Equanimity: The Overlooked Foundation of Quality Culture

I occasionally strive to be open about what I’m personally working on: situational humility, coping with uncertainty, silence, my mental health, and humbleness, among other things. I believe these are all ways to approach a continuous journey aimed at my growth as a leader. I like to think I am on a constant path of improvement, but as organizations evolve and our roles within them change, it’s crucial to reflect on our experiences and aim for betterment. Sometimes, this requires shifting the perspective I use to assess my development. Today, my focus is on the concept of equanimity.

In today’s fast-paced organizational landscape, where constant change and disruption are the norm, the ability to maintain inner balance while facing complex challenges is a vital yet often overlooked leadership skill. Equanimity—an even-tempered state of psychological stability and composure that remains undisturbed by emotions, pain, or external pressures—becomes a fundamental element in creating resilient, quality-driven cultures. Unlike complacency, which silently undermines innovation and organizational excellence, equanimity equips leaders and professionals with a mental framework to stay responsive without becoming reactive, engaged without becoming entangled.

This balanced mindset fosters clear decision-making and steady leadership, necessary for nurturing environments where quality is not merely a compliance requirement but a cultural imperative. As organizations navigate increasingly turbulent markets and regulatory challenges, understanding and cultivating equanimity serves as a powerful antidote to the cycles of complacency that threaten long-term viability and stakeholder trust.

The Anatomy of Equanimity in Professional Contexts

Equanimity, derived from the Latin “aequanimitas” meaning evenness of mind, represents more than mere calmness—it constitutes a sophisticated mental framework that allows individuals to process and respond to experiences without becoming overwhelmed by them. In professional contexts, equanimity manifests as the capacity to remain present and engaged with challenging situations while maintaining psychological balance. Buddhist scholar Peter Harvey aptly described this state as being “stirred but not shaken”—the opposite of James Bond’s martini—highlighting how equanimity allows us to fully experience workplace events while preventing emotional entanglement that clouds judgment.

This mental stance creates a critical space between stimulus and response, where professionals can observe both external circumstances and their own emotional reactions without immediate judgment. Consider a quality assurance specialist discovering a significant product defect just before shipment. Equanimity enables this professional to feel the appropriate concern without spiraling into panic, allowing them to assess the situation clearly, communicate effectively with stakeholders, and implement necessary corrective actions. The equanimous mind acknowledges reality as it is—not as we wish it to be—creating the foundational awareness needed for effective quality management.

A common misconception portrays equanimity as emotional detachment or apathy—a mischaracterization that fundamentally misunderstands its nature. True equanimity does not suppress passion or diminish concern for quality outcomes; rather, it channels these energies more effectively. Professionals operating with equanimity remain deeply invested in excellence while freeing themselves from counterproductive emotional reactivity that might otherwise cloud their judgment or diminish their effectiveness. This balanced approach proves especially valuable in high-stakes quality scenarios where both clear perception and appropriate concern must coexist.

Equanimity as the Antidote to Complacency Cycles

Where complacency operates as a silent organizational saboteur, equanimity functions as its natural counteragent. Complacency cycles—characterized by reduced vigilance, resistance to innovation, and workforce disengagement—systematically undermine quality culture through self-reinforcing patterns of mediocrity. Equanimity disrupts these cycles by maintaining alertness without anxiety, openness without impulsivity, and engagement without exhaustion.

The “stagnation phase” of complacency begins when initial success breeds overconfidence and teams prioritize efficiency over improvement. Equanimity counters this tendency by facilitating a balanced perspective that acknowledges achievements while maintaining awareness of potential improvements. Rather than becoming complacent with current performance levels, equanimous professionals maintain a curious stance toward emerging risks and opportunities.

Similarly, during the “normalization of risk” phase, where minor deviations from standards become habitual, equanimity provides the mental clarity to recognize incremental drift before it culminates in significant failures. The equanimous mind remains attuned to subtle changes in quality parameters without becoming desensitized to gradually evolving risks. This vigilance represents a crucial firewall against the erosion of quality standards that typically precedes major quality incidents.

Most critically, equanimity prevents the “crisis trigger” phase by maintaining consistent attention to potential quality issues rather than requiring catastrophic events to reinstate vigilance. Unlike the boom-bust pattern of attention often observed in complacent organizations, equanimity sustains a steady awareness that prevents the accumulation of quality deficits in the first place. This proactive stance transforms quality management from a reactive crisis response into a continuous practice of excellence maintenance.

How Equanimity Transforms Leadership

Leadership serves as the linchpin in establishing and sustaining quality culture, with a leader’s responses and behaviors creating ripple effects throughout the organization. Research reveals concerning patterns in leadership reactions under pressure, with many leaders becoming more close-minded and controlling while others become more emotionally reactive during challenging situations—precisely when clarity and openness are most needed. Equanimity directly addresses these tendencies by creating the psychological space necessary for more deliberate, effective responses.

When leaders demonstrate equanimity during quality challenges, they effectively model how the organization should process and respond to adversity. Consider a manufacturing executive facing a significant product recall. An equanimous response—acknowledging the severity while maintaining composed problem-solving—signals to the organization that challenges represent opportunities for systemic improvement rather than occasions for blame or panic. This leadership stance creates psychological safety, enabling more transparent reporting of potential quality issues before they escalate into crises.

Equanimity also enhances a leader’s ability to make balanced decisions when confronting quality dilemmas that involve competing priorities. The pharmaceutical industry regularly faces tensions between production timelines and quality verification procedures. Leaders practicing equanimity can more effectively navigate these tensions, maintaining unwavering commitment to quality standards while acknowledging business realities. This balanced approach prevents the “diminished problem-solving rigor” that characterizes complacent organizations, where teams favor quick fixes over root-cause analysis.

Beyond individual decisions, equanimity transforms a leader’s overall approach to quality governance. Rather than oscillating between hypervigilance during crises and inattention during stable periods, equanimous leaders maintain consistent quality focus through various organizational phases. This steady attention prevents the “ceremonial governance” pattern where quality oversight becomes a performance rather than a genuine inquiry into systemic risks. By modeling emotional stability while maintaining quality vigilance, leaders create environments where excellence becomes self-sustaining rather than crisis-dependent.

Developing Equanimity as a Professional

Cultivating equanimity requires intentional practice rather than mere philosophical appreciation. For professionals seeking to develop this capacity, several evidence-based approaches offer practical pathways toward greater psychological balance in workplace settings.

