influence how an organisation deals with safety. Both the Rogers Challenger report about the Challenger disaster (Roger Commission Report, 1986), as the NASA report about the Columbian disaster (NASA 2007), argue that the technological faults that resulted in the accident were rooted in the lacking safety culture within the organisation, as the faults were usually known. In both the Challenger as the Columbia disaster a large blame of the lacking safety culture was appointed to the management, and according to some scholars it is especially the (senior) management that is able, and deciding, in enhancing the safety culture (Cox & Cox, 1991).

Introduction to HRT

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are often high. Organisations that operate in these circumstances, and that apply these organisational strategies, were deemed High Reliability Organisations (HRO). The research of Rochlin, La Porte and Roberts (1987) was the offset for theories about HRO’s, which on occasion can be strongly inspired by both resilience and safety culture theory, but differ from them as HRT is an overarching organisational theory that, in the end, focuses on organisational performance. Both High Reliability Organisations

(HRO’s) and High Reliability Theory (HRT), is used interchangeably since the beginning of this academic niche. It should be noted that HRT refers to the theoretical body of knowledge, while HRO refers to an organisation that functions in a complex system with high stakes, no opportunity for trial and error, and that applies organisation strategies (HRT) to cope with it (Weick, 1987).

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Other Side of the Coin: Normal Accident Theory

Where HRT investigates how HRO's work in complex and challenging surroundings, Normal Accident theory (NAT) focuses on why organisations fail in these circumstances. Perrow (1984) argued that in systems that are characterized by complexity and tight-coupling, accidents are inevitable, as complexity yields unexpected results, and due to the tight-coupling, errors can escalate quickly. Due to these circumstances, it is expected or 'normal' that accidents occur, that they are referred to as normal accidents. In essence, it appears that HRT and NAT are two sides of the same coin. Sagan (1993) was the first scholar that compared the two theories, by studying a nuclear facility and its (near) accidents, to see which theory offered the best explanation. Sagan found that, while no real accidents had occurred, (although Sagan concluded that luck played a large role here) NAT was better able to offer the best explanations. While Sagan deemed NAT superior in explaining the near misses at the nuclear facility, he wondered whether both theories could be used in conjunction with each other. While the Berkeley school, the founders of HRT, argued that HRT and NAT cannot be compared or contrasted, Rijpma (1997) found that both theories show a remarkable amount of overlap and can indeed be compared and contrasted. According to Rijpma, this would result in a so-called cross-fertilization, where both theories can complement, spot weaknesses, and adopt elements of each other, which will make both more thorough. An example Rijpma gives is the fact that faster responses due to decentralized decision making, a principle of HRT, can be dangerous in tight-coupled system where unanticipated behaviour can interfere with the quality of the decision. Involving NAT in an assessment of HRT is important, because the contrast between the two theories outlines what HRT can and cannot do, or in other words, what its limitations are.

Downer (2009) in his study about the relationship between redundancy and reliability in the context of technical systems stipulates another limit of HRT. He argues that

complete reliability is impossible to measure and therefore forever remains unknown; hence it is futile to strive for complete reliability, as you never know when this is achieved. Downer therefore concludes that one can never be sure it is working with (completely) reliable systems. It is possible to interpreted Downer's conclusion outside its technological context, as it is never possible to know with what kind of degree of

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Contemporary HRT

Over the years, HRT knowledge has accumulated, often responding to criticism or identified flaws. A recent book of Weick and Sutcliffe (2015) summarizes the latest HRT principles, providing an accurate and contemporary overview of the essentials. In

Managing the Unexpected, Weick and Sutcliffe identify five key principles that underline recent HRT (Weick & Sutcliffe, 2015).

1) Preoccupation with failure. Weick and Sutcliffe argue that accidents occur when organisations mismanage anomalies within their system and try to normalize them. Instead, an organisation should be pre-occupied with failure, and always monitor and be aware of anomalies in the system that can grow into issues. Besides watching closely for indications of failures, HRO's continuously visualise and outline the biggest risks for their operations, increasing anticipation.

2) Reluctance to simplify. Many organisations simplify their operations, especially when they operate in complex systems. However, simplification leads to a lesser awareness of details in the system, meaning that preoccupation with failure becomes more difficult. An organisation should be careful to simplify and try to be aware of the details within the context of its functioning.

3) Sensitivity of operations. According to Weick and Sutcliffe, people within the

organisation should always know what an organisation is doing regardless of its original design or recent plans and know their place within this system. Seeing 'the bigger picture' enables them to take more efficient action. Furthermore, this principle emphasizes that an organisation should be aware that during operations an unlimited number of

interdependencies is linked to a limited conception, meaning that in essence, one never can fully understand the possible consequences of all actions taken. Thereby, this principle seems to acknowledge an important aspect of NAT, namely that complexity yields an unlimited amount of unknown results.

4) Commitment to resilience. In Managing the unexpected the fact that accidents are bound to happen (as is the premise of NAT) seems to be accepted, as resilience is stressed as a key element of any HRO. Weick and Sutcliffe define resilience in HRO's as the capacity to remain functional during errors, and their capacity to quickly restore from these errors.

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the most information at hand to make a good decision. This principle largely builds upon Weick's earlier work, in which he concluded that HRO's are ably to decentralize decision-making. It should be noted however, that in this principle, decentralization is not

necessarily marked as the correct mechanism, as according to this principle, decision-making can be distributed upwards or be centralized as well.

