Reiman 2011: Understanding Maintenance Work in Safety-Critical Organisations

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Theoretical Issues in Ergonomics Science

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Understanding maintenance work in safety-critical organisations managing the performance variability

Teemu Reiman
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Available online: 29 Jun 2011
To cite this article: Teemu Reiman (2011): Understanding maintenance work in safety-critical organisations managing the performance variability, Theoretical Issues in Ergonomics Science, 12:4, 339-366 To link to this article: http://dx.doi.org/10.1080/14639221003725449
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Theoretical Issues in Ergonomics Science Vol. 12, No. 4, JulyAugust 2011, 339366
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)
Downloaded by [VTT], [Teemu Reiman] at 10:24 29 June 2011
Human and organisational performance variability has been identified as a cause of many latent and active failures in maintenance. Seldom has the variability been considered as an integral and inherent part of the maintenance activity to be managed by organisational means. The article deals with the challenge of understanding maintenance work in safety-critical organisations. The aim is to review the current literature on maintenance work and illustrate the organisational research challenges of managing performance variability in maintenance. This article presents six major research challenges in managing performance variability in maintenance. The article concludes by noting that a holistic theory on maintenance work is needed to manage the variability and turn it into a positive force. Maintenance has the potential to produce positive performance variability and guard against negative instability in complex sociotechnical systems. 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 or production safety, maintenance work involves occupational safety hazards of various kinds (physical forces, chemicals, radiation, etc.). Thus, maintenance organisations can be considered as safety-critical organisations. This means that safety is a central goal of the maintenance organisation and the organisation has to identify, remove, control and prevent the various hazards associated with its work. Several accident investigations have uncovered inadequate or faulty maintenance as one of the main contributors to unanticipated events in various safety-critical domains, including the railway, offshore oil drilling, chemical, petrochemical, aviation and nuclear industries (Department of Transport 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, Baker 2007, Sanne 2008a). Thus, maintenance activities can be considered as having a highly significant positive or negative impact on the effectiveness of the entire sociotechnical system, including safety.
*Email: teemu.reiman@vtt.fi
ISSN 1463922X print/ISSN 1464536X online 2011 Taylor & Francis DOI: 10.1080/14639221003725449 http://www.informaworld.com
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Maintenance activities have been under various organisational changes and restructuring initiatives, aiming at, e.g. reduced costs, increased availability of the machines, better knowledge sharing and increased flexibility (Patankar 2005b, Reiman et al. 2006, Pettersen 2008). This development has been going on for years in various safety-critical domains. For example, in the aviation domain, the US Federal Aviation Administration has identified a need for better efficiency in aviation maintenance to cope with the ever-growing workloads caused by the increase in the number of passenger miles flown by the airlines. The rise in traffic has not been accompanied by a similar increase in resources, e.g. the number of maintenance technicians. Price-based competition has 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/NEA 2000), the ongoing generation turnover (OECD/NEA 2001) and the deregulation of the electricity market (Bier et al. 2001) have been the main drivers in the recent organisational changes (see also IAEA 2001, OECD/NEA 2002). These changes put an even stronger emphasis on understanding the maintenance work and its requirements as well as managing the performance variability in maintenance. This article deals with the challenge of understanding maintenance work in safety-critical organisations and its characteristic sources of performance variability. The aim of this article is to review the current literature on maintenance work in safety-critical organisations and to illustrate, with the help of the literature review and theoretical work, the organisational research challenges of managing performance variability in maintenance work.
1.2. Performance variability in maintenance One of the challenges of maintenance work is that while it is necessary for the technology in use, it can be a source of latent as well as active failures in the system. In addition, some of the errors are hard to notice. Errors made during preventive maintenance can manifest after a long time. Quick fixes in failure repairs might do more harm than good in the long run. Event investigations almost always find actions outside the prescribed boundaries and label these human errors or violations (Reason 1997). The foci of studies on human performance 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 human work (Hollnagel 2009b, p. 85), including maintenance. Human performance variability is 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, dynamic relations between phenomena and the connections between environmental cues are so vast that there can never be full certainty of the effects of the maintenance actions or of the various phenomena associated with the object of work. It is important to understand that uncertainty is never caused by an individual alone but is rather related to the object of work, such as the condition of technical systems in nuclear power plants (NPPs) or the reliability of measurement data in process control. The object of work contains uncertainty; the progress and effects of work can never be fully predicted. This is why employees 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 human performance. 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 is based 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 are considered 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 or her 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 to counteracting and controlling performance variability: the first builds on restricting and constraining human behaviour through rules and procedures, the second builds on the strengths, competence and motivation of the personnel. The former approach is based on the assumption that variability is inherently bad, whereas the latter approach treats 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 various approaches 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 Reasons (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 errors or 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, Pyy 2001, 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 source of 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 latent failures 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 the study, 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. When discussing 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 Pyy 2001) reviewed approximately 4400 failure reports from a Finnish NPP from the period of 19921994 and searched for human errors related to maintenance. They were especially interested in human-related common cause failures (CCF)1 and the mechanisms causing these failures. For single human errors, they (Laakso et al. 1998) identified instrumentation and control (84 cases out of a total of 206 single human errors) plus electrical equipment (40 cases) as being more error prone than other kinds of maintenance. Laakso et al. (1998) identified 14 CCF from the failure reports. The distribution of CCF was similar 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 and Williamson 2003, Reason and Hobbs 2003) the most dominant error category was that of commission. Weaknesses in work planning and in the design and layout of the equipment 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 authors further identified that most errors had stemmed from the refuelling outage periods and plant modifications and that they were discovered only after the outage during power operation. Reason and Hobbs (2003) note that the most common human errors in maintenance in NPPs as well as in the aviation industry are errors of omission: failing to do something that should have been done (see also Reason 1990, Hobbs and Williamson 2003, Patankar and Taylor 2004b). They also note that these errors are commonly associated with reassembly or installation activities. They have categorised the major types of unsafe acts: . recognition failures, such as misidentification of objects or signals and non-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 absentmindedness or external distraction or slipping into a familiar course of action when required or intended to perform a less familiar action; . errors of habit, such as applying bad rules and developing bad routines that have no immediate negative effect; . mistaken assumptions, such as applying a good principle or rule-of-thumb in a situation for which it is not appropriate; . knowledge-based errors, such as problem solving in new situations or unfamiliar tasks; . violations, such as intentional deviations from procedures to save time, get the job done or due to personal thrill-seeking (Reason and Hobbs 2003, pp. 4058). Some of the types of unsafe acts identified by Reason and Hobbs (2003) such as bad routines can be called performance-shaping factors that increase the probability of human errors. The conditions and factors influencing human errors have also been extensively studied. Suzuki et al. (2008) asked in their article on aviation maintenance related incidents, why cannot (the already established) safety procedures prevent human errors. Their study showed that coordination problems weakened these safety procedures. They call for increased sense of responsibility for preventing future coordination failures. Patankar and Taylor (2004a, 2004b) have listed the dirty dozen (originally developed by Gordon Dupont in 1993 as the key component to the human performance in maintenance

Fatigue Stress Complacency Lack of assertiveness Lack of knowledge Lack of awareness Pressure Unsafe norms Lack of communication Lack of resources Distraction Lack of teamwork
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Figure 1. The dirty dozen elements causing errors in aviation maintenance according to Patankar and Taylor (2004a, b).