Mindfulness meditation stands as perhaps the most well-established method for developing equanimity. Regular practice—even in brief sessions of 5-10 minutes—enhances the ability to observe thoughts and emotions without becoming entangled in them. This mental training directly strengthens the neural pathways associated with emotional regulation and cognitive flexibility, enabling professionals to respond more skillfully to quality challenges. A quality engineer practicing mindfulness might notice anxiety arising when discovering a potential compliance issue but can observe this reaction without allowing it to dominate their problem-solving approach.

Emotional intelligence development complements mindfulness by enhancing awareness of emotional patterns that undermine equanimity. By understanding personal triggers and typical reaction patterns, professionals can identify situations where their equanimity might be tested before they become emotionally activated. This anticipatory awareness creates an opportunity to implement self-regulation strategies proactively rather than reactively. Quality professionals with high emotional intelligence recognize when perfectionism or defensiveness might cloud their judgment and can consciously adjust their approach accordingly.

Gratitude practices offer another avenue toward equanimity by broadening perspective beyond immediate challenges. Regular reflection on positive aspects of work—successful quality initiatives, collaborative team dynamics, or personal growth—creates psychological resources that buffer against stress during difficult periods. This expanded awareness prevents quality challenges from consuming a professional’s entire attention, maintaining the balanced perspective essential for effective problem-solving.

Pre-mortem analyses—mentally simulating potential quality failures before they occur—paradoxically strengthen equanimity by reducing uncertainty and surprise when challenges arise. By anticipating possible issues and preparing response strategies in advance, professionals reduce the cognitive and emotional load of real-time problem-solving. This preparation creates a sense of capability and readiness that supports composed responses during actual quality incidents.

Cultivating Organizational Equanimity Through Systems Approach

While individual practices build personal equanimity, organizational systems and structures must support these efforts for sustainable impact. Leaders can implement several systemic approaches to foster equanimity throughout their quality culture.

Transparent communication systems represent a foundational element in organizational equanimity. When information about quality metrics, emerging risks, and improvement initiatives flows freely throughout the organization, uncertainty decreases and collective sense-making improves. Digital dashboards tracking real-time quality indicators, regular cross-functional quality briefings, and systematic feedback loops all contribute to an information environment where sudden surprises—a primary threat to equanimity—become less frequent.

Leadership development programs should explicitly address equanimity as a core competency rather than treating it as an incidental personality trait. Training modules focusing on mindfulness, emotional intelligence, and stress resilience build the individual capacities necessary for equanimous leadership. When combined with peer coaching circles where leaders candidly discuss quality challenges and share regulation strategies, these formal development efforts create a leadership culture where balanced responses to pressure become the norm rather than the exception.

Recognition systems that reward equanimous handling of quality challenges—rather than just technical problem-solving—reinforce the importance of balanced responses. Acknowledging professionals who maintain composure while addressing complex quality issues sends a powerful message about organizational values. These recognition practices might highlight situations where teams maintained psychological safety during compliance audits or demonstrated composed problem-solving during manufacturing disruptions.

Resource optimization initiatives that address workload management directly support equanimity by preventing the overwhelm that undermines psychological balance. Realistic staffing models for quality functions, appropriate technological support for monitoring activities, and adequate time allocations for improvement projects all contribute to an environment where maintaining equanimity becomes feasible rather than heroic.

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Leadership’s Role in Modeling and Sustaining Equanimity

Executive leadership bears particular responsibility for establishing equanimity as a cultural norm through consistent modeling and systemic reinforcement. Leaders demonstrate their commitment to equanimity not just through words but through visible behaviors during challenging quality scenarios.

Leaders practice vulnerability and transparency by openly discussing their own experiences with maintaining equanimity during difficult situations. When executives share stories about managing their reactions during regulatory inspections, customer complaints, or internal quality failures, they normalize the emotional challenges inherent in quality work while demonstrating the possibility of balanced responses. This transparent approach creates psychological safety for others to acknowledge their own struggles with maintaining equanimity.

Participation in frontline quality activities provides another powerful demonstration of leadership equanimity. Executives who join quality audits, improvement workshops, or failure investigations gain firsthand exposure to quality challenges while modeling composed engagement. An executive participating in monthly gemba walks not only identifies systemic risks but also demonstrates how to approach quality issues with balanced curiosity rather than blame or anxiety.

Restructuring performance metrics represents a systemic approach to supporting equanimity by emphasizing leading indicators over lagging ones. When leaders prioritize metrics like preventative corrective actions, near-miss reporting, or improvement suggestion implementation, they create an information environment that supports proactive quality management rather than crisis response. This shift reduces the emotional volatility associated with reactive approaches while maintaining appropriate quality vigilance.

Cross-functional collaboration initiatives further support equanimity by distributing quality responsibilities across the organization rather than isolating them within quality departments. When leaders establish quality SWAT teams with representation from various functions, they create shared ownership for quality outcomes while preventing the isolation that can lead to overwhelm within quality functions. This collaborative approach supports equanimity by ensuring that quality challenges receive diverse perspectives and adequate resources.

Equanimity as a Journey, Not a Destination

Equanimity in professional contexts represents an ongoing practice rather than a permanent achievement—a perspective that itself embodies equanimous thinking. Like quality culture more broadly, equanimity requires continual renewal through intentional individual practices and supportive organizational systems. The interplay between complacency cycles and quality culture creates a perpetual tension that demands vigilance without anxiety, commitment without rigidity, and excellence without perfectionism.

Organizations that recognize equanimity as a foundational element of quality culture gain a significant advantage in navigating the complexities of modern business environments. By cultivating this balanced mental state throughout their workforce—particularly within leadership ranks—they establish psychological conditions where quality thrives as a natural expression of organizational values rather than a compliance obligation. This cultural foundation supports the relentless leadership commitment, systems thinking, and psychological safety necessary for sustained excellence.

As professionals and leaders journey toward greater equanimity, they transform not only their individual effectiveness but also the cultural fabric of their organizations. Each composed response to a quality challenge, each balanced decision during a crisis, and each steady commitment during uncertainty contributes to an organizational environment resistant to complacency yet free from reactivity. In this way, equanimity operates not just as a personal virtue but as a collective capability—one that enables organizations to maintain quality focus through changing conditions while remaining adaptive to emerging requirements. The cultivation of equanimity thus represents not merely a philosophical aspiration but a practical necessity for organizations committed to enduring excellence in increasingly turbulent times.

