Ambiguity, Guest Editorial

AmbiguityWhen you have an event, you can intervene in thewrong moment and cause catastrophic failure.By thetime you see the problem, the catastrophic event hasoccurred.

Michael Gallo, Kelly Space & Technology, Inc., on highenergy testing

Ambiguity may lead us to construct a world that,while supported by evidence, is not true.This is the

danger of ambiguity – we select evidence and interpre-tations for their plausibility, but later events show wewere wrong.After an unwanted result, ambiguity allowsus to select interpretations to blame people, accept theinevitability of failure or announce this result as success.Carroll (1995) describes this as ‘root cause seduction’.These inconsistencies among self-perception, percep-tion and sensemaking are the essence of ambiguity.

In Gallo’s scenario, intervening at the right momentmay prevent catastrophe, while intervening at thewrong moment causes catastrophic failure. Here, wecannot be uncertain, or even aware, about the rightmoment, as it has passed before we can take the correctaction.We can, rather, search for context and give valueto what is known in an effort to identify early heralds offailure. The right moment is ambiguous. The observercan respond to an anomaly by collecting more informa-tion and be wrong before error can be identified. Orthe observer can respond to an anomaly by givingmeaning to existing information to better interpretobservations. Information describes the circumstance,while meaning reflects context and the value of infor-mation. Context and value influence the success orfailure of ambiguous situations, a pragmatic, rather thanphilosophical or theoretical, distinction.

We must distinguish between uncertainty and ambi-guity in a radically distinct way. Information, as data ordescription, lessens uncertainty, a word stemming fromcert (sure or decided).Ambiguity, from ambigere (to goaround, ambi both + igere drive, lead or act), describesinformation that contains more than one meaning.Thedistinction between uncertainty and ambiguity is critical

to those who work in hazardous situations. Uncertaintycompels the search for information, ambiguity thesearch for meaning.

Uncertainty–certainty is binary, our information isright or not right, there is a correct answer. Informationhas fidelity to reality. Our goal becomes one of findingthis correct answer and achieving fidelity.Ambiguity, onthe other hand, is multifaceted and describes multiple,reasonable explanations of events; multiple, likely pre-dictions; or multiple responses to a single intervention.Ambiguity has limited fidelity to the situation, particu-larly when the situation is in flux or a dynamic state.

Ambiguity is, to some degree, uncertainty with a timedimension.When taken as a single moment in time, it ispossible to reduce a situation towards the spectrum ofcertainty and uncertainty.Ambiguity develops when weadd the element of time – the addition of a past createsmultiple ways the situation developed; the addition of afuture creates multiple possible developments; the addi-tion of only one intervention, added to the complexityof the situation, creates multiple possible responses. Inthis definition, adding the element of time makes ambi-guity a special case of uncertainty.

More information does not resolve ambiguity, as therelevance of information may change with a differentpast or future. We want to learn about causationwithin the event, something we cannot observe withoutexperimentation. Operators experiment throughengagement of the situation, observing responsivenessto their actions.Action by short feedback loops gener-ates information while also giving it meaning fromcontext and causation, even as it changes the situation.Compare this to observation, where information col-lected as the situation changes becomes almost imme-diately outdated. Information generated by action, alongwith knowledge and experience, allows the operator togive meaning to the situation. Operators can betterresolve ambiguity through engagement, as discussed inpapers of this special issue,or passively,with the passageof time.

In preparation for the Eighth International High Reli-ability Organizing Conference, hosted by the Universityof North Texas, Fort Worth, March 2014, I consideredbringing experts together to discuss how organizationsrespond to uncertainty. Marc Otten (ContainR Media,Amsterdam, the Netherlands) suggested asking thequestion, ‘How do organizations respond to ambi-guous information?’ He recommended this because

Warren E. Watson, PhD, Regents Professor of Management,University of North Texas, Denton, TX, participated in thedevelopment of this special issue from the beginning. Hisunexpected death in July 2014 prevented him from carryingthis to completion. His participation and guidance are feltthroughout this work.

Journal of Contingencies and Crisis Management Volume 23 Number 2 June 2015

© 2015 John Wiley & Sons Ltd DOI: 10.1111/1468-5973.12082

organizations can respond to uncertainty withincreased information and evaluation but the sameresponse to ambiguity will not be effective.This specialissue of the Journal of Contingencies and Crisis Manage-ment arises from that conference session.

Ambiguous information occurs within stochastic pro-cesses or dynamic states. Uncertainty is the result ofstochastic processes, but during the process, we seeambiguity. The difficulty lies in giving meaning to infor-mation when there is uncertainty of ‘before, now, andfuture’. Because the interpretation of informationduring dynamic situations depends on events that havehappened or will happen, collecting more informationto reduce uncertainty does not relieve ambiguity.

