Justification shift and uncertainty: why are low-probability near misses underrated against organizational routines?

Abstract

Knowledge of near misses is helpful in preventing accidents, but it does not always lead to changes in organizational routines or contribute to accident prevention. In this article, the authors argue that low-probability near misses reinforce beliefs of experts and professionals in existing routines, proposing a concept of justification shift. Justification shift is underestimation of risks of known near misses vis-à-vis overestimation of reliabilities of existing routines. Consequently, signals of "close calls" tend to be disregarded, and accidents become more likely. When justification shift occurs, experts and professionals who want changes in routines face burden of proof about risks of those routines. Uncertainty in requirements and data may increase the burden and make justification shift more likely. To explore how justification shift occurs and how uncertainty influences the shift, the authors have developed an agent-based model based on theories in organizational studies and the case of the space shuttle Challenger accident in 1986. From the simulation using the model, it becomes clear that uncertainty does not make a difference in frequencies and degrees of justification shift. The authors also discuss implications of this finding to efforts to utilize knowledge of near misses and to further research on the efforts and organizational decisions.

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Categorization of Near-Collision Close Calls Reported to the Aviation Safety Reporting System

“…Actions by aviators and flight crews are generally predictable based on Air Traffic Control directives, mandates from the FAA, directives from flight carriers, and actions of other aircraft operators. Research has shown that unless the high probabilities of risks are known, current routines are unlikely to change unless accidents or incidents have occurred (Shimazoe & Burton, 2013).…”

“…Research has acknowledged that in the mind of the individual human decision maker, close calls are usually deemed as "successes" and the near misses reinforce the individual's current routine. When a "justification shift" occurs, it leads to an underestimation of the known risk (or close call) and an overestimation of the reliability of the routine (Shimazoe & Burton, 2013). To better communicate these risks, it is essential to first understand the differences that exist among the types of close call events.…”