Self-Reflection

In the quiet moments of self-reflection, I have discovered that equanimity—that elusive state of mental calmness and composure, especially under trying circumstances—represents not a destination but an ongoing practice. The journey toward equanimity has been important for me, particularly as I’ve incorporated journaling as a companion practice. This written exploration serves as both a retrospective lens through which to examine past conversations and a preparatory tool for navigating difficult moments with greater balance. Equanimity teaches us to be with whatever shows up, to notice what shuts us down, pushes us away, or tears us wide open. Through the disciplined practice of putting pen to paper, I have found a pathway toward standing equally in both clear and muddy waters, remaining present with each moment exactly as it is.

The act of putting feelings into words helps with cognitive reappraisal—reframing situations to reduce their emotional impact by engaging the prefrontal cortex, our brain’s control center for planning, decision-making, and emotional regulation.

When I first implemented a consistent journaling practice, I noticed immediate benefits in managing workplace stress. After particularly challenging meetings or interactions, taking time to write about these experiences created distance from immediate emotional reactions. Research supports this experience, suggesting that writing about emotional events can benefit both mental and physical health. Journaling has been linked to decreased mental distress, reduced anxiety, and help with breaking cycles of obsessive thinking. Studies even indicate potential physical benefits, with participants who wrote about upsetting events healing faster after medical procedures than those who wrote about neutral topics.

Beyond retrospective analysis, journaling serves as a powerful preparatory tool for approaching challenging situations with greater equanimity. Before difficult conversations or high-stakes presentations, I’ve found that writing helps clarify intentions, anticipate potential triggers, and develop strategies for maintaining balance. This practice creates a foundation for equanimity that proves invaluable when emotions run high.

Pre-mortem analyses—mentally simulating potential failures before they occur—paradoxically strengthen equanimity by reducing uncertainty and surprise when challenges arise. By writing through possible difficult scenarios, I develop response strategies in advance, creating a sense of capability and readiness that supports composed responses during actual difficulties. This preparation reduces the cognitive and emotional load of real-time problem-solving in stressful situations.

Complacency Cycles and Their Impact on Quality Culture

In modern organizational dynamics, complacency operates as a silent saboteur—eroding innovation, stifling growth, and undermining the very foundations of quality culture. Defined as a state of self-satisfaction paired with unawareness of deficiencies, complacency creates cyclical patterns that perpetuate mediocrity and resistance to change. When left unchecked, these cycles corrode organizational resilience, diminish stakeholder trust, and jeopardize long-term viability. Conversely, a robust quality culture—characterized by shared values prioritizing excellence and continuous improvement—serves as the antidote.

The Anatomy of Complacency Cycles

Complacency arises when employees or teams grow overly comfortable with existing processes, outcomes, or performance levels. This manifests as:

Reduced Vigilance: The Silent Erosion of Risk Awareness

Reduced vigilance represents a critical failure mode in quality management systems, where repetitive tasks or historical success breed dangerous overconfidence. In manufacturing environments, for instance, workers performing identical quality checks thousands of times often develop “checklist fatigue”—a phenomenon where muscle memory replaces active observation. This complacency manifests in subtle but impactful ways:

  • Automation Blindness: Operators monitoring automated systems grow dependent on technology, failing to notice gradual sensor drift.
  • Normalization of Deviations
  • Metric Myopia: Organizations relying solely on lagging indicators like defect rates miss emerging risks.

The neuroscience behind this phenomenon reveals disturbing patterns: fMRI scans show reduced prefrontal cortex activation during routine quality checks compared to novel tasks, indicating genuine cognitive disengagement rather than intentional negligence.

Resistance to Innovation: The Institutionalization of Obsolescence

Complacency-driven resistance to innovation creates organizational calcification, where legacy processes become dogma despite market evolution. This dynamic operates through three interconnected mechanisms:

  1. Cognitive Lock-In: Teams develop “expertise traps” where deep familiarity with existing methods blinds them to superior alternatives.
  2. Risk Asymmetry Perception: Employees overestimate innovation risks while underestimating stagnation risks.
  3. Hierarchical Inertia: Leadership teams reward incremental improvements over transformational change.

Disengagement: The Metastasis of Organizational Apathy

Disengagement in complacent cultures operates as both symptom and accelerant, creating self-reinforcing cycles of mediocrity. Key dimensions include:

Cognitive Disinvestment: Employees mentally “clock out” during critical tasks. .

Professional Stagnation: Complacency suppresses upskilling initiatives.

Social Contagion Effects: Disengagement spreads virally through teams.

This triad of vigilance erosion, innovation resistance, and workforce disengagement forms a self-perpetuating complacency cycle that only conscious, systemic intervention can disrupt.

These behaviors form self-reinforcing loops. For example, employees who receive inadequate feedback may disengage, leading to errors that management ignores, further normalizing subpar performance.

    The Four-Phase Complacency Cycle

    1. Stagnation Phase: Initial success or routine workflows breed overconfidence. Teams prioritize efficiency over improvement, dismissing early warning signs.
    2. Normalization of Risk: Minor deviations from standards (e.g., skipped safety checks) become habitual. NASA’s Columbia disaster post-mortem highlighted how normalized risk-taking eroded safety protocols.
    3. Crisis Trigger: Accumulated oversights culminate in operational failures—product recalls, safety incidents, or financial losses.
    4. Temporary Vigilance: Post-crisis, organizations implement corrective measures, but without systemic change, complacency resurges within months.

    This cycle mirrors the “boom-bust” patterns observed in safety-critical industries, where post-incident reforms often lack staying power.

    How Complacency Undermines Quality Culture

    Leadership Commitment: The Compromise of Strategic Stewardship

    Complacency transforms visionary leadership into passive oversight, directly undermining quality culture’s foundational pillar. When executives prioritize short-term operational efficiency over long-term excellence, they inadvertently normalize risk tolerance. This pattern reflects three critical failures:

    • Resource Misallocation: Complacent leaders starve quality initiatives of funding.
    • Ceremonial Governance
    • Metric Manipulation

    These behaviors create organizational whiplash—employees interpret leadership’s mixed signals as permission to deprioritize quality standards.