Basics of Risk Management

Another field that occupies itself with limiting errors within the conducts of an organisation is risk management. Risk management can be defined as the discipline of identifying, monitoring and limiting risk (Benigno, 2016). Risk management is a

continuous process, happening in both the pre-emptive state as well as during the time that actions are taken. Currently there is no general accepted definition of risk (Aven, 2011B). Aven provides a common understanding of risk, as he identifies risk as the effect of uncertainty on objectives (Aven, 2011A). Key characteristics are the fact that they have a negative impact on operations or the organisation, and they carry a degree of uncertainty. Aven makes the case that in our understanding of risk, we should think of uncertainty rather then probability, as directly thinking in probability can result in the missing of uncertainty factors, often creating a quantitatively skewed understanding of risk (Aven, 2010). When assessing risk there is usually a distinction between the change of a risk occurring, and loss or impact- the 'loss of value' that happens when a risk ‘occurs’ (Benigno, 2016). The process of risk management is usually seen as iterative and is composed of multiple continuous stages: analysing and monitoring risk, designing appropriate counter measures, executing counter measures and evaluating contemporary impact of risk (Lindenaar, 2008). This process should repeat itself, ideally prioritizing the risk with the greatest uncertainty/ probability and loss (Benigno, 2016). The cycle that risk management follows is usually similar in goal; the techniques being used can vary, from qualitative approaches like SWOT (Strengths, Weakness, Opportunity, Threat) to Monte Carlo simulations to quantitatively assess the impact of risk (Lester, 2014).

Risk Management and Preoccupation with Failure

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upon it, thus it serves largely the same goal as the first principle of HRO's as outlined by Weick and Sutcliffe: preoccupation with failure. According to Weick and Sutcliffe (2015), the HRO is preoccupied with failure in three ways: 1) HRO's work hard to detect small, ermering failures, 2) HRO's work hard to anticipate and specify significant mistakes that they do not want to make, 3) HRO's know that people's knowledge of the situation, the environment, and their own group is incomplete. Risk management similarly tries to detect possible failures beforehand, is strongly aware of mistakes that an organisation or project does not want to make, and does this in a continuous process. That is not to say that risk management is similar to the first principle of preoccupation with failure, but that risk management can be seen as an strong way of upholding this principle.

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3 Methodology

Methodology

The aim of this study is to see how HRT can be used to assess the reliability of specific cases, in this case the Dutch Defence organisation, and see what issues are at play that undermine reliability. HRT will at the same time be used to search for solutions to the aforementioned issues. Therefore, the study follows an explorative research question:

How can High Reliability Theory be used to find issues that undermine an organisation's reliability, and inspire solutions that counter these issues and thus increase an organisation's reliability? The question reflects the two parts of this study. Firstly, there is the question of how exactly HRT can be used to assess an organisation's status quo. This study in its research design will outline a theoretical framework for its analysis, which will be used to link observations to certain pre-determined issues that undermine reliability. The second part of the question concerns itself with whether HRT can form a base for the solutions of the problems it highlights. This section of the study will outline the methods used, explain the case-type and will lastly outline the theoretical framework and its operationalisation. It concludes with an acknowledgement of certain limits and issues it has faced, and how these either limited the study in a way, or could be bypassed.

Methods

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observations and its effect to a framework based on HRT is therefore the most solid approach. Furthmore, using inductive research can be used whilst following a specific theory (Saunders, 2012). Thus, following a deductive approach by working from a specific theory to test in a given context, and by using an inductive approach to reliably link observations, to patterns, and eventually link this to theory. This provides the study with the opportunity to study in-depth with details, whilst being guided by a theory that will be the core of the analysis.

A Single Case Study

By looking specifically at the Dutch Defence organisation, the study works by a single case study structure. According to Gerring (2004), a single case study lends itself for intensive and in-depth research, which is necessary to create a detailed understanding of the issues at play within the Defence organisation, and link this to theory. Furthermore, a single case study is a good approach for theory building, as it is usually linked to an explorative study. Both Lijphart (1971) and George & Bennet (2005) argue that a goal of the single case study is to reveal causal mechanisms and contribute to theory building. The goal of this study is to see if and how HRT can be used as both a source to judge the Dutch Defence organisation by, as well as a source to face issues and challenges of the Defence organisation. HRT is rarely used to assess the organisation on its flaws, nor has this analysis of issues with their potential solutions been done in this specific way. Hence, the theory building potential of a single case study fits the character of the study.

Other structures have been considered, namely the comparative method. Comparing cases, different militaries, would have made the conclusions of the study stronger, improving external validity. However, this kind of study is not feasible because of

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Research Design

The study will be a qualitative single case study, using a deductive and inductive analytical framework to analyse the gathered information in comparison with HRT. The analytical framework will take certain issues as 'measurable' factors, based on the five principles of HRT as outlined by Weick and Sutcliffe (2015), since they provided a contemporary and complete overview of the most important components of HRT. From investigative reports of the Dutch Safety Board and reviews from the 'Inspector-General vd.