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 different phenomena, including issues at the individual, group and organisational levels. In order to shed more light on performance variability in maintenance as well as on how safe or unsafe acts are decided on, studies have tried to identify sources of professionalism in maintenance, including decision-making strategies, rule following and mental models or conceptions concerning the maintenance work. 2.2. Professionalism and decision making as contributing to performance variability A classic work that sheds light on the technicians work within an organisational context is that of Orr (1996). He has conducted ethnography on the work of field service technicians at Xerox. He noted that the technical knowledge and the professional identity of the technicians were strongly dependent on face-to-face encounters between the technicians 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 specific situations (Orr 1996, p. 127). He (Orr 1996, p. 91) also argues that when technicians talk about specific machines in their territories (areas of responsibility), it is clear that these machines are individuals. Their different histories, different patterns of use, and different social 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 any mutual acquaintance. He noted that the technicians consider the machines to be both perverse and fascinating. What really interests the technicians is a failure situation that they do not understand (Orr 1996, pp. 9597). They take pride in being able to cope with the machines. The technicians must diagnose, repair, maintain and adjust the machines in an environment that is inherently unpredictable. Orr (1996, p. 104) notes that in all of these activities, and perhaps most critically in diagnosis, the technicians must understand the machines. Understanding is central also for anticipating and preparing for future problems. Orr points out that the corporation had a different view of the technicians work, one that emphasised not understanding but rather the following of directive documentation (see McDonald et al. (2000), for a similar finding in aviation maintenance). On the other hand, in providing directive documentation, the corporation is assuming responsibility for solving the machines problems, and in the eyes of the corporation, technicians are only responsible for failure to fix a machine if they have not used the documentation. However, while the technicians are quite willing to let the corporation assume any blame, their own image of themselves requires that they solve the problems if at all possible (Orr 1996, p. 111).
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Orr (1996) conducted his study in a non-safety-critical domain. However, somewhat similar 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. Orrs (1996) findings on the motivation and 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 projects concerning aircraft maintenance. He notes that the technicians did not follow the procedures 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. 134138, Hobbs and Williamson 2003, p. 196). Also, according to McDonald (2006, p. 163), for many aircraft maintenance organisations, there appears to be an unresolved tension between effective planning and the requirement of flexibility to meet the normal variability of the operational environment. He then generalises from a number of surveys in different organisations the core professional values of aircraft maintenance personnel. These values included the following characteristics: . . . . . . strong commitment to safety; recognising the importance of teamwork and coordination; valuing the use of ones own judgement and not just following rules; being confident in ones own abilities to solve problems; having a low estimate of ones vulnerability to stress; being reluctant to challenge the decisions of others.
Taylor and Christensen (1998, pp. 8384) have defined the characteristics of a professional aviation maintenance technician as including competence, centrality, control and commitment regarding flight safety. McDonald (2006) noted that the above-mentioned professional values in many ways matched the deficiencies found in the same organisations. Professionalism compensates for organisational dysfunction. A problem is that the double standard of work as formally specified and unofficial ways of working is hidden (McDonald 2006). McDonald et al. (2000) and McDonald (2001) argue that evidence from aviation maintenance indicates that the current quality and safety management systems do not provide an adequate picture 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 three in-depth case studies with his colleagues (Reiman et al. 2005, Reiman and Oedewald 2006). The case studies employed interviews, surveys, seminars, document analysis and group work. The study consisted of an analysis of maintenance culture combined with a core task analysis (cf. Norros 2004) of the maintenance core task. On the basis of core task modelling, the maintenance core task was defined as balancing between three critical demands: anticipating the condition of the plant and conducting preventive maintenance accordingly, reacting to unexpected technical faults and monitoring and reflecting on the effects of maintenance actions and the condition of the plant. The overall objective of the maintenance activity was defined as follows: maintaining the operational reliability and the economic value of the nuclear installation so that its power production can continue as long as planned. The case plants differed in terms of their emphasis on, the interpretation of 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 the paramount 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 psychologically challenging issues at all the plants. Critical attitudes towards management and the values prevalent in the organisation existed at all the plants. The hands-on nature of maintenance work was emphasised as a source of identity at the NPPs. Maintenance work produced a feeling of meaningfulness, especially when there were technical problems to solve or failure 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 to guarantee it. Reiman (2007) proposes that maintenance work should be considered as knowledge-intensive work and concludes by arguing that the nature and significance of maintenance work should be better acknowledged by the maintenance workers themselves 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 preventive maintenance (cf. Seminara and Parsons 1982, p. 186) in two domains: nuclear and chemical. They show how mental models and implicit assumptions influence decision making. Both industries had trouble developing their