    Communication & Collaboration: The Silencing of Collective Intelligence

    Complacency breeds information silos that fracture quality systems. NASA’s Challenger disaster exemplifies how hierarchical filters and schedule pressures prevented engineers’ O-ring concerns from reaching decision-makers—a communication failure that cost lives and destroyed $3.2 billion in assets. Modern organizations replicate this dynamic through:

    • Digital Fragmentation
    • Meeting Rituals
    • Knowledge Hoarding

    Employee Ownership & Engagement: The Death of Frontline Vigilance

    Complacency converts empowered workforces into disengaged spectators.

    • Problem-Solving Atrophy: Complacent environments resolve fewer issues proactively.
    • Initiative Suppression
    • Skill Erosion

    Continuous Improvement: The Illusion of Progress

    Complacency reduces a learning culture to kabuki theater—visible activity without substantive change. Other failure modes include:

    • Incrementalism Trap
    • Metric Myopia
    • Benchmark Complacency

    Technical Excellence: The Rot of Core Competencies

    Complacency transforms cutting-edge capabilities into obsolete rituals. Specific erosion patterns include:

    • Standards Creep
    • Tribal Knowledge Loss
    • Tooling Obsolescence

    Mechanisms of Erosion

    1. Diminished Problem-Solving Rigor: Complacent teams favor quick fixes over root-cause analysis. In pharmaceuticals, retrospective risk assessments—used to justify releasing borderline batches—exemplify this decline.
    2. Erosion of Psychological Safety: Employees in complacent environments fear repercussions for raising concerns, leading to underreported issues.
    3. Supplier Quality Degradation: Over time, organizations accept lower-quality inputs to maintain margins, compromising end products.
    4. Customer Disengagement: As quality slips, customer feedback loops weaken, creating echo chambers of false confidence.

    The automotive industry’s recurring recall crises—from ignition switches to emissions scandals—illustrate how complacency cycles gradually dismantle quality safeguards.

    Leadership’s Pivotal Role in Breaking the Cycle

    Leadership’s Pivotal Role in Breaking the Cycle

    Leadership serves as the linchpin in dismantling complacency cycles, requiring a dual focus on strategic vision and operational discipline. Executives must first institutionalize quality as a non-negotiable organizational priority through tangible commitments. This begins with structurally aligning incentives—such as linking 30% of executive compensation to quality metrics like defect escape rates and preventative CAPA completion—to signal that excellence transcends rhetoric. For instance, a Fortune 500 medical device firm eliminated 72% of recurring compliance issues within 18 months by tying bonus structures to reduction targets for audit findings. Leaders must also champion resource allocation, exemplified by a semiconductor manufacturer dedicating 8% of annual R&D budgets to AI-driven predictive quality systems, which slashed wafer scrap rates by 57% through real-time anomaly detection.

    Equally critical is leadership’s role in modeling vulnerability and transparency. When executives participate in frontline audits—as seen in a chemical company where CEOs joined monthly gemba walks—they not only uncover systemic risks but also normalize accountability. This cultural shift proved transformative for an automotive supplier, where C-suite attendance at shift-change safety briefings reduced OSHA recordables by 24% in one year. Leaders must also revamp metrics systems to emphasize leading indicators over lagging ones.

    Operationalizing these principles demands tactical ingenuity. Dynamic goal-setting prevents stagnation. Cross-functional collaboration is accelerated through quality SWAT teams. Perhaps most impactful is leadership’s ability to democratize problem-solving through technology.

    Ultimately, leaders dismantle complacency by creating systems where quality becomes everyone’s responsibility—not through mandates, but by fostering environments where excellence is psychologically safe, technologically enabled, and personally rewarding. This requires perpetual vigilance: celebrating quality wins while interrogating successes for hidden risks, ensuring today’s solutions don’t become tomorrow’s complacent norms.

    Sustaining Quality Culture Through Anti-Complacency Practices

    Sustaining Quality Culture Through Anti-Complacency Practices

    Sustaining a quality culture demands deliberate practices that institutionalize vigilance against the creeping normalization of mediocrity. Central to this effort is the integration of continuous improvement methodologies into organizational workflows. Such systems thrive when paired with real-time feedback mechanisms—digital dashboards tracking suggestion implementation rates and their quantifiable impacts for example can create visible accountability loops.

    Cultural reinforcement rituals further embed anti-complacency behaviors by celebrating excellence and fostering collective ownership. Monthly “Quality Hero” town halls at a pharmaceutical firm feature frontline staff sharing stories of critical interventions, such as a technician who averted 17,000 mislabeled vaccine doses by catching a vial mismatch during final packaging. This practice increased peer-driven quality audits by 63% within six months by humanizing the consequences of vigilance. Reverse mentoring programs add depth to this dynamic: junior engineers at an aerospace firm trained executives on predictive maintenance tools, bridging generational knowledge gaps while updating leadership perspectives on emerging risks.

    Proactive risk mitigation tools like pre-mortem analyses disrupt complacency by forcing teams to confront hypothetical failures before they occur.

    Immersive learning experiences make the stakes of complacency tangible. A medical device company’s “Harm Simulation Lab” recreates scenarios like patients coding from insulin pump software failures, exposing engineers to the human consequences of design oversights. Participants identified 112% more risks in subsequent reviews compared to peers trained through conventional lectures.

    Together, these practices form an ecosystem where complacency struggles to take root. By aligning individual behaviors with systemic safeguards—from idea-driven improvement frameworks to emotionally resonant learning—organizations transform quality from a compliance obligation into a collective mission. The result is a self-reinforcing culture where vigilance becomes habitual, innovation feels inevitable, and excellence persists not through enforcement, but through institutionalized reflexes that outlast individual initiatives.

    Conclusion: The Never-Ending Journey

    Complacency cycles and quality culture exist in perpetual tension—the former pulling organizations toward entropy, the latter toward excellence. Breaking this cycle demands more than temporary initiatives; it requires embedding quality into organizational DNA through:

    1. Relentless leadership commitment to modeling and resourcing quality priorities.
    2. Systems thinking that connects individual actions to enterprise-wide outcomes.
    3. Psychological safety enabling transparent risk reporting and experimentation.

    Sustained quality cultures are possible, but only through daily vigilance against complacency’s seductive pull. In an era of accelerating change, the organizations that thrive will be those recognizing that quality isn’t a destination—it’s a mindset forged through perpetual motion.