Krijgsmacht’1_{(IGK) certain problems, mistakes or issues are assessed as 'observations'.}

All the observations that these reports mention are then analysed by looking at the specific effect and meaning, and are linked to the 'greater issues' on the analytical framework. Thereby, it becomes clear which greater issues are at play in the Dutch Defence organisation, impacting HRO capabilities, and how this exactly happens. The measured greater issues of the framework will then be divided in 'potentially solvable' and 'problematic'. The observations and the accompanied effects or indicators will tell whether the issue can be solved via organisational and cultural change, making it a potentially solvable issue, or whether the issues are based on a lack of resources, which considering the current financial status of the Dutch Defence organisation, places them in the 'problematic' issue category.

An important part of the study is to see what kind of problematic observations are at play within the Defence organisation, before applying HRT-inspired solutions.

Observations are individually assessed, and then linked to the issues of the framework, discovering larger patterns or trends. For example, multiple reports specified issues with training personnel, a lack of qualified manpower and concerns about the decreased availability of educational facilities and budget. These three re-occurring factors are then linked to the larger issue at play, namely the lack of experienced, educated and qualified personnel. This way, the study is able to distillate out of a great number of problematic observations, over a time period of five years, the most pressing greater issues.

Analytical Framework

The analytical framework devised in this study is based upon the five principles of HRO's as outlined by Weick and Sutcliffe, with additional information about risk

management and the redundancy-resilience paradigm (Downer, 2009). In the framework,

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each of the five HRT principles outlined by Weick and Sutcliff is translated to a 'greater issue' that undermines reliability in an HRO. For example, where principle 1

'preoccupation with failure' increases organisational reliability by thinking about failure and risk, greater issue 1 'lacking understanding and attention of risk, both in and outside the organisation', assesses how organisation's decrease their reliability by not being aware or paying attention to risk. However, because some of the five principles are quite complex, this framework breaks them down in more measurable 'greater issues', resulting in a framework of 9 greater issues, corresponding to the 5 principles. This thesis will shortly recap the key components of each HRT principle, and then outlines per principle the greater issue(s) that correspond to it. Just like that each of the HRT principles largely influence each other, these 9 greater issues, while placed at a certain principle, sometimes also very much correspond to each other.

HRT principle 1: preoccupation with failure

An HRO should have a strong preoccupation with failure, meaning it monitors systems and processes in the organisation searching for symptoms that indicate problems to increase the change of preventing issues before they escalate (Weick and Sutcliffe, 2015). An organisation that focuses on preoccupation with failure becomes a risk-driven organisation, as it let searching and addressing risks be a key part of their operations. This principle result in one measurable greater issue.

1. - Lacking understanding and attention of risk, both in and outside the organisation.

A preoccupation with failure is a key component of a HRO (Weick & Sutcliffe, 2015, p.45-61), and a proper risk management strategy would ensure that an organisation actively searches for threats that might result in failure, and prevents them. This issues concerns itself with: whether organisation has formalized their 'preoccupation with failure' into risk management or risk analytical bodies, whether there is a culture in which people understand what risk is and actively communicate about this, and whether key parts of the organisation recognize risk and are familiar with its key workings.

HRT principle 2: reluctance to simplify

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versus complicated system issue, since organisations can go too much in the other way and become so complicated that they lose oversight and clarity. Complexity is according to Weick and Sutcliffe the ideal middle ground, where simplification does not happen but where a clarity and efficiency in the system is maintained. In order to adequately assess this principle, the framework will measure two greater issues. Firstly it will see whether certain processes are either simplified or complicated, and whether someone within the organisation is responsible for these processes. In other words, it assesses processes and agency. Since large organisational structures can be prone in becoming complicated, the second greater issue will look to the logistical and bureaucratic processes, their efficiency and whether inefficiency is due to simplification or

complication. The main difference is that the first greater issue will be concerned with the organisation's capacity to monitor processes to prevent simplification or

complication, whereas the second greater issue assesses currently existing organisational structures that result in sluggishness by being either too simple or too complicated.

2. - No overall owner of certain processes, resulting in accountability deficits.

Weick and Sutcliffe argue that an organisation should be reluctant to simplify (principle 2), whilst at the same time avoid becoming a 'complicated' rather than a complex organisation (2015, p.62-76). Processes should be monitored to avoid simplification and complication, especially in larger organisations, for example on the governmental level. This greater issue measures how an organisation ensures to avoid simplification and complication of its processes, and how it determines responsibility.

3. -Sluggishness in logistical and bureaucratic processes

This issue largely coincides with the above issue. Many principles of HRO depend on an organisation that is adaptable, flexible and fast. Weick and Sutcliffe argue that

simplification should be avoided so that an organisation is able to pick up anomalies and investigate them before they turn into threats (2015, p.62-65) and to increase an

understanding of the operations at play and their consequences (2015, p.79-80).

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and duties are not clear, or due to the fact that there are no mechanics in place that defer decision making to the right person.

HRT principle 3: sensitivity to operations

The main focus of this principle on how well an organisation understands its operations, how slight changes play out in the future and how the organisation ensures that people are attentive and knowledgeable about the operations they engage in. Weick and Sutcliffe identify three key components of this principle: talking with your people, especially the ones at the front line; understanding what you are doing and why; having the ability to translate observations into action (Weick & Sutcliffe). Due to the fact that each component is quite distinct from one another, and because they each on itself have a great influence on the organisations sensitivity to operations, they are measured separately.

4. - Lack of interaction between (higher) management and the front line.

