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Inside Hazardous Technological Systems Inside Hazardous Technological Systems Methodological Foundations, Challenges and Future Directions Edited by Kenneth Pettersen Gould and Carl Macrae First edition published 2021 by CRC Press 6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742 and by CRC Press 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN © 2021 Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, LLC Reasonable efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the consequences of their use. The authors and publish- ers have attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmit- ted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, access www .copyright .com or con- tact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. For works that are not available on CCC please contact mpkbookspermissions@ tandf. co. uk Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identification and explanation without intent to infringe. ISBN: 9780367226947 (hbk) ISBN: 9781032033273 (pbk) ISBN: 9780429281587 (ebk) Typeset in Nemilov by Deanta Global Publishing Services, Chennai, India Contents Foreword: Qualitative Inquiries into Safety Research .............................................vii Silvia Gherardi Preface....................................................................................................................xiii Editors .....................................................................................................................xv Contributor Biographies .........................................................................................xvii Chapter 1 Hazardous Technological Systems from the Inside Out: An Introduction ....................................................................................1 Kenneth Pettersen Gould and Carl Macrae Chapter 2 Turner and the Sociology of Disasters ...............................................19 Andrew Hopkins Chapter 3 Access, Methods and Knowledge When Exploring High-Hazard Systems: Lessons from the Past for the Future ..................................33 Mathilde Bourrier Chapter 4 In the Footsteps of Turner: From Grounded Theory to Conceptual Ethnography in Safety ....................................................49 Jean-Christophe Le Coze Chapter 5 Case Studies in Safety Research ........................................................69 Stian Antonsen and Torgeir Kolstø Haavik Chapter 6 Actor Network Theory and Sensework in Safety Research ...............85 Torgeir Kolstø Haavik Chapter 7 Learning to Do Ethnography in Complex Systems .........................101 Christian Henrik Alexander Kuran Chapter 8 Work as Planned, as Done and as Desired: A Framework for Exploring Everyday Safety-Critical Practice ...................................115 Andrew J. Rae, David E. Weber and Sidney W. A. Dekker v vi Contents Chapter 9 Combining Lenses: Pragmatics and Action Research in Safety Science ..............................................................................................133 Trond Kongsvik and Petter G. Almklov Chapter 10 Bridging an Unsafe Divide: In Search of Integrated Safety Science Research ..............................................................................151 Paul R. Schulman Chapter 11 Large-Scale Mixed-Methods Evaluation of Safety Programmes and Interventions ..............................................................................169 Graham Martin, Jane O’Hara and Justin Waring Chapter 12 Putting Senior Management in Focus: A Critical Reflection on the Direction of Safety Science Research ........................................187 Jan Hayes and Sarah Maslen Chapter 13 Politics, Accident Research and Analysis: The Evolution of Investigation Methods and Practices in Healthcare .........................203 Siri Wiig, Jeffrey Braithwaite and Geir Sverre Braut Chapter 14 Exploring the Grey Area of Cyber Security in Industrial Control Systems (ICS): A Qualitative Research Matter ..................221 Alberto Zanutto Afterword: Connoisseurship, the Sociological Imagination and Turner’s Qualitative Method ..................................................................................237 Nick Pidgeon Bibliography ...........................................................................................................249 Index ......................................................................................................................279 Foreword Qualitative Inquiries into Safety Research Silvia Gherardi1 The present collection of chapters organised around the idea of looking inside “haz- ardous systems” with the lens of qualitative methodologies, offers a distinctive con- tribution to safety research because it is positioned at the crossroad of two entwined conversations. On one side the organisational approach to risk and disasters, which changed the conception of risk in the early 1980s, and on the other side the challenge of qualitative methodologies for conducting research on safety in the 1990s. Both conversations are deeply indebted and shaped by the legacy of Barry Turner and his Man-Made Disaster (MMD) model (Turner, 1978, Turner and Pidgeon, 1997) that contributed to the development of a type of scientific inquiry which considers organisational factors in the aetiology of accidentally caused disasters. In reading this book, we can see the materialisation of an outstanding contribution that, after more than 40 years, is still able to inspire new ways of doing empirical research and develop new problematisations of ongoing challenges to safety. Man-Made Disasters, as a book, a model of analysis and as the symbol of Turner’s theorisation on safety culture, is a cultural fact in itself because it represents an inscription in the world of culture. It is also a neologism in the vocabulary of risk and safety, since “Man-Made Disaster” is a term which denotes a class of phenom- ena which constitutes a distinct social reality in the flux of experience. With this term Turner marked out a type of disaster previously undistinguished from natural disasters. He was the first to conceive of disasters in terms of a process of incubation and not as “bolts from the blue” (as he loved to say). The man-made disasters model, both as a descriptive tool and in its later development as a diagnostic and learning aid (Toft and Turner, 1987, Toft and Reynolds, 1994), is about how technical, social, institutional and administrative arrangements can produce disasters. It is about the relationship between information, error and surprise in organisations, “for we know that responsibility for failure can be just as dispersed and fragmented as responsibil- ity for success” (Turner, 1978, p. xv). In this quote we may trace the shift that took place in the 1980s “from technical risk to safety culture” and the direction of such a shift towards the consideration of the complexity induced by organisational and cultural factors in doing research and theorising risk and safety. Turner provided the first item of evidence to show that crises – like those induced by MMD – may constitute a threat but they also