programmes of preventive maintenance. Carroll et al. (1998, pp. 109110) argue that difficulties in managing maintenance arise, in part, from limitations in mental models, which they define as individual, shared and embedded beliefs and understandings. They write: Preventive maintenance is a prototypical activity that seems to be a low priority in the face of immediate demands to keep the machines running at lower cost, and the ultimate effects of 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 change from a culture of corrective maintenance to a culture of preventive maintenance with a maintenance game. The mental models, however, proved very hard to change. These studies have illustrated the complexities of the interaction between the technicians and the technical system as well as the challenges facing the personnel in making decisions within the social context of the maintenance organisation. The findings emphasize the need to take into account the social and organisational aspects in order to better 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 maintenance contexts. 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 and Oedewald (2006), rules and procedures were a source of tension and ambiguity for the personnel. They were afraid of losing their professional identities as skilled craftsmen and becoming a small cog in a big machine, but they felt this was the goal of the organisation and also to some extent their daily reality (Reiman and Oedewald 2006). They felt that the strong 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. Hackman and Oldham 1980, p. 75, Bourrier 1996, p. 106, Dekker 2005). Sanne (2008a, p. 647) also points out a need in railway maintenance to identify the practices of risk taking and rule bending and the process of how they are produced and reproduced in the social context of maintenance. Often adaptation and interpretation of rules is considered an integral part of the work. 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, and their relationship in the production of safety. He provides empirical accounts of how the technicians conduct their work and make decisions within the social context in which they work. He utilised participant observation, document analysis and interviews in a Norwegian aircraft maintenance company. His analysis emphasised the roles of human agency the capacity of the technicians to decide and act and the unofficial social system in creating safety. Pettersen argues that the technicians constantly sought to revise their knowledge and their degree of certainty about it. He illustrates how the technicians both valued and distrusted formal descriptions of work (procedures, rules and regulations) as guides for work practice. The technicians adapted their practices and local organising depending on the situation at hand. These adaptations were, however, supported by a strong cultural imperative to achieve safety and by the technicians awareness of the imperfection and uncertainty of both knowledge and practice. Pettersen (2008, p. 85) notes that technicians individual choices and actions take place within the context of a historical system where, among other things, maintenance planning, materials supply, a legal institutional framework and safety management systems constitute structured relationships of actions that constrain and enable how the technicians can act in ways not regularly accounted for. Bourrier (1996, 1999) has compared practices in four maintenance units in France and the USA. She spent between 3 and 4 months at each site and conducted a total of 300 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 the plants. Each plant had its own official or unofficial way of following the procedures and acting when the procedures did not cover the work in question. For example, at one of the plants, organisational reliability was based on situational improvisation when no suitable procedures could be found. Foremen unofficially accepted the practice and trusted the expertise of their workers and themselves. At another plant, reliability was based on following the procedures strictly; for cases where no procedure existed, the plant had a procedure with which the appropriate procedure could be quickly produced. According to Bourrier, a drawback of this strategy was that it did not support individual decision making on the part of the workers. In conclusion, Bourrier states that local adjustments to and re-arrangements of rules and, at times, even rule violations, are not only constant but necessary for organizations to effectively pursue their goals (Bourrier 1996, p. 106). Sanne (2008b) studied incident reporting and storytelling in railway infrastructure maintenance. He was interested in the reasons for the low number of reported incidents and its consequences for organisational learning. He illustrates how different accident aetiologies shape incident reporting and storytelling. For the railway technicians, an accident is seen as a breakdown of occupational practices, skills, and values, rather than as a system breakdown (Sanne 2008b, p. 1212). Consequently, this shapes what is considered an incident in the technicians community. On the other hand, incidents that pose a threat to the technicians identity as a responsible and careful professional can be framed as insignificant a one-off event in terms of learning. Shame, blame and fear of disciplinary actions decrease the willingness to submit reports. Some of the technicians had never thought about what the organisation as a whole can learn from incidents. Also, the modest and often negative feedback the technicians get from the reports they have made does not promote further reporting or learning. Incidents that do not result in injury are normalised as ordinary, unproblematic practice, not requiring learning or other corrective actions. In the occupational aetiology of accidents, the attention warranted by an event is defined 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 promotes the reproduction of occupational communities and provides a means of transferring knowledge to, e.g. newcomers. However, storytelling is usually restricted to local practice and does not address the systemic causes behind the accidents and incidents. The stories are also often told as a way to justify and legitimise technicians practice rather than to teach something new. Studies on the social aspects of maintenance have clarified the role that group-level factors play in the maintenance context. They have shown how the social context plays a dialectic role with the formal ways of organising and managing maintenance. Local practices influence and are influenced by the organisation-level practices, procedures and rules of conduct.