The front line are the people within an organisation close to the operations and tasks itself (Weick & Sutcliffe, 2015, p.93). For an organisation to be sensitive to operations (principle 3) there should be a clear and strong relationship between the central organs of an organisation and the front line. Managers need to know what is happening at the front line to truly understand certain operations. This becomes difficult if management is not familiar with the front line. Therefore the analytical framework assesses the relationship between the management, in this case commanders and officers, and the front line, people active during missions and operations.

5. - Lacking understanding of operations.

By being sensitive to operations an HRO ensures that it notices moment-to-moment change, is fast to act upon this, and has a high degree of adaptability because they understand the operations as a whole rather then by components (Weick & Sutcliffe, 2015, p.79-80). Therefore, this framework assesses whether an organisation understands their operation, which entails whether they are watchful for change, translate

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6. - Inability to translate worrisome observations into action.

There is a difference between not being sensitive to operations and moment-to-moment change because the organisation does not understand the operation completely, or because it lacks the resources. This issue distinguishes itself from the fifth issue because it focuses on the ability of an organisation to actually do something with their awareness of a situation. Resources of organisations, especially governmental ones, can be very limited so therefore this study assesses not only the capability but also the possibility of acting upon observations. This does not only focus on the third principle: sensitivity to operations, but also the first: pre-occupation with failure. Risk management is an iterative process in which observing and analysis is only one side of a coin. The end goal is that these observations, the pre-occupation with failure, eventually leads to action. Anytime that does not happen because the organisation is for some reason not capable, be it due to the absence of a risk culture or lacking attention to operations, it falls under issue 1 and 5 respectively. However, if the lack of action is caused by a lack of resources, it is seen as an inability.

HRT principle 4: commitment to resilience

According to Weick and Sutcliffe, an organisation's resilience dictates how well it can remain functional when error occur, and how fast it can recover from these errors

(Weick & Sutcliffe, 2015). Preparedness for errors and other issues that fall outside of the daily routine is decided by both the training of people; the readiness of the people and equipment; and the redundancy within the operation. This principle is measured by two greater issues, namely the level of preparedness of units and equipment in terms of training, and the redundancy of the equipment and materials. The reason for this split is that training for preparedness can be done with low investment, and an organisation can do a number of things to increase preparedness. However, redundancy largely involves duplicating material and equipment, which can be very expensive, and can only be improved by investing. So the nature of how these two components can be solved decides that they should be assessed individually.

7. - Decreased resilience because units or equipment are not prepared.

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to adequately deal with a given situation. Since a military organisation relies so heavily on its equipment, the state of equipment becomes an integral part of resilience.

Preparedness in this issue refers to the amount of training people have had, whether they can function properly in the current status quo (both men and equipment) and how fast, both units and equipment, can respond to situations. Since 'accelerated' feedback is a key feature of strong resilience, as it provides units at the front line with key information to follow moment-to-moment change, lacking IT infrastructure that hampers

communication can be placed under this issue as well. Furthermore, some observations that indicate sluggishness in logistical and bureaucratic processes also influence the resilience of an organisation, since it limits efficiency and response time.

8. - Decreased resilience due to lacking redundancy.

Redundancy in this context refers to having spare part and equipment in order to

respond on certain errors, or to remain functional despite certain errors (Downer, 2009). Weick and Sutcliffe (2015) also argue that organisations that are prone to limit

redundancy hamper their resilience, as it limits the response capacity of an organisation on errors. This issue is separated from issue eight, because this issue specifically focuses on the availability of (spare) equipment, whereas the latter issue concerns itself with the current state of units and equipment. There is a difference between equipment that is not functional and ready, hence hindering preparedness, and equipment that is simply not present. Also, the underlying cause can differ greatly. There are multiple causes that result in equipment not being prepared, such as sluggish logistics, inexperienced

personnel or communications issues. Hence, there are also numerous solutions to solve this issue. Just like with the inability to translate worrisome observations into action, the issue of redundancy can be linked with resource availability. Therefore, since the cause can potentially be different, and since the solutions require a different approach as well, for instance different resource distribution, the issue of redundancy is separately

assessed.

HRT principle 5: deference to expertise

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determine the ability to defer to expertise will be the availability of experienced, educated and qualified personnel, and consequently, whether an organisation has a culture that facilitates continuous learning to generate these experts. Having decision making structures in place to actually migrate the decision making is also important, but since this largely involves the organisational structures and processes, this is measured by greater issues 2 and 3. However, the analysis takes outcomes of these two greater issues that also influence this principle into consideration.

9. - Lack of experienced, educated and qualified personnel.

Any organisation needs good personnel to function, but it can be argued that due to the complex and unforgiving circumstances many HRO's operate in, that good people are an absolute necessity. Experienced, educated and qualified people, or good people, are valuable for any of the five principles defined by Weick and Sutcliffe but the 'deference to expertise' principle very much relies on the quality and experience of an organisation's personnel. For this principles foundation is made by the experts, which per definition requires a certain amount of experience and training. Due to the large focus on the need of trained and qualified people, this issue also measures the organisational culture and whether 'continuous learning', a key characteristic of the organisational culture of an HRO, is present. A culture focused on learning is essential for HRO's. It is included in this issue because a lack of a 'continuous' learning culture will result in a shortage of experienced, educated and qualified people. Hence, observations that indicate an absence or low degree of 'continuous learning' or development opportunities are placed under this issue, as the inherent consequence is linked to the quality of personnel.