    Worker’s Empowerment

    Empowerment is a foundational element of a quality culture, where workers are entrusted with the authority to make decisions, initiate actions, and take responsibility for the outcomes of their work. This approach not only enhances job satisfaction and productivity but also fosters a culture of autonomy and participation, which is essential for achieving high organizational performance. However, the concept of empowerment has sometimes been misinterpreted within quality management frameworks such as Total Quality Management (TQM), Lean, and Six Sigma. In these contexts, empowerment rhetoric is occasionally used to justify increased work demands and managerial oversight, rather than genuinely empowering workers to contribute to quality improvements. A true quality culture, therefore, requires a genuine commitment to empowering workers, ensuring that they have the autonomy to drive continuous improvement and innovation.

    History of Worker Empowerment

    The concept of empowerment has its roots in social movements, including the civil rights and women’s rights movements, where it was used to describe the process of gaining autonomy and self-determination for marginalized groups. In the context of management, empowerment gained prominence in the 1980s and 1990s as a way to improve organizational performance by engaging workers more effectively.

    Several management thinkers have discussed and advocated for worker empowerment, contributing significantly to the development of this concept. Here are some key figures and their contributions:

    Mary Parker Follett

      • Autonomy and Collective Power: Follett emphasized the importance of giving workers autonomy to complete their jobs effectively. She believed that when workers have the freedom to work independently, they become happier, more productive, and more engaged. Follett’s “power with” principle suggests that power should be shared among many, rather than concentrated in a few hands, fostering a collaborative environment.
      • Collaboration and Flexibility: Follett advocated for establishing personal ownership of company goals while allowing flexibility in achieving them. This approach encourages agile problem-solving and creative solutions that benefit the business.

      Tom Peters

        • Self-Managing Teams: Peters has been a strong advocate for creating self-managing teams where leadership roles rotate among members. He emphasizes the importance of listening to workers and believing in their unlimited potential. Peters’ philosophy includes empowering front-line staff to act as business teams, which can significantly enhance organizational performance.
        • Empowerment through Leadership: Peters suggests that managers should be retrained to become listeners rather than talkers, fostering an environment where every worker feels valued and empowered to contribute.

        W. Edwards Deming

          • Involvement and Autonomy: Deming’s 14 Points for Management include principles that support worker empowerment, such as removing barriers to pride of workmanship and encouraging collaboration across departments. These principles aim to create an environment where workers feel valued and empowered to improve processes.
          • Continuous Improvement: Deming’s emphasis on continuous improvement processes, like kaizen, involves worker participation, which can be seen as a form of empowerment. However, it is crucial to ensure that such participation is genuine and not merely rhetorical.

          Rosabeth Moss Kanter

            • Change Management: Kanter’s change management theory emphasizes creating a collaborative and transparent work environment. Her approach involves empowering worker by encouraging them to speak up, team up, and continuously work towards positive change within the organization.
            • Empowerment through Participation: Kanter’s principles promote worker engagement and loyalty by involving them in organizational changes and decision-making processes.

            Elton Mayo

              • Human Relations Theory: Mayo’s work highlights the importance of social and relational factors in motivating workers. While not directly focused on empowerment, his theory suggests that workers are more motivated by attention and camaraderie than by monetary rewards alone. This perspective supports the idea that empowering workers involves recognizing their social needs and fostering a supportive work environment.

              These thinkers have contributed to the understanding and implementation of worker empowerment by emphasizing autonomy, collaboration, and the importance of recognizing employee contributions. Their ideas continue to influence management practices today.

              Dimensions of Empowerment

              Empowerment can be understood through several key dimensions:

              • Meaning: This refers to the sense of purpose and significance that employees derive from their work. When employees feel that their work is meaningful, they are more likely to be motivated and engaged.
              • Competence: This dimension involves the skills and abilities that employees need to perform their jobs effectively. Empowerment requires that employees have the necessary competencies to make decisions and take actions.
              • Self-Determination: This is the ability of employees to make choices and decisions about their work. Self-determination is crucial for empowerment, as it allows employees to feel in control of their tasks and outcomes.
              • Impact: This dimension refers to the influence that employees have on organizational outcomes. When employees feel that their actions can make a difference, they are more likely to be empowered and motivated.
              Four dimensions of empowerment

              Implementation Practices

              Implementing empowerment effectively requires several key practices:

              1. Clear Communication: Employees need clear expectations and goals to understand how their work contributes to the organization’s objectives.
              2. Training and Development: Providing employees with the necessary skills and knowledge to make informed decisions is essential for empowerment.
              3. Autonomy and Decision-Making Authority: Employees should have the freedom to make decisions within their scope of work.
              4. Feedback and Recognition: Regular feedback and recognition of employee contributions help reinforce empowerment by acknowledging their impact.

              Deming’s Involvement in Worker Empowerment

              W. Edwards Deming, a pioneer in quality management, emphasized the importance of employee involvement and empowerment through his 14 Points for Management. Specifically:

              • Point 3: Cease dependence on inspection to achieve quality. Eliminate the need for inspection on a mass basis by building quality into the product in the first place. This point encourages organizations to empower workers by giving them the tools and training needed to ensure quality during production.
              • Point 9: Break down barriers between departments. People in research, design, sales, and production must work as a team to foresee problems of production and in use that may be encountered with the product or service. This emphasizes collaboration and cross-functional teamwork, which is a form of empowerment.
              • Point 12: Remove barriers that rob the hourly worker of his right to pride of workmanship. The responsibility of supervisors must be changed from sheer numbers to quality. This point directly addresses the need to empower workers by removing obstacles that prevent them from taking pride in their work.

              Deming’s philosophy aligns with genuine empowerment by focusing on building quality into processes, fostering teamwork, and recognizing the value of worker pride and autonomy.

              Denison and Organizational Culture

              Daniel Denison’s work on organizational culture, particularly through the Denison Model, assesses culture across four critical traits: Mission, Involvement, Adaptability, and Consistency. Each of these traits is further divided into three indexes, providing a comprehensive framework for understanding and improving organizational culture.

              Involvement and Empowerment

              Denison’s model emphasizes the importance of Involvement, which is the degree to which individuals at all levels are engaged and feel a sense of ownership in the organization. This trait is crucial for empowerment, as it involves aligning employees with the business direction and positioning them to contribute to its success. The indexes under Involvement include aspects such as empowerment, team orientation, and capability development, all of which are essential for creating a culture where employees feel valued and empowered.

              Empowerment through Cultural Alignment

              Denison suggests that empowerment is not just about giving employees authority but also about ensuring they are aligned with and committed to the organization’s mission. By fostering a culture where workers are engaged and capable, organizations can enhance their performance metrics such as innovation, customer satisfaction, and worker satisfaction. Denison’s approach emphasizes the need for leaders to manage culture effectively, recognizing that culture can either support or hinder organizational goals.