2.4. The influence of the organisation and management of maintenance activities on 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 on slack resources in the organisation. They conducted a qualitative study of the line maintenance organisation of a Norwegian regional airport with the aim of understanding the dynamics of safe work practices. They demonstrate how the line technicians emphasised the importance of practical competence, e.g. in defining the normal operative state of a component or a technical system. The formal maintenance documentation system had grey areas, where experience, practical skills, support from colleagues and trial-and-error strategies were required in troubleshooting and problem solving. Level-headedness and humility about ones own skills and knowledge were considered as desirable traits by the technicians. Further, as the technicians were under a constant pressure to get airplanes operational within planned schedules, they had institutionalised a way of slowing things down in order to create slack in the otherwise tightly coupled system. 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, competence and tangible assets) can be viewed as structural preconditions for the existence and effectiveness of several forms of safe practices. They caution against treating slack solely as a 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 leading indicators in the framework of resilience engineering and their ability to provide information on changes in risk. They argue that leading indicators should provide a signal of unintended system interactions and focus on the normal operation of the system instead of failures. They give some examples of leading indicators: the resources available, the capacity to identify circumstances beyond the experience (of the maintenance personnel), the possibility to reflect-on-action, openness, communication, the current technical state of the aircraft, maintenance oversight, and implementation of preventive maintenance. Bier et al. (2001) have studied the effect of deregulation on safety in the US aviation and rail industries and the UK nuclear power industry. They raised the issue that cutting corners in maintenance in these industries is a troubling trend from the safety point of view. 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 been surprisingly little studied in maintenance or other safety-critical fields (Reiman et al. 2006). Ramanujam (2003, p. 614) argues that the current explanations of the organizational origins of accidents understate, or even ignore, the role of organisational change. According to the few studies that have been made, some common issues of concern in organisational changes include vague responsibilities about safety matters during the transition period from one organisational form to another, loss of competence, deteriorating morale and employee motivation, deteriorating relations between employees and 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). Herrera et al. (2009) express in their study on changes in aviation a worry on the safety effects of increased subcontracting of maintenance activities at airline operators. They recommend that before outsourcing the companies should conduct risk analyses to consider what parts of the maintenance function and what competence is needed to keep in-house in order to ensure safety. Pettersen and Aase (2008) studied the role of change and restructuring in the line maintenance organisation of a Norwegian regional airport. The technical organisation, including its line maintenance department, was merged with a larger airlines technical 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 under the 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 the organisation . . . these resources functioned as reservoirs of knowledge, competence and resources that could be used by line maintenance in their efforts towards creating safe practices. 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 competence boundaries of the line maintenance department. These changes do not directly produce accident risk, but change the dynamics of operational practice.
They also noted changes in the information flow, opportunities for learning, communication between technicians and pilots and the amount of training (especially refresher courses) offered. This means that change efforts alter the ways in which safety is achieved. The line technicians expressed their concern about losing operational experience and knowledge in the new organisation. Reiman et al. (2006) have studied the safety effects of recently implemented changes in four Nordic NPP maintenance organisations. Their analysis of selected changes showed that all of these changes faced plenty of obstacles and had unforeseen or unintended consequences or side-effects on organisational practices and culture. Cost reduction, enhancement of the efficiency of maintenance activities and maintaining and developing competence were identified as goals of all of the reviewed changes. In addition to these goals, the interviewees came up with many other secondary or implicit goals. Many of these dealt with cultural issues such as communication, status, personnel issues and stagnation (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 the change process. Despite the prevalence of soft goals, few organisational and personnel development methods were used in these cases. Change management was approached from a very technical standpoint, and Reiman et al. (2006) concluded that a more dynamic framework, including the consideration of human and organisational factors, is needed for assuring safety during change in safety-critical organisations.
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Studies on the organisation and management of maintenance activities have illustrated the effect of the organisational structural solutions and especially, change in those solutions to the performance variability. Change creates instability in the organisation and exposes the organisation to the negative effects of performance variability. These effects are exacerbated if there is ambiguity among the personnel about the organisational goals or 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 challenging in terms of occupational safety. Maintenance activities can thus be viewed as posing a risk to 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 of the theoretical approaches presented above often on the human error view. Occupational safety studies that consider the relation of occupational safety to the other goals of the system are reviewed in this section. Mercier (1988, pp. 8687) characterises the maintenance work of an NPP as follows: It is rare for so many non-repetitive tasks to be concentrated in an industrial environment that is so very hostile to human activity. The forces in this environment are considerable. Temperatures, pressures, the multitude of fluids, mechanical power, omnipresent electricity, even the sheer weight of the equipment . . . all culminate to make maintenance actions potentially dangerous and to weigh against success. The nuclear hazard and the associated radiation protection restraints are simply one more risk, but a risk that is often quite minimal compared to the others. In all safety-critical domains, there are various occupational risks that affect the way work is carried out and that have to be balanced with the other goals of the organisation, such as efficiency, economics and system or production safety. Reason and Hobbs (2003, p. 59) argue that different forms of human errors are associated with incidents threatening the safety of operation and with incidents threatening worker safety. Thus, different remedies are needed to address both types of outcomes. According to Reason and Hobbs, the three most common types of errors threatening operation safety are (in descending order) memory lapses, violations and knowledge-based errors. Worker safety is threatened especially by slips of action and violations. Lind (2008, pp. 929930) found in her study of accident reports that the most important latent conditions in fatal or non-fatal occupational accidents in industrial maintenance were defects in planning or managing the work and defective work instructions (cf. Reason 1997). Sanne (2008a) conducted ethnography of railway infrastructure maintenance in Sweden. He studied how the maintenance personnel framed occupational risk-taking. Sanne (2008a, p. 645) notes that the railway technicians have a double-order relationship to risk: their job of achieving public safety and protecting the public from risk necessarily exposes them to occupational hazards. In addition, they must trade train safety against other ends, such as punctuality, time limits, economic constraints, and their own safety (Sanne 2008a, p. 646). Sanne argues that the technicians took occupational responsibility for 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 ones actions in a tightly coupled and complex railway context. He illustrates how the technicians bear a sense of responsibility for each others 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 fatal consequences 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 responsibility towards 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 is needed 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 risks to 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 inspired one 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 main ethical 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 for a 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 into managers 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 held accountable 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 by the 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 of buying 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 for aviation, (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 above individuals 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 role models 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 explained to 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), the airplane is in, its down, its there to be repaired, and sent back out in as good a fashion as possible. . . . (Patankar 2005b, p. 52)