Operationalisation

In order for this theoretical framework to actually measure the empirical reality (Jonker, 2010) it will follow three steps. With the issues in mind, the analysis will first go over the reports looking for 'observations', certain smaller issues that are noticeable in relation to the framework. The reports are a representation of an empirical reality, as they provide an overview of what is happening, and more important, what goes wrong in the Dutch Defence organisation.2_{In step two each observation is individually assessed, looking at}

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the negative effects and indications and, according to this, link them to one or more greater issues as defined by the framework. Tables will be included in which the observations and effects are summarized, and the links with the issues are visible (a process called 'theming'). The final step is to see which issues indeed have many observations linked to them, and therefore assess the impact and implications it has on the Dutch Defence organisation. In short, the framework poses nine issues that undermine the five HRO principles and harm reliability. By collecting relevant

observations, the analysis shows which issues indeed are present, and how this impacts the HRO status of an organisation.

Data collection

Studying the internal workings of the Dutch Defence organisation proved to be difficult in terms of transparency and availability of information. The two main data sources are three investigative reports from the Dutch Safety board, and four year-reviews of the IGK.

The Dutch Safety Board (DSB) is tasked with investigating safety incidents in the

Netherland and is currently known for their research into the MH-17 plain crash and the Mali mortar explosion. The DSB is an objective investigative body and has their own researchers who carry out the research, by means of studying reports, investigating on scene and conducting interviews. This study uses three investigations of the DSB in the last five years: The incident signals of the 336 Squadron of the air force, The Mali mortar grenade incident, and the Shooting incident in Ossendrecht. The reason to look at investigations in the last five years is because older research might not be representative anymore for the status quo at the Dutch Defence organisation. Each report follows the same structure, as in that it firstly gives a detailed overview of what exactly happened, before conducting an analysis revealing mistakes, organisational or human.

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subjects, to create more insight. Just like with the DSB, this study uses reports from 2013 till 2016, in order to not work with information that has become 'old'. Report 2017 unfortunately has not been accessible yet. The IGK reports offer a great insight of many issues that the personnel of the Defence organisation are struggling with, highlighting certain structural issues that are of great importance since they indicate that on certain areas the Dutch Defence organisation is crippled due to resources shortages.

The data gathered comes from a limited number of sources, however, the detail of these sources, often hundreds of pages, provide the study with the necessary ability to gather in-depth knowledge. Other sources have been considered. A WOB3_{request for more}

information about specific conducts of the Dutch Defence organisation (for instance, risk management procedures) have not been answered at the time of writing this. Interviews may have provided additional information, but also could be very subjective due to personal bias. In addition, because the IGK provide very thorough reports themselves, and due to time constrains, the study chose to not carry out interviews.

Validity and Reliability

The approach of this study, together with its explorative character, ensures reliability and validity to a sufficient extend. Studies into military organisations often prove to be challenging in terms of reliability, since these organisations are rarely transparent.

Gathered data may be sensitive, meaning that scholars cannot always reveal their sources or details about data, creating reliability issues. However, in the case of this research that issue is circumvented by working with publicly accessible information. The used reports, both by the DSB and IGK can be accessed online. Since the data is publicly accessible, and the analytical process is clearly outlined, the study in itself is transparent, and can easily be checked and/or replicated to validate the results and conclusions.

By being a single case study, the external validity of the study is low. The specific context that is created from the information is unique, and it is highly unlikely that other military organisations face the same issues and/or could aspire the same solutions. However, the goal of the study was more focused on theory building, in this case applying HRT in a military context and as a tool to find improvement. This method in itself can be applied

3_{Wet Openbaar Verstuur (WOB), a request every Dutch citizen may make to request access to}

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outside of the context of this study. Thus, the generic framework does maintain an good level of external validity.

Limitations

The most pressing limitation of this study was the accessibility of information of the Dutch Defence organisation. Many of the inner workings of the military remain

unknown and collecting primary data for an analysis has proven to be to difficult in the current timeframe. Like mentioned above, using reports of the DSB, which is an objective party, and the IGK largely circumvented this issue. The downside is that the study itself could not make direct observations itself. The plus side however, is that behind each of these reports is thousands of hours of work by experts, meaning that in the course of five years, it gives a more detailed and complete insight that this study with its time constrain could do.

The lack of transparency of the Defence organisation leads to a difficulty in the research, namely that it does not have any knowledge about available resources within the Defence organisation. This is problematic for differentiating in solutions for certain issues that potentially can work, and certain solutions that only work with the investment of resources, which the Defence organisation often lacks.4_{However, what the limit of}

resource of the Dutch Defence would be is unclear, as well as what motivates Defence organisation to spend resources on. After the Ossendrecht shooting incident, the Defence followed the recommendations of the DSB and invested heavily in new instructors and shooting houses for the KCT5_{(Defence, 2017). The Defence}

organisation, after years of budget cuts, has a shortage of resources, but appereantly they did had resources to implement these recommondations. Therefore, for this study it remains unclear how much resources are available, and what the Defence organisation is willing to spend it on. Hence, during the analysis, any solution that requires hefty

investment is deemed 'problematic'.