              Leadership and Empowerment

              Denison’s model implies that leaders should focus on creating an environment where workers feel empowered to contribute. This involves not only setting a clear mission but also ensuring that systems and processes support worker involvement and adaptability. By doing so, leaders can foster a culture where workers are motivated to drive organizational success. Denison’s philosophy underscores the importance of balancing internal consistency with external adaptability, ensuring that organizations remain responsive to market changes while maintaining internal cohesion.

              Denison’s work provides a structured framework for understanding how empowerment fits into a broader organizational culture. By emphasizing involvement and alignment, organizations can create an environment where workers feel empowered to contribute to success.

              Misuse of Empowerment Rhetoric in Quality Methodologies

              Total Quality Management (TQM)

              TQM emphasizes worker involvement and empowerment as part of its comprehensive approach to quality improvement. However, the emphasis on continuous improvement and customer satisfaction can sometimes lead to increased workloads and stress for workers, undermining genuine empowerment.

              Lean Manufacturing

              Lean manufacturing focuses on eliminating waste and maximizing efficiency, often using empowerment rhetoric to encourage workers to participate in continuous improvement processes like kaizen. However, this can result in workers being manipulated into accepting intensified workloads without real control over their conditions.

              Six Sigma

              Six Sigma uses a structured approach to quality improvement, relying on trained professionals like Green and Black Belts. While it involves worker participation, the focus on defect reduction and process optimization can lead to a narrow definition of empowerment that serves managerial goals rather than worker autonomy.

              Avoiding the Misuse of Empowerment Rhetoric

              To avoid misusing empowerment rhetoric, organizations should focus on creating a genuine culture of empowerment by:

              Ensuring Autonomy

              Ensuring autonomy in the workplace is crucial for empowering workers. This involves providing them with real decision-making authority and the freedom to act within their roles. When workers have autonomy, they are more likely to feel a sense of ownership over their work, which can lead to increased motivation and productivity. Autonomy allows workers to make decisions that align with their expertise and judgment, reducing the need for constant managerial oversight. This not only speeds up decision-making processes but also fosters a culture of trust and responsibility. To implement autonomy effectively, organizations should clearly define the scope of decision-making authority for each role, ensure that workers understand their responsibilities, and provide the necessary resources and support to facilitate independent action. By doing so, organizations can create an environment where workers feel valued and empowered to contribute to organizational success.

              Fostering Meaningful Work

              Fostering meaningful work is essential for creating a sense of purpose and engagement among workers. This involves aligning worker tasks with organizational goals and ensuring that work contributes to a broader sense of purpose. When workers understand how their tasks fit into the larger picture, they are more likely to be motivated and committed to their work. Meaningful work encourages workers to see beyond their immediate tasks and understand the impact of their contributions on the organization and its stakeholders. To foster meaningful work, organizations should communicate clearly about organizational objectives and how individual roles contribute to these goals. Additionally, providing opportunities for workers to participate in goal-setting and strategic planning can enhance their sense of purpose and connection to the organization’s mission. By making work meaningful, organizations can create a workforce that is not only productive but also passionate about achieving shared objectives.

              Developing Competence

              Developing competence is a critical aspect of empowering workers . This involves investing in training and development to enhance their skills and abilities. When workers feel competent in their roles, they are more confident and capable of making decisions and taking initiatives. Competence development should be tailored to the needs of both the organization and the individual worker, ensuring that training programs are relevant and effective. Organizations should also provide ongoing opportunities for learning and growth, recognizing that competence is not static but rather something that evolves over time. By investing in worker development, organizations can create a skilled and adaptable workforce that is better equipped to handle challenges and drive innovation. Moreover, when workers see that their employer is committed to their growth, they are more likely to feel valued and committed to the organization.

              Recognizing Impact

              Recognizing the impact of workers contributions is vital for reinforcing their sense of empowerment. Regularly acknowledging and rewarding worker achievements helps to demonstrate that their work is valued and appreciated. This can be done through various means, such as public recognition, bonuses, or promotions. However, recognition should be genuine and specific, highlighting the specific contributions and outcomes that workers have achieved. Generic or superficial recognition can undermine its effectiveness and lead to skepticism among workers. To make recognition meaningful, organizations should establish clear criteria for what constitutes impactful work and ensure that recognition is timely and consistent. By acknowledging workers contributions, organizations can foster a culture of appreciation and motivation, encouraging workers to continue striving for excellence and making significant contributions to organizational success.

              Encouraging Self-Determination

              Encouraging self-determination is essential for empowering workers to take ownership of their work processes and outcomes. This involves supporting workers in making choices about how they complete their tasks and achieve their objectives. Self-determination allows workers to work in ways that best suit their skills and work styles, leading to increased job satisfaction and productivity. To encourage self-determination, organizations should provide workers with the flexibility to design their work processes and set their own goals, as long as these align with organizational objectives. Additionally, organizations should foster an environment where workers feel comfortable suggesting improvements and innovations, without fear of criticism or reprisal. By giving workers the autonomy to make decisions about their work, organizations can tap into their creativity and initiative, leading to more effective and efficient work processes. This approach not only empowers workers but also contributes to a more agile and responsive organization.

              By focusing on these aspects, organizations can move beyond rhetorical empowerment and create a truly empowered workforce.

              Conclusion

              Worker empowerment is a powerful concept that, when implemented genuinely, can lead to significant improvements in organizational performance and worker satisfaction. However, its misuse in quality methodologies like TQM, Lean, and Six Sigma can undermine its potential benefits. By understanding the dimensions of empowerment and aligning practices with Deming’s principles, organizations can foster a culture of true empowerment that benefits both workers and the organization as a whole.

              Building a Safe Space for Reflection: Leveraging Psychological Safety Towards a Quality Culture

              Creating a safe space for reflection is crucial for fostering innovation, problem-solving, and continuous improvement. This environment is deeply rooted in psychological safety and a quality culture, where employees feel empowered to express themselves freely, share ideas, and challenge existing norms without fear of judgment or reprisal.

              Understanding Psychological Safety

              Psychological safety refers to a shared belief among team members that they are safe to take risks, share their thoughts, and learn from their mistakes without fear of negative consequences. This concept is foundational to building a culture where individuals feel valued, included, and motivated to contribute their unique perspectives. It is the bedrock upon which effective collaboration, creativity, and problem-solving are built. In environments where psychological safety is prioritized, employees are more likely to engage in open dialogue, admit mistakes, and explore new ideas, leading to enhanced innovation and productivity.