The dual objectives of maintenance in ensuring safety and maintaining operations or schedules and the general tension between safety and efficiency have been identified in many 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 for situational judgement or adaptation, emerges as an important dimension in balancing the different organisational goals. Thus, maintenance personnel seem to consider the capability for performance variability an integral aspect of professionalism. However, it is not clear what constitutes professionalism in a maintenance context and by what means it 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 her analysis of event handling in the nuclear industry how the industrys culture of control is very engineering driven, emphasising probabilities, measures and risk estimates. This culture largely discounts qualitative and experiential knowledge. These collective ways of thinking influence, e.g. how the power plants convert ambiguity into certainty and separate judgement from reason (Perin 2005, p. 225). She also emphasises the importance of 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 technicians and on their work as being more similar to knowledge work or engineering work than is commonly accepted. Technicians knowledge is more contextual than engineers or designers 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 science and pragmatic knowledge including an understanding of the overall work process in the organisation. Endsley and Robertson (2000) have applied the concept of situation awareness (SA) to aircraft maintenance teams. They define SA as a three-level phenomenon; level 1 SA means being aware of the aircraft system one is working on. Level 2 SA involves the technicians comprehension of the significance of observed system states. Level 3 SA denotes the ability to project the state of the system in the near future. Technician with level 3 SA would be able to project what effect a particular defect might have on the performance of the aircraft in the future. Endsley and Robertson (2000) performed task analysis to determine the specific SA requirements in the aircraft maintenance arena. They also conducted an SA resource analysis to identify the resources used in the maintenance environment to achieve the identified SA requirements. The results indicated that the largest problem for team SA exists when there are gaps due to, e.g. mismatched goals, 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) conclude by 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 required to effectively communicate that knowledge, and they require the ability to recognise what information needs to be exchanged among and between team members (Endsley and Robertson 2000, p. 323). Oedewald and Reiman (2007b) have studied the theoretical knowledge of maintenance newcomers and experienced personnel in a longitudinal study of a Nordic NPP maintenance organisation. The aim of their study was to evaluate the effectiveness of a training programme for newcomers and to identify the general training needs in maintenance. A measure of conceptual knowledge was developed in cooperation with technical experts and trainers from the case organisation. The measure contained 75 multiple-choice questions in nine knowledge areas: mechanical and electrical engineering, I&C, radiochemistry, technical specifications, process control, design basis of the plant, maintenance planning and maintenance procedures. The conceptual knowledge of all 10 new workers was measured three times during the 3-year project, and they were interviewed twice during the project. In addition, 43 experienced maintenance workers (mean tenure 16.5 years) completed the conceptual knowledge questionnaire (Oedewald and Reiman 2007b). The results showed that the newcomers overall scores improved during the first 2 years of work. However, some basic concepts, such as redundancy, were difficult for many respondents. In the experienced worker sample, the overall scores varied substantially and did not correlate with tenure. Questions concerning process control and electrical engineering were frequently answered incorrectly. Basic concepts were not self-evident for the experienced group either. Furthermore, the experienced workers tended to be optimistic about their knowledge concerning, e.g. the process control area, since they did not often answer with the option I do not know and got plenty of minus points for choosing the wrong answers. Oedewald and Reiman (2007b) argue that personal orientation towards the work is important for the development of expertise (cf. Sandberg 2000, Norros 2004). Those newcomers who scored extraordinarily well in the third test had a slightly different orientation towards maintenance work from the beginning. According to the study, the high-scoring newcomers seemed to be more aware of the uncertainties inherent in complex systems and in the interviews, they emphasised the importance of having an overall picture of the plant. Other studies in various safety-critical domains have also shown that recognising uncertainties in the technology and risks in the activities facilitates learning (Norros 2004). Crew resource management (CRM) has been applied successfully also in maintenance domains. The goals of CRM (or maintenance resource management, MRM) training include improving communication skills and teamwork, facilitating the use of human performance tools (pre-job briefing, post-job briefing, etc.) and increasing awareness of human performance issues such as norms, fatigue, communication and their safety effects (Reason and Hobbs 2003, pp. 114116, Patankar and Taylor 2004a). In aviation maintenance, the US Federal Aviation Administration (FAA 2000) has defined the overall goal of MRM as to integrate the technical skills of maintenance personnel with interpersonal skills and basic human factors knowledge in order to improve communication 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 that successful MRM programmes require that organisations be willing and able to provide specific feedback to safety-related recommendations, establish secure and effective self-reporting systems, provide a simplified and effective process to update/change maintenance procedures, reward safety-compliant behaviours, and above all practice
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(high) ethical standards. They have developed a MRM/technical operations questionnaire for 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 categories within maintenance (Patankar and Taylor 2004b, pp. 98116). Studies on competence management and training have shown the multifaceted nature of professionalism in maintenance. They also have provided compelling evidence on the significance of investing in the development of maintenance competence as a way of managing 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 includes variability in tasks, work conditions, condition of the equipment, environmental requirements, resources and time constraints. Some characteristic sources of performance variability have been identified in the various maintenance studies (cf. Reason and Hobbs 2003, Patankar and Taylor 2004b, Reiman 2007, Pettersen 2008, see also Figure 1). These include: . the changing nature of the task depending on the specific inspection findings, available resources including tools, spare parts and personnel, as well as time constraints; . the difficulty of predicting the time and other resource requirements of the various tasks; . The object of maintenance actions can be in operation, shut down/out of use or broken, with each state imposing different demands for maintenance; . effects of many maintenance actions are delayed, making it hard to develop ones work practices based on feedback from the object of work; . wide range and mix of required skills and competencies due to the great variety in the tasks and activities necessary for reliable operations; . maintenance of a safety-critical system involves many rules and regulations, the quality of which can vary; . challenges in coordinating complex work and communicating relevant information; . 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 false consensus belief that everyone else does it, belief that management promotes rule breaking in the name of efficiency); . innovation and inventiveness of the maintenance personnel to adapt to the situation 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 in studies of maintenance errors and their consequences. Furthermore, organisational issues
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Vigilance and energy Motivation and mental resources Self-criticism and reflection
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Assertive attitude to safety issues Adequate task and safety knowledge Situation awareness Social permission to carry work thoroughly Norms supporting safety Clear communication Flexible organization and slack resources Good task and work design Functioning teamwork and cooperation
Figure 2. Positive elements affecting maintenance, corresponding to and opposed to the dirty dozen identified by Patankar and Taylor (2004b) arranged in order from individual to social to organisational factors.