may, from one point of view, be vii viii Foreword considered as opportunities for pursuing social change. Turner (1978, p. 22) recalls that the two Chinese characters used to express the word “crisis” mean “danger” and “opportunity” in order to show that crises may be considered as opportunities within an organisation, or even as a means of aiding personal growth for individual manag- ers. In fact, Turner at the end of his life when he and Nick Pidgeon were revising the 1978’s version of MMD, moved to see crisis as an opportunity for organisational learning, thus exploring how knowledge maybe de-contextualised from the original situation (crisis) and re-contextualised within organisational procedures as knowl- edge in use. The complexity inherent in the cultural and organisational approach to disasters is that any epistemic practice (any organisational culture) is at the same time “a way of seeing [that] is always also a way of not seeing” (Turner, 1978, p.49). Organisational culture – as a way of seeing – can be conceived as embedded in the equipment that organisations use in operating upon the world, as cultural elements for relating to the tasks at hand, to the environments in which they are immersed and to the manner in which those within the organisation interact with each. This is plainly a sociomate- rial conception of culture which breeds an orientation to action situated in the opera- tional context and which does not undervalue the material culture inscribed in the use of equipment and technology. At the same time a culture is a way of not seeing; it is “a collective blindness to important issues, the danger that some vital factors may be left outside the bounds of organizational perception” (Turner, 1978, p. 47). This union of opposites – culture as a tool for seeing and not seeing – takes us to a topic that Turner resumed later when he proposed a reading of Derrida applied to the use of software for hazard control (Turner, 1994a). In this light, culture is viewed as spo- ken language, as a system of marks, whether these are the technology, the computer software or the semantic networks he was writing about. In fact, the sociological literature on disasters was enriched in those years by a further shift away from organisational factors understood in the mainly structural or sociotechnical sense towards the cultural factors used in interpreting safety prob- lems (Gephart et al., 1990; Wright, 1994; Pidgeon, 1995; Gherardi, 2004). The main assumption is that organisations are concerned with intention and the execution of intention. Disasters always represent a failure of intention, a failure of foresight. Turner and Pidgeon view a sociological definition of disaster as raising a challenge against existing cultural assumptions. A disaster was conceived as an “an event, concentrated in time and space, which threatens a society or a relatively self-suffi- cient subdivision of a society with major unwanted consequences as a result of the collapse of precautions which had hitherto been culturally accepted as adequate” (Turner and Pidgeon, 1997, p. 70). The advantage of this definition is that it covers instances where the amount of physical damage is not great, but the mishap reveals a gap in defences which were regarded as secure and a need for cultural readjustment. Thus, by adopting the MMD model of analysis, we may follow Turner and Pidgeon by formulating a definition that does not refer to the physical impact or scale of the event. Instead, in sociological terms, an accident can be defined “as the overturning and disruption of cultural norms and expectations for dealing with risk and safety matters” (Turner and Pidgeon, 1997, p. 74). The MMD model suggests Foreword ix that “technical, human, managerial and cultural dimensions interact in a contingent open-ended process that precludes deterministic analysis” (Horlick-Jones, 1996, p. xx). In those years the linguistic turn was establishing itself stating that language does not describe reality but creates it and, therefore, the borders between ontology and epistemology were blurring. In fact, through language and through epistemological practices the object of study (be it, safety, risk, disaster) is constructed and conse- quently we can use the term “onto-epistemology” (Barad, 2007). Thus, a new chal- lenge is facing qualitative research: how to conduct qualitative research once the researchers consider themselves and their epistemic practices as part of the research assemblage? To the first conceptualisation of disasters in sociotechnical terms we may apply notions drawn from actor-network theory and see in the disappearance of the hyphen from “sociotechnical” systems the demise of the distinction between the social and the technical, the social and the material (as in sociomateriality). In this case, the boundaries among the material, technical, human, managerial or cultural vanish, so that an accident can be defined simply as a breakdown or dis-alignment in what hitherto was a way of ordering heterogeneous materials. In the duality and ambivalence of language-in-use in organisational context we can trace a theme that years later became central in Science and Technologies Studies and was expressed as “multiplicity of objects” (Mol, 2002) or “empirical ontologies” (Law and Lien, 2013). It is the idea that an object (a definition of risk, or hazard or safety) is not a single “reality” but may be constructed as multiple “reals” in different parts of an organisation and in relation to different apparatuses of detection and/or measurement. This theme was already present in the conception of culture in MMD but continues to be overlooked. In MMD the ambiguity in language and of language is a theme inherent to the description of information difficulties in the incubation of disasters, and the risks that organisations cause through operational management or maintenance deficiencies. Plurality of interpretations is present, but what is not stressed is that risk, hazard or safety are multiple and depend on the epistemic prac- tices that identify them. I stress the point of view that culture may be formulated as a particular knowledge structure and value system that has received normative status. The reason for link- ing culture to knowledge and to knowing is that a cultural approach to safety and disasters implies the methodological choice of studying culture in socially situated knowledgeable practices. We find this methodological challenge anytime that safety is defined in relation to knowledge and to practice and thus when safety is researched as a collective knowledgeable doing and an emergent social competence (Gherardi, 2006). What qualitative approaches have in common is in particular that safety, risk and disasters are studied as social in origin and this epistemological framework induces us to give attention to what is known, what is not known, who does not know, and why it is so (Pettersen Gould, 2020). The contemporary debates that we may read in this book have their roots in the qualitative social science approaches of the 1980s and 1990s that showed that the

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