              The Role of Leadership in Fostering Psychological Safety

              Effective leadership plays a pivotal role in establishing and maintaining a culture of psychological safety. Leaders must set the tone by modeling vulnerability, encouraging open communication, and demonstrating empathy towards their team members. They should establish clear expectations of respect and inclusivity, ensuring that diverse perspectives are welcomed and valued. By doing so, leaders create an environment where employees feel comfortable sharing their thoughts and ideas, which is essential for driving innovation and solving complex problems.

              In the past post on Psychological Safety, Reflexivity, and Problem Solving, I explored how psychological safety enables individuals to behave authentically and express themselves candidly, which is crucial for effective problem-solving and reflexivity in organizations. This authenticity allows teams to tackle challenges more effectively by leveraging diverse viewpoints and experiences.

              Building a Quality Culture

              A quality culture is deeply intertwined with psychological safety. It emphasizes continuous improvement, learning from mistakes, and a commitment to excellence. In such a culture, employees are encouraged to reflect on their processes, identify areas for improvement, and implement changes that enhance overall performance. This reflective practice is facilitated by psychological safety, as it allows individuals to share insights and ideas without fear of criticism, thereby fostering a collaborative and adaptive environment.

              Strategies for Creating a Safe Space for Reflection

              Creating a safe space for reflection involves several strategic steps:

              Establishing Open Communication Channels

              Organizations should implement transparent and constructive communication channels that allow employees to express their thoughts, concerns, and ideas without fear of negative consequences. This can be achieved through regular team meetings, anonymous feedback systems, or open forums where employees feel comfortable sharing their perspectives. Active listening and empathy are crucial in these interactions, as they reinforce the sense of safety and encourage further participation.

              Implementing Psychological Safety Training

              Providing comprehensive training on psychological safety is essential for building awareness and equipping employees with the skills needed to navigate complex interactions and support their colleagues. These programs should emphasize the importance of trust, vulnerability, and inclusivity, and offer practical strategies for fostering a psychologically safe environment. By educating employees on these principles, organizations can ensure that psychological safety becomes an integral part of their culture.

              Encouraging Active Participation and Feedback

              Encouraging active participation involves creating opportunities for employees to engage in collaborative discussions and provide feedback. This can be facilitated through workshops, brainstorming sessions, or project meetings where diverse perspectives are sought and valued. Feedback loops should be open and constructive, allowing employees to learn from their experiences and grow professionally.

              Measuring Psychological Safety

              Measuring psychological safety is critical for understanding its impact on organizational culture and identifying areas for improvement. This can be achieved through surveys, behavioral indicators, and engagement scores. Surveys should include questions that assess employees’ perceptions of safety, trust, and openness within their teams. Behavioral indicators, such as the frequency of idea sharing and openness in feedback loops, can also provide valuable insights into the level of psychological safety within an organization.

              In our previous discussions on on this blog, I have emphasized the importance of a culture that supports open dialogue and continuous improvement. A few examples include:

              1. Communication Loops and Silos: A Barrier to Effective Decision Making in Complex Industries: This post highlights the challenges of communication loops and silos in industries like aviation and biotechnology. It emphasizes the need for open dialogue to bridge these gaps and improve decision-making processes.
              2. Change Strategies for Accelerating Change: This post discusses strategies such as promoting cross-functional training, fostering informal interactions, and implementing feedback loops. These strategies are crucial for creating a culture that supports open dialogue and continuous improvement.
              3. Reducing Subjectivity in Quality Risk Management: Aligning with ICH Q9(R1): This post focuses on reducing subjectivity through structured approaches and data-driven decision-making. It underscores the importance of a culture that encourages open communication to ensure that decisions are based on comprehensive data rather than personal biases.

              These examples illustrate the importance of fostering a culture that supports open dialogue and continuous improvement in complex industries.

              Overcoming Challenges

              Despite the benefits of psychological safety, several challenges may arise when attempting to implement it within an organization. Fear and resistance to change are common obstacles, particularly in hierarchical structures where speaking up can be perceived as risky. To overcome these challenges, organizations should identify influential champions who can model psychological safety behaviors and inspire others to do the same. Regular assessments and feedback sessions can also help identify areas where psychological safety is lacking, allowing for targeted interventions.

              Sustaining Psychological Safety

              Sustaining a culture of psychological safety requires ongoing effort and commitment. Organizations must regularly assess the effectiveness of their psychological safety initiatives and refine their strategies based on feedback and performance data. This involves ensuring that leadership behaviors consistently reinforce psychological safety principles and that training programs are scaled to reach all levels of the organization.

              Conclusion

              Building a safe space for reflection within an organization is a multifaceted process that relies heavily on psychological safety and a quality culture. By fostering an environment where employees feel valued, included, and empowered to share their ideas, organizations can unlock their full potential and drive innovation. Psychological safety is not a static state but a continuous journey that requires leadership commitment, effective communication, and ongoing evaluation. As we continue to navigate the complexities of modern organizational challenges, prioritizing psychological safety will remain essential for creating a workplace where employees thrive and contribute meaningfully.

              By embracing psychological safety and fostering a quality culture, organizations can create a safe space for reflection that drives innovation, enhances collaboration, and promotes continuous improvement. This approach not only benefits the organization but also contributes to the well-being and growth of its employees, ultimately leading to a more resilient and adaptive workforce.

              Communication Loops and Silos: A Barrier to Effective Decision Making in Complex Industries

              In complex industries such as aviation and biotechnology, effective communication is crucial for ensuring safety, quality, and efficiency. However, the presence of communication loops and silos can significantly hinder these efforts. The concept of the “Tower of Babel” problem, as explored in the aviation sector by Follet, Lasa, and Mieusset in HS36, highlights how different professional groups develop their own languages and operate within isolated loops, leading to misunderstandings and disconnections. This article has really got me thinking about similar issues in my own industry.

              The Tower of Babel Problem: A Thought-Provoking Perspective

              The HS36 article provides a thought-provoking perspective on the “Tower of Babel” problem, where each aviation professional feels in control of their work but operates within their own loop. This phenomenon is reminiscent of the biblical story where a common language becomes fragmented, causing confusion and separation among people. In modern industries, this translates into different groups using their own jargon and working in isolation, making it difficult for them to understand each other’s perspectives and challenges.