have been shown to be important for explaining performance variability in the maintenance context. However, current research on maintenance work is fragmented in terms of its focus; individual studies are seldom put into the larger context of safety science or 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 the negative outcomes of the variability (errors), social factors affecting the variability (Pettersen 2008, Sanne 2008b), the knowledge and psychological (mental) characteristics of the maintenance personnel (Endsley and Robertson 2000, Patankar 2005a, 2005b, Oedewald and Reiman 2007b, Rouse 1979) or the organisational functions such as safety management 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 (Orr 1996, Bourrier 1999, McDonald 2006, Reiman 2007, Pettersen and Aase 2008). Next, we will look at the research challenges in combining these various foci into a holistic view on maintenance work in safety-critical organisations. Patankar and Taylors (2004a, 2004b) list in Figure 1 is focused on the dimensions creating negative performance variability in maintenance. A similar list could be devised on the elements creating positive variability in the maintenance organisation. Figure 2 presents a preliminary outline of a pure dozen success factors in maintenance. Figure 2 illustrates the multilevel nature of the challenges of effective maintenance work. For example, motivation is an individual-level dimension (having to do with the mental states and models of the personnel), whereas norms belong to the social level and work design to the organisational level. The dimensions in Figure 2 are not exhaustive in terms of describing a high reliability maintenance organisation, and they probably partly overlap. In addition, the dimensions as such do not explain the mechanisms or process by which, for example, norms, communication or complacency are created in the organisation. Some indications of the mechanisms and various social processes can be found in the literature, and these are dealt with in the next section. The organisational challenges of maintenance stem from the nature of the maintenance core task and its inherent variability. In order to understand the performance variability in maintenance, the maintenance core task and its demands in various domains have to be understood first. The core task of maintenance and the inherent hazards of the technology that is maintained have to be taken into account (Reiman 2007). Figure 3 presents a conceptualisation of the key content themes and research challenges of maintenance work in safety-critical domains. The content themes are based on the analysis of the current literature and the theoretical framework of key

1. Role of individual factors in maintenance 6. Leading indicators for effective maintenance Mental states and mental models Technological hazards Organisational functions Maintenance core task Social processes
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2. Effect of social processes on performance Effectiveness and performance variability 5. Holistic evaluation methods for maintenance organisations
4. Maintenance core task and its requirements 3. Tools for the management of maintenance activities
Figure 3. The main dimensions of organizational factors and the associated research challenges critical to safety of maintenance.
organisational dimensions proposed by Reiman and Oedewald (2007). Figure 3 illustrates the 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 maintenance core task as influencing elements, as well as performance variability as the main element of concern in studies of human and organisational factors in maintenance to date. The content themes of past research are categorised into four main organisational dimensions in Figure 3: mental states and models, organisational functions, social processes and performance variability. When considering safety and effectiveness of maintenance, the technological hazards as well as the core task of the maintenance function have to be taken into account in addition to the four dimensions. Next, the research 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 individual and social factors (the role of human agency, cf. Pettersen 2008) in performance variability of the maintenance activities. This concerns questions such as individual assertiveness concerning safety issues or the role of social networks and informal connections in daily work. When assertive safety behaviour is against the norms of the workplace, what factors define how the employee will act? How strong of a coupling exists between the official system and the informal social organisation? How do the gaps in these two systems affect safety? Furthermore, research should address the tensions and differences in priorities and conceptions between maintenance and other functions of the company. Especially, the significance of the differences to system safety as well as the well-being of the maintenance
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personnel should be addressed, along with ways of developing a joint understanding of system goals and priorities. The current literature on human factors in maintenance has identified several psychological 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, Patankar 2005a, 2005b, Sanne 2008a), safety awareness and mindfulness (Endsley and Robertson 2000, 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, the effect of these characteristics on situational judgement (e.g. in terms of rule bending, goal prioritisation or specific maintenance actions) within the social context of maintenance is a topic for empirical investigations. Research should also specify the social and individual mechanisms 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 performance of the work (Oedewald and Reiman 2007b)? The corrosion incident at DavisBesse in 2002 is an example of an incident that could have been prevented by responsible and mindful maintenance personnel. For example, maintenance personnel regularly found rust particles clogging air-conditioning and water filters. Maintenance had to change the air filters every 2 days for 2 years, whereas the industry norm was to change the filters once a month (Perin 2005, p. 216). This accumulation of rust was a weak signal of wider problems that could have been detected had people questioned the reasons why the filters were being replaced (Weick and Sutcliffe 2007, p. 46). However, rust accumulation was not a failure that people felt was significant enough to warrant a strong response (Weick and Sutcliffe 2007, p. 48). Maintenance personnel are motivated by the complexities and problems of the technical system, the safety consequences of their work and the chances to complete significant 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 often considered motivating (Sanne 2008a). The motivating aspect of the problems and fault situations is a paradox in the sense that one of the goals of maintenance is to avoid problems and keep the technology running reliably. This can be dangerous if the technical system exhibits a lot of glitches and faults. IAEA (2005, p. 6) warns that constant repairs tend to create a firefighter mentality among the workers, which is further bolstered by both the feeling of satisfaction after the repairs are successfully completed and rewards or praise following a job well done. These feelings contrast starkly with the otherwise mundane and systematic approach of preventive maintenance (cf. Carroll et al. 1998, p. 102) Routine work also poses challenges for the maintenance personnel: it decreases motivation (Hackman and Oldham 1980, Carroll et al. 1998, p. 117) and can lead to lower quality or increased slips and lapses due to inattention. Too much routine can be avoided by organisational practices, e.g. by the division of the tasks and job rotation. Maintenance personnel strongly identify themselves as craftsmen. Attending to the machinery, for example, 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 such significant jobs, precisely because the task is so important, management designs and supervises 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 acknowledge the impossibility of proceduralising all the aspects of the maintenance work and the inadequacy 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 of ones professionalism to be the knowledge of how to interpret, apply and neglect the procedures in a manner that work can be carried out as thoroughly and as efficiently as needed (cf. Hollnagel 2004, 2009b). Succeeding with this adaptive and variable way of working requires a good knowledge of the task and its hazards. An experienced maintenance