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4 Analysis

This chapter will describe the analysis of the study. It will first summarize the main findings of the reports in the tables. Each table reflects the information from the reports, shortly outlining the 'observations', the 'effect' of this observation, or the meaning (indication) behind it, and then the 'greater issue' of the framework it is linked to. Then the split follows, and for each greater issue in the potential category, the solutions are shortly discussed, inspired by the HRT. For the 'problematic' category, the study outlines how it diminishes the HRO value within the Defence organisation.

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Report Summary result

Table 1: the Mali mortar incident report by the DSB.

DSB Mali mortar Incident No

. Observation Effect or Indication Greater issue

1 Unclear and unnecessary

stress during purchase period (DSB, 2017, p.57-58)

- Diffused responsibility - Lost control or overview of the process

- Increased risk for making mistakes

- Sluggishness in logistical and Bureaucratic process

- Lacking understanding of risk, inside and outside the

organisation

2 No check by the TDL

(DSB, 2017, p.61-62) - Procedures not followed, possibly because overview was lost

- Increased risk of faults

- Sluggishness in logistical and bureaucratic process

- No overall owner of certain processes

3 M6-N over M52-B3

(DSB, 2017, p.58-59) - Financial gains over safety --> lack of concerning the front line

- No scenario thinking--> worst that can happen

- Lacking understanding of risk, in and outside the organisation

4 Bought mortar grenades

did not match the mortar (DSB, 2017, p.58-59(

- No interaction between the 'buyers' and the 'sellers'

- No understanding of possible risks

- Lack of interaction between management and frontline - Lacking understanding of risk, in and outside the organisation

5 Wrong storage

temperature communicated (DSB, 2017, p.60)

- No one responsible for entire process, who could have noticed the differences - Increased risk in use of grenades

6 No follow-up in

Veenhuizen on remarks about quality and flaws of the mortar grenades 63-64)

- Indicates a strong lack of sensitivity to operations - No understanding for possible risks

- Lack of accountability

- Inability to translate worrisome observation and notifications into actions

7 BWM report about rust

disregarded (DSB, 2017, p.65)

- lack of accountability

Inability to translate worrisome observations and notifications into action

8 DMB disregarded

complains about the mortar grenades

(DSB, 2017, p.63-65, 68)

- Lack of accountability

Inability to translate worrisome observations and notifications into action

- Lacking understanding of risk, in and outside the organisation 9 No check after the 'stress'

of the Afghanistan mission

(DSB, 2017, p.663-64,

98-- Indicates a strong lack of sensitivity to operations - No understanding for possible risks

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- Unclear bureaucratic procedures --> lost sight of what is important

10 Storage in Kidal exceeded recommended

temperature

(DSB, 2017, p. 71-72)

- lack of accountability - Diffused responsibility, who was watching ammunition storage?

- Inability to translate worrisome observations and notifications into actions

11 No formal storage

supervision in Kidal (DSB, 2017, p.71)

- Diffused responsibility - Underestimated consequences

12 No follow-up on action

points by technicians in Kidal

(DSB, 2017, p.66, 72)

- No clear accountability - No sensitivity to operation - No understanding, or strong underestimation of the risks concerning grenades

- Lacking understanding of risk, in and outside the organisation - Inability to translate worrisome observations and notifications into actions

13 Over exposure of sun

during training (DSB, 2017, p.75)

- On a local level, lacking understanding of risk - Not attentive enough to situation at hand

- Lacking understanding operations

- Lacking understanding or risk, in and outside the organisation 14 Risk of medical situation

incorrectly assessed (DSB, 2017, p.82-84)

- Shows a strong lack of

understanding how risk work - Lacking understanding operations

- Lacking understanding or risk, in and outside the organisation 15 Role 2 in use while not up

to standards. (DSB, 2017, p.87)

- Political gains over safety - Disregarded respect for impact of said risk

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Table 2: the Ossendrecht shooting incident report by the DSB.

DSB Ossendrecht shooting incident

No. Observations Effect or Indication Greater Issues

16 Incomplete rules and procedures for shooting exercises

(DSB, 2017, p.51)

- Not attentive enough to situation at hand

- Underestimation of risks

- Lacking understanding of operations

17 Rule and procedures

often not abided by (DSB, 2017, p.52)

- Underestimation of risks - Lacking understanding of risk, in and outside the organisation

18 Shortage of qualified instructors

(DSB, 2017, p.52)

- Not enough knowledge on the field --> increases risk - Using unqualified people shows an underestimation of risk

- Indicates a lack in resources

- Lack of experienced, educated and qualified personnel

19 Constrains in education of firing instructors

(DSB, 2017, p.52-53)

- Indicates a lack in resources - Instructors not developed to fullest potential

- constrains an educational culture

20 No proper understanding

of the risk of life firing exercises

(DSB, 2017, p. 52)

- Lacking risk analysis before hand

- Underestimation of risk - Not attentive enough to operations

- Lacking understanding of risk, in and outside the organisation - Lacking understanding of operations

21 Use of an unchecked, and

later disapproved, shooting house (DSB, 2017, p.52)

- Underestimation of risk

- No sensitivity to operations - Lacking understanding of risk, in and outside the organisation

22 Loyalty over safety mentality

(DSB, 2017, p.53)

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Table 3: the 336 Squadron report by the DSB.

DSB 336 Squadron Report

No. Observation Effect or Indication Greater Issue

23 No risk and safety culture (DSB, 2014, p. 36-38, 39-40)

- Risks are not shared, no complete knowledge of possible risks

- Near misses are not accounted for, thus no learning opportunities arise

24 Mar-1 not fully implemented, not transparent

( DSB, 2014, p. 38-39)

- Procedures and bureaucratic chains are not clear

- Lacking overview

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Table 4: The IGK report of 2013.