              For instance, in aviation, air traffic controllers (ATCOs), pilots, and managers each have their own “loop,” believing they are in control of their work. However, when these loops are disconnected, it can lead to miscommunication, especially when each group uses different terminology and operates under different assumptions about how work should be done (work-as-prescribed vs. work-as-done). This issue is equally pertinent in the biotech industry, where scientists, quality assurance teams, and regulatory affairs specialists often work in silos, which can impede the development and approval of new products.

              Tower of Babel by Joos de Momper, Old Masters Museum

              Impact on Decision Making

              Decision making in biotech is heavily influenced by Good Practice (GxP) guidelines, which emphasize quality, safety, and compliance – and I often find that the aviation industry, as a fellow highly regulated industry, is a great place to draw perspective.

              When communication loops are disconnected, decisions may not fully consider all relevant perspectives. For example, in GMP (Good Manufacturing Practice) environments, quality control teams might focus on compliance with regulatory standards, while research and development teams prioritize innovation and efficiency. If these groups do not effectively communicate, decisions might overlook critical aspects, such as the practicality of implementing new manufacturing processes or the impact on product quality.

              Furthermore, ICH Q9(R1) guideline emphasizes the importance of reducing subjectivity in Quality Risk Management (QRM) processes. Subjectivity can arise from personal opinions, biases, or inconsistent interpretations of risks by stakeholders, impacting every stage of QRM. To combat this, organizations must adopt structured approaches that prioritize scientific knowledge and data-driven decision-making. Effective knowledge management is crucial in this context, as it involves systematically capturing, organizing, and applying internal and external knowledge to inform QRM activities.

              Academic Research on Communication Loops

              Research in organizational behavior and communication highlights the importance of bridging these silos. Studies have shown that informal interactions and social events can significantly improve relationships and understanding among different professional groups (Katz & Fodor, 1963). In the biotech industry, fostering a culture of open communication can help ensure that GxP decisions are well-rounded and effective.

              Moreover, the concept of “work-as-done” versus “work-as-prescribed” is relevant in biotech as well. Operators may adapt procedures to fit practical realities, which can lead to discrepancies between intended and actual practices. This gap can be bridged by encouraging feedback and continuous improvement processes, ensuring that decisions reflect both regulatory compliance and operational feasibility.

              Case Studies and Examples

              1. Aviation Example: The HS36 article provides a compelling example of how disconnected loops can hinder effective decision making in aviation. For instance, when a standardized phraseology was introduced, frontline operators felt that this change did not account for their operational needs, leading to resistance and potential safety issues. This illustrates how disconnected loops can hinder effective decision making.
              2. Product Development: In the development of a new biopharmaceutical, different teams might have varying priorities. If the quality assurance team focuses solely on regulatory compliance without fully understanding the manufacturing challenges faced by production teams, this could lead to delays or quality issues. By fostering cross-functional communication, these teams can align their efforts to ensure both compliance and operational efficiency.
              3. ICH Q9(R1) Example: The revised ICH Q9(R1) guideline emphasizes the need to manage and minimize subjectivity in QRM. For instance, in assessing the risk of a new manufacturing process, a structured approach using historical data and scientific evidence can help reduce subjective biases. This ensures that decisions are based on comprehensive data rather than personal opinions.
              4. Technology Deployment: . A recent FDA Warning Letter to Sanofi highlighted the importance of timely technological upgrades to equipment and facility infrastructure. This emphasizes that staying current with technological advancements is essential for maintaining regulatory compliance and ensuring product quality. However the individual loops of decision making amongst the development teams, operations and quality can lead to major mis-steps.

              Strategies for Improvement

              To overcome the challenges posed by communication loops and silos, organizations can implement several strategies:

              • Promote Cross-Functional Training: Encourage professionals to explore other roles and challenges within their organization. This can help build empathy and understanding across different departments.
              • Foster Informal Interactions: Organize social events and informal meetings where professionals from different backgrounds can share experiences and perspectives. This can help bridge gaps between silos and improve overall communication.
              • Define Core Knowledge: Establish a minimum level of core knowledge that all stakeholders should possess. This can help ensure that everyone has a basic understanding of each other’s roles and challenges.
              • Implement Feedback Loops: Encourage continuous feedback and improvement processes. This allows organizations to adapt procedures to better reflect both regulatory requirements and operational realities.
              • Leverage Knowledge Management: Implement robust knowledge management systems to reduce subjectivity in decision-making processes. This involves capturing, organizing, and applying internal and external knowledge to inform QRM activities.

              Combating Subjectivity in Decision Making

              In addition to bridging communication loops, reducing subjectivity in decision making is crucial for ensuring quality and safety. The revised ICH Q9(R1) guideline provides several strategies for this:

              • Structured Approaches: Use structured risk assessment tools and methodologies to minimize personal biases and ensure that decisions are based on scientific evidence.
              • Data-Driven Decision Making: Prioritize data-driven decision making by leveraging historical data and real-time information to assess risks and opportunities.
              • Cognitive Bias Awareness: Train stakeholders to recognize and mitigate cognitive biases that can influence risk assessments and decision-making processes.

              Conclusion

              In complex industries effective communication is essential for ensuring safety, quality, and efficiency. The presence of communication loops and silos can lead to misunderstandings and poor decision making. By promoting cross-functional understanding, fostering informal interactions, and implementing feedback mechanisms, organizations can bridge these gaps and improve overall performance. Additionally, reducing subjectivity in decision making through structured approaches and data-driven decision making is critical for ensuring compliance with GxP guidelines and maintaining product quality. As industries continue to evolve, addressing these communication challenges will be crucial for achieving success in an increasingly interconnected world.


              References:

              • Follet, S., Lasa, S., & Mieusset, L. (n.d.). The Tower of Babel Problem in Aviation. In HindSight Magazine, HS36. Retrieved from https://skybrary.aero/sites/default/files/bookshelf/hs36/HS36-Full-Magazine-Hi-Res-Screen-v3.pdf
              • Katz, D., & Fodor, J. (1963). The Structure of a Semantic Theory. Language, 39(2), 170–210.
              • Dekker, S. W. A. (2014). The Field Guide to Understanding Human Error. Ashgate Publishing.
              • Shorrock, S. (2023). Editorial. Who are we to judge? From work-as-done to work-as-judged. HindSight, 35, Just Culture…Revisited. Brussels: EUROCONTROL.