team might manage daily tasks without a perfect understanding of the fault mechanisms and details of the working methods. This is due to the 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 the existing knowledge surface when established routines are challenged by unusual disturbances or events (Hopkins 2000, Kletz 2003, Feldman 2004). One means of tackling this problem is to analyse the maintenance personnels conceptions and mental models of their task. Norros (2004) has argued based on her studies in various safety-critical domains that reflective as opposed to procedural orientation towards work facilitates learning. The reflective orientation is also more flexible (i.e. variable) and adaptive to the situation at 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. formation of norms, social identity) on performance variability in maintenance. In terms of social processes, more information is needed on the ways technicians develop their practices and learn from their daily work within the social structures of their company (Pettersen 2008, Sanne 2008b). For example, how do the various safety management systems affect field-level practices? How do the social identities of the maintenance personnel incorporate models of errors, accidents and professionalism? What are the potential safety consequences of strong professional identities that are based on local practice and individual responsibility (Sanne 2008b) versus those based on collective responsibility and structured practice (Reiman 2007)? Do these solutions depend on the nature of the core task or the cultural features and history of the organisation? Both quantitative questionnaire studies and qualitative case studies have a role in clarifying the contents and effects of the various individual, social and organisational level dimensions. Maintenance workers need to adapt to local circumstances and sometimes contradictory goals, and work with the skills, resources, tools and time that they have. Norms and local practices develop, and subcultures form based on technical disciplines, hierarchy and physical location. The bending of rules or innovative utilisation of tools is used to compensate for organisational deficiencies and to accomplish goals deemed professionally important. In many cases, minor adjustments to local procedures do not constitute negligence but are done with good intentions (to get the job done, to save money). The work and the organisational processes can be such that employees have to bend the rules in order to get the work done. All this happens in a social context, where maintenance personnel jointly construct their view on the work and their image of the maintenance profession, 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 formal organisational structure. Social processes and informal practices of the maintenance communities can lead to the normalisation of small deviations and incidents as ordinary aspects of the work (Sanne 2008b). Normalisation of deviance means a process where small changes new behaviours, technical anomalies or variations that are slight deviations from the normal course of events gradually become the norm, providing a basis for accepting additional deviance (Vaughan 1996). Normalisation of deviance produces disregard and misinterpretation neutralisation of potential danger signals. A signal of potential danger is information that deviates from expectations, contradicting the existing worldview (Vaughan 1996, p. 243). Since many maintenance actions and practices have effects that carry over a long time period, the normalisation of deviance is a particularly significant social process in the maintenance domain.
4.3. Management of the maintenance organisation Many studies have shown that the achievement of effective and reliable maintenance is dependent on good management of the maintenance organisations. Management does not mean solely upper-level managers, but all activities geared towards ensuring that the organisation is capable of functioning effectively. Maintenance organisations need to be able 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 changes in tasks, and they need to be able to update their knowledge of the sociotechnical system that they are simultaneously part of as well as maintaining. Two of the major challenges facing maintenance organisations are the almost constant process of societal change and the various restructuring initiatives launched within the companies owning the maintenance organisations (Kecklund 2004, Reiman et al. 2006). These are reflected in the maintenance organisations as organisational changes. Changes have 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 on unofficial practices are especially vulnerable to changes (in technology, organisations and personnel). Maintenance belongs to that category. Changes in maintenance have usually been heavily technology driven (cf. Clegg and Walsh 2004). Human factors have been considered only when problems occur, e.g. the personnel show change resistance or do not otherwise act as planned by the change agents (Reiman et al. 2006). Change management is an organisational function that would benefit from a more explicit focus on human and organisational factors. Research should aim at providing tools and methods to accomplish this. Training is one of the instruments for creating an awareness of hazards as well as sufficient skills for carrying out the work in a safe manner. An ongoing generational change in the workforce calls for tools to analyse the existing know-how of the personnel so that effective training programmes can be created. Maintenance work in safety-critical organisations is not a routine-like activity that could be carried out just by following the procedures. It requires different types of skills and knowledge. Practical craftsman skills, overall understanding of the functioning of and couplings between the systems as well as technical 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 and Reiman 2007b). Learning from near misses, failures and events is important for the continuous improvement of maintenance activities. This involves certain challenges. First, reporting of events is often inadequate. Second, even if events are reported, there are difficulties in analysing the significance of events in terms of what they tell about the effectiveness of maintenance activities. Third, even if analysed correctly, getting the results back into the field presents its own challenges. Consequently, maintenance activities remain rooted in local history and local adaptations, without necessarily taking the entire organisation or the experience of other parties into account. Another approach to competence management is to seek to decrease the probability of the occurrence of human errors with various human performance management and error prevention tools (Reason and Hobbs 2003, Patankar and Taylor 2004a). Reason and Hobbs (2003, p. 95) list a number of error management techniques in maintenance, including training, work planning, job cards, licence-to-work systems, licensing and certification, audits, procedures, disciplinary procedures, human resource management and total quality management. They note that these techniques have not been effective in preventing a steady rise in maintenance-related errors during the past decade. They comment on the techniques that their limitations include being piecemeal rather than principled, reactive rather than proactive, and fashion-driven rather than theory-driven. Safety management systems are an integrated formal way of managing organisations and their safety. Many safety management systems are based on a rational or a non-contextual image of an organisation (Reiman and Oedewald 2007). The role of management in supervising and directing organisational behaviour is emphasised. Waring and Glendon (1998, p. 175) criticise safety management systems that are based on an overly rational image of the organisation and argue that they may be only partly effective while 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 very different from the ideal set out in formal documents and systems. For example, in the context of aviation maintenance, McDonald et al. (2000) and McDonald (2001) argue that evidence indicates that the current quality and safety management systems seldom provide an adequate picture of the way the work is actually carried out. The social structure and the inherent performance variability need to be taken into account. The role of safety management systems and human performance tools in steering the work in maintenance and controlling unwanted performance variability is an important topic for future research.