IGK 2013

25 Lacking Wifi/ internet

structures

(IGK, 2013, p.26)

- Constrains communication - Constraint communication can hamper certain logistical and bureaucratic chains.

26 No overall

responsibility for logistical chains (IGK, 2013, p.64)

- Diffused responsibility - No one to own certain issues, thus solution efforts are slow or none existent

27 high 'flow through' in function within the organisation (IGK, 2013, p.32)

- Loss of expertise in certain functions

- No accumulation of experience and knowledge - Not enough experts available

- Decreased resilience because units or equipment is not prepared

28 High outflow of

military personnel (IGK, 2013, p.32, 49)

- 'Brain drain' lose of expertise - Not enough qualified people available for task at hand - Can influence operations negatively

29 Limited possibility for further development (IGK, 2013, p.32)

- Constrains a culture of continuous learning - Decreases availability of experts or qualified people - Also reason for larger outflow, thus shortage

30 Decreased operational

availability due to shortage of personnel; (IGK, 2013, p.32, 49)

- Even while units are prepared, executing their duties can be inefficient due to shortage of personnel

- Response repertoire of units decreased, harms resilience

- Decreased resilience because units and equipment is not prepared

31 'Just in time, just enough' principle leads to decreases operability (IGK, 2013, p.52-53)

- In practice people not fully equipped for their duties - Operational units miss expertise

- Harms a culture that facilitates learning

32 Development and

active duty are too intertwined (IGK, 2013, p.49)

- Hampers opportunities for development

- Constrains the learning culture

- Increases shortage of qualified personnel

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(IGK, 2013, p.55-57) duties

- Undermines resilience prepared

34 Lacking 'high tech' facilities

(IGK, 2013, p.61)

- Issues in communication due to lacking IT infrastructures - Slows down certain processes due to inefficient communication

- Slow feedback loops

- Decreased resilience because units and equipment are not prepared

35 Much equipment only

partially functional (IGK, 2013, p.61, 63-64)

- Harms the response

efficiency of equipment, thus from the greater unit

- lack of spare parts indicates a lacking redundancy

- Decreased resilience due to lacking redundancy

36 Lack of spare parts

(IGK, 2013, p.63) - When need to, damaged or old equipment cannot be replaced quickly

- Strongly decreases response time

- Decreases response quality

37 Logistical processes of equipment cannot keep up with operational speed (IGK, 2013, p.64)

- Indicates flawed and slow processes

- Indicates complicated logistics

- Strongly decreases response efficiency, as units depend on equipment

- Sluggish logistical and bureaucratic process

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IGK 2014

No Observations Effect or Indication Greater Issue

38 Working pressure to

high, harming morality and quality

(IGK, 2014, p.16)

- May contribute to high outflow, thus loss of qualified personnel

- Stress may influence performance negatively

39 Shortage in equipment

and materials (IGK, 2014, p.16, )

- No spare parts available, decreases redundancy - Units need to perform duties with insufficient resources

- Units cannot be fully prepared for planned or unplanned duties

40 Higher demand for risk

analysis without covering with funds (IGK, 2014, p.16)

- Risk analysis sometimes lacks uses, as results are disregarded

- Risks are not adequately dealt with

- Decreases sensitivity to operations, as risks are not known

- Indicates a lack of financial resources --> risk is not a priority

41 Split in management

organisation

(IGK, 2014, p.18-20)

- Indicates over-extended lean goals

- Decreases efficiency of certain logistical and bureaucratic processes - Slows down decision making

- Sluggishness in logistical and bureaucratic process- Lack of understanding of operations

42 Recruitment issues

(IGK, 2014, p.20-21)

- Not enough personnel to fulfil duties

- Lacking experts that understand operations

- Lack of understanding of operations

43 Re-organisations lead to merger of jobs (IGK, 2014, p.29)

- People unqualified for merged duties

- Unqualified management slows down processes

44 Not enough

development and training opportunities (IGK, 2014, p.20,30)

- People are not qualified (enough) for their duties - Constrains a continuous learning culture

45 SPOT runs behind

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- Hampers quality of education

46 IT structured are

inadequate (IGK, 2014, p.36)

- Decreases efficiency of certain processes

- Slows down feedback loops

- Decreased resilience as units and equipment is not prepared

47 AGV proves to be

inefficient

(IGK, 2014, p.37-38)

- Diffused responsibility - Overly complicated processes

- Inefficient processes

- No overall process owner - Sluggishness in logistical and bureaucratic process

48 Coordination of

operable units hindered by bureaucracy

(IGK, 2014, p.40)

- Indicates that certain

decision-making processes are to slow or inefficient

49 Centralisation and

'chains of broken responsibilities' (IGK, 2014, p.43)

- Inefficient centralisation resulted in slow decision making

- Diffused responsibility - Lacking accountability --> problems take too long to be solved

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IGK 2015

50 Tedious procedures

hamper personnel and equipment during missions

(IGK, 2015, p.6, 12)

- Slows down response time - Indicates inefficient procedures and processes

51 Shortage of capacity and knowledge within organisation

(IGK, 2015, p.6

- Not enough qualified personnel for their duties - Indicates that learning and education is not a priority