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 contact with the largest number of failures, at earlier stages of development, and have an ongoing sense of the vulnerabilities in the technology, sloppiness in the operations, gaps in the procedures, and sequences by which one error triggers another. Maintenance is a key function for a resilient organisation to use the term coined by Hollnagel et al. (2006) to denote the intrinsic ability of an organisation (system) to maintain or regain a dynamically stable state, which allows it to continue operations after a major mishap and/or in the 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. the necessary adaptations or adjustments having consequences beyond the local and intended effects. This is exactly where maintenance comes into play, as an adaptive force as well as the last line of defence against the unseen effects of organisational instability. The role of maintenance in increasing the resilience of the sociotechnical system is a somewhat neglected aspect in research (cf. Reiman 2007). Maintenance is supposed to have a crucial role in creating safety and resilience in the sociotechnical system as well as in the negative sense, creating vulnerabilities and having a strong tendency towards exhibiting performance variability. Maintenance personnel have hands-on experience with the plant equipment and know its condition best. The maintenance function is able to perceive new vulnerabilities in their development stages. In the opinion of the author, being resilient means being aware of the boundaries of safe activity, being able to recognise how the organisation is currently creating safety, monitoring whether or not ones model of safety and hazards is adequate and steering the organisational processes in the necessary manner. These processes include recovery from incidents or even accidents. The ability and willingness of the organisation to carry out its core 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 the overall task of the organisation, and in defining more specific criteria for a resilient maintenance organisation. For example, how do the core tasks of aviation maintenance and NPP maintenance differ, and how are the differences reflected in the maintenance cultures? How much of this difference is explained by technological differences and how much by historical reasons or differences in regulations? Research should also tackle the outside 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 change or have some new requirements?
4.5. Evaluation methods for maintenance organisations The methods for evaluation should provide the organisations with information on how they currently perceive and respond to their core task. It is not sufficient to rely on general criteria such as safety attitudes or participative leadership. In addition to these, the task of the organisation and the constraints and requirements that this task sets for maintenance have to be taken into account. Organisational evaluation is one way of reflecting on the ability of the organisation to carry out its task properly. This ability includes that the organisation is able to monitor its current state, anticipate possible deviations, react to expected 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 evaluating the functioning of the maintenance organisations holistically, taking into account the individual, social and organisational elements. This includes understanding and explaining the different trade-offs in maintenance work, for example between efficiency and thoroughness (Hollnagel 2004), occupational safety and system safety (Sanne 2008a), rule following versus rule bending (Bourrier 1999), certainty and uncertainty (Reiman 2007) and individual and collective action (Pettersen 2008). The development of methods for the evaluation of maintenance organisations is connected 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 complex sociotechnical systems in terms of understanding their safety and effectiveness. This research should draw also on the recent developments in the organisation science paradigm.
4.6. Leading indicators of the maintenance function It has been recognised that incident rates and other lagging indicators such as personal injuries do not provide an adequate picture of the health of the system in relation to major accidents (HSE 2006, Herrera et al. 2009). If one wants to evaluate the effectiveness of development initiatives as well as the functioning of the current maintenance organisation, reliable indicators are needed. Based on an understanding of the social context and core task of maintenance, future research should identify the relevant leading indicators for developing the safety and effectiveness of maintenance activities. These indicators should be able to direct the development initiatives and provide indications of whether the organisation is improving or not. These indicators can be used in a feed-forward manner (cf. Hollnagel 2008) to adjust the functioning of the maintenance organisation before its performance deteriorates.
5. Conclusions Maintenance has too often been considered as mostly manual labour requiring little or no mental work. This correlates also to maintenance quite often being at the bottom of the hierarchy (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 maintenance work suffers from a dirty hands image. Perin (2005, p. 262) states that given the significance of maintenance activities to risk reduction in all high hazard industries, in this twenty-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 the maintenance organisations themselves (Reiman 2007). Research on maintenance has focused mainly on human errors and individual-level issues, even though social and organisational factors have received increasing attention in recent years. Still, studies of normal work, practices and cultures of maintenance have been scarce. Research and development in the maintenance context should acknowledge that maintenance is a function that not only produces safety, but also gives rise to latent failures. Maintenance personnel and the activity of the maintenance function can help the entire organisation to be better aware of the boundaries of safe activity, the condition of the technical equipment and the effectiveness of current practices and conceptions in creating safety. In addition to its preparatory and anticipatory role, maintenance plays a critical role in recovering from expected breakdowns and unexpected system perturbations. A holistic theory on maintenance work is needed to manage the variability and turn it into a positive force. At its best, maintenance produces positive performance variability in terms of needed adjustments and adaptations to the condition of the technical infrastructure and guards against negative instability in terms of equipment perturbations, safety system breakdowns, slow degradation of technical infrastructure and the other changing vulnerabilities of the technology in use.
362 Acknowledgements
T. Reiman
The author is grateful to the two anonymous reviewers for providing useful comments and suggestions to an earlier version of the article. The work has been funded by the Finnish national nuclear safety research programme (SAFIR2010) and VTT.
Note
1. Common cause failures (CCF) are failure causes or mechanisms that may apparently result or have resulted in multiple functionally critical failures in redundant components in real demand situations (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 redundant trains 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. His dissertation focused on evaluation of organisational culture at maintenance units of Nordic nuclear power plants. Currently he holds the position of senior research scientist at VTT Technical Research Centre of Finland. His current work is concentrated on understanding performance of complex sociotechnical systems and improving system safety in various safety-critical domains including nuclear and healthcare.

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Theoretical Issues in Ergonomics Science

Understanding maintenance work in safety-critical organisations managing the performance variability

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3. Contributions of current research

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