52 Decision made by

management not communicated with frontline

(IGK, 2015, p.7)

- Indicates a lack of communication between management and front line - Indicates management is not sensitive to operations - Harms efficiency of processes, central decisions for local users

- No interaction between management and frontline - Sluggishness in logistical and bureaucratic process

53 Knowledge is not

always shared (IGK, 2015, p.8)

- Indicates a lacking culture

that facilitates learning - Lack of experienced, educated and qualified personnel

54 Clashing integration of different units

(IGK, 2015, p.8)

- Conflict constrains efficiency

- Different duties hamper efficiency of integration - Complication over complexity

55 AGV proves to be

problematic (IGK, 2015, p.10)

- Diffused responsibility - Overly complicated processes

- Inefficient processes - Inefficient procedures for equipment that should be operable might harm response time

56 Overall quality and

quantity of equipment is low

(IGK, 2015, p.12)

- low quantity means low redundancy

- Low quality effects response repertoire of units

57 Operability decreased due to slow logistical processes

- Indicates slow logistical processes

- Decreased operability due

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- Decreased response time

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IGK 2016

No. Observations Effect or Indication Greater Issues

58 Shortages leads to 'un-readiness' of troops (IGK, 2016, p.6)

- Demonstrates a lack of qualified personnel - Shortages in spare part harms redundancy

- Un-readiness of equipment harms 'preparedness of troops

- Un-readiness harms response quality of troops

-Lack of experienced, educated and qualified personnel

59 Task cannot be

executed because equipment is not ready or not present

(IGK, 2016, p.6)

- Demonstrates a lack of qualified personnel - Shortages in spare part harms redundancy

- Un-readiness of equipment harms 'preparedness of troops

- Un-readiness harms response quality of troops

60 Shortage of spare parts

(IGK, 2016, p.6) - Shortages in spare part harms redundancy - Decreased resilience due to lacking redundancy

61 Large outflow of

personnel (IGK, 2016, p.6)

- 'Brain drain' leads to a

shortage of good personnel - Lack of experienced, educated and qualified personnel

62 Risk management does

not lead to action (IGK, 2016, p.8)

- Underestimation of risk and its impact

- No sensitivity to operations --> what is the moment-to-moment change?

- Indicated no resources available for action

- Lacking understanding of risk, in and outside the organisation - Inability to translate worrisome observations and notifications into action

63 Notifications about

bad security and safety circumstances

(working with dangerous materials) (IGK, 2016, p.8)

- Disregard or

underestimation of risk - Indicates lack of resources to take action

- Lacking understanding of risk, in and outside the organisation - Inability to translate worrisome observations or notifications into action

64 Frontline cannot act

due to centralisation (IGK, 2016, p.11)

- More obstacle for response, decrease response efficiency - Lacking authority for experts, decreases deference to expertise

- Centralisation which harms

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front line indicates slow bureaucratic processes

65 Not enough qualified

and trained personnel (IGK, 2016, p.6-8)

- Not enough good

personnel - Lack of experienced, educated and qualified personnel

66 Lacking IT

infrastructure (IGK, 2016, p.6)

- Slows down processes, harming logistical and bureaucratic chains

- Slows down feedback loops - Hampers information sharing

- Sluggishness in logistical and bureaucratic processes

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Potential issues

Issue 1: Lacking understanding of risk in and outside the organisation

A reoccurring theme among the issues within the Defence organisation is the small role risk usually plays. The DSB has raised multiple concerns about the fact that risk analysis was not carried out or did not get any follow-up, creating a lack of understanding of safety issues as is shown in table 1 (issue: 17, 18, 20). Furthermore, in other parts of the organisation, there is a lack of capacity to carry out risk analysis, let alone monitor these risks, as shown by table 2 (issue: 20), table 5 (issue: 40) and table 7 (issue: 63). Lastly, risk also does not seem embedded in the organisational culture, as many issues and problems reflect that both personnel at the front line, as personnel in higher management levels often show a lack of risk oriented thinking or any pre-occupation with failure, as

demonstrated by table 2 (issue: 18, 22) and table 3 (issue: 23). This furthermore complies with the DSB notification that risk concerns are often not shared within the organisation, seen in table 3 (Issue: 23).

This lack of risk understanding harms several principles of HRO's. Thinking about risk, both as a mind-set, as well as having people or a department dedicated to this task, means there is an understanding about what can go wrong. By not doing this, the organisation might miss certain cues that are symptoms for larger problems, be it now or in the future (Weick & Sutcliffe, 2015). Furthermore, being aware of the risks means that one can deal with them. Also, not understanding risk within the organisation decreases the sensitivity to operations (identified in the previous section as principle 2).

Understanding risk enables one to better assess certain processes or operations, and also to know how certain changes can create risks in the future.

Solutions:

Stimulating a risk-oriented culture within the organisation.

Weick and Sutcliffe argue that a general sense of preoccupation with failure in the organisation can be created when people articulate their expectations clearly, especially regarding errors, create awareness of vulnerability and make preoccupation or risk part of the strategy (Weick & Sutcliffe, 2015). Following these notions will create an

High Reliability Theory and the Dutch Defence Organisation

High Reliability Theory and the Dutch Defence

Organisation

Table of Contents

1

Introduction

2

Theoretical Framework

3

Methodology

4

Analysis