Wolfberg (2006) describes this dilemma as puzzle-solving vs. mystery-solving. There is only one rightanswer in puzzle-solving and the puzzle has its owninternal logic. Collecting puzzle pieces leads to a solu-tion. Mystery-solving accepts the multifaceted nature ofevents and, while Wolfberg refers to this as uncertainty,the concept of ambiguity I use here better fits hisdescription of how mystery-solving opens up a universeof possibilities.This occurs when the operator engagesthe situation.

How the organization responds to ambiguous infor-mation may predict resilience and adaptability to agreater extent than the organization’s response touncertainty. The organization can reduce uncertaintythrough systems for collecting and better understand-ing information.Ambiguity, on the other hand, occurs indynamic, real-time interactions and responds to usingtacit knowledge with shared sensemaking, use of localand general context, the flow of information and migra-tion of authority.The detailed intimacy of an organiza-tion’s reliable response to ambiguous information maybe inaccessible to observers and, possibly, even toexecutives within the organization.

The silent danger of ambiguity comes from ourfailure to consider multiple paths and trajectories orthe denial of ambiguity itself.With only one path to theevent and one trajectory away from it, one can easilysearch for information that supports decisions made(confirmation bias) and, as events progress, memorytriggers will readily occur to bias decision-makingtowards easily recalled information (availability heuris-tic). In a dynamic state, this rapidly increases the vulner-ability of the operator and the system.

This sense of vulnerability drives the search for earlyheralds of problems and threats while also informingthe decision-making that increases information (infor-mation entropy and certainty). The multiple possiblemeanings in ambiguous events hinder us from easilyreducing the situation to a few simple components. Byaccepting ambiguity, operators also accept the possibil-ity of diverse responses to their interventions andremain watchful for interventions that make the

problem worse. Operators must remain engaged withthe situation, as multifaceted events will change even asthe operators grasp the structure of the problem. Bymaking choices, operators develop local information incontext; this local expertise can influence decisionsothers will make.Response to the inherent vulnerabilitythat comes from ambiguous information drives resil-ience and reliability when the organization is faced withunexpected crisis or catastrophic situations.

These responses by individuals and the organizationreflect the five principles of High Reliability describedby Weick and Sutcliffe (2011): pre-occupation withfailure, reluctance to simplify, sensitivity to operations,commitment to resilience and deference to expertise inrespective order of the above paragraph.The organiza-tion’s response to ambiguity may also reflect its level ofHigh Reliability.

Three forms of uncertainty are in common use: dic-tionary definitions,Werner Heisenberg’s famous Uncer-tainty Principle and Claude Shannon’s InformationEntropy. Dictionary definitions derive from the Latinroot cert for sure, settled or decided and relate toconfidence vs. doubt, accuracy and precision, andunknown or unpredictable states.These definitions donot incorporate the dynamics inherent in the definitionof ambiguity.

Heisenberg, using wave mechanics, found an uncer-tainty relation between the position and momentum(mass ! velocity) of a subatomic particle. Increasinglyprecise measurement of one decreases the precision ofthe other.This uncertainty affects causality and predic-tion of the particle’s behaviour. Uncertainty principlesresult from wave mechanics and oscillation in lineartime-variant systems (as their name implies, they varyor oscillate in a linear manner over time). Collectinginformation over one dimension relies on the other,affecting precision in that measurement, somewhatanalogous to our macro experience in crisismanagement.

In crisis management, the relation between events(position) and time (momentum) interferes withprecise evaluation of an event. At a specific time, theprecision of information for that moment is low or wecan have a greater precision of information about theevent but obtained over a longer time interval.There-fore, in crisis management, we can know what is hap-pening but not when it happened, or we can know whenit happened but not fully what happened. This is mostobvious when the trajectory of events accelerates orchanges direction.This change moves the uncertainty ofevents into ambiguity.

Shannon (1948) identified information entropy fromthe mathematics he used to solve the fundamentalproblem of communication – transmitting informationin a reliable manner between transmitter (encoder)and receiver (decoder). To evaluate information in a

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mathematical formula he used base 2 (‘certainty’ vs.‘uncertainty’) and introduced the concept of ‘bit.’ [‘If thebase 2 is used the resulting units may be called binarydigits, or more briefly bits, a word suggested by Tukey.A device with two stable positions, such as a relay or aflip-flop circuit, can store one bit of information’(Shannon, 1948).] The equation he found is the sameequation used for thermodynamic entropy, the measureof randomness vs. order in a thermodynamic system.Thermodynamic entropy increases as energy dissipatesand randomness increases. Information entropy, a vari-able of state for information scientists, also increases asinformation is corrupted, as measured from certainty(order) towards uncertainty (randomness).

Entropy, for thermodynamics and information, is astate measure on the spectrum between certainty anduncertainty. In Information Theory, entropy increaseswith random sources (uncertainty). For Shannon, theact of choosing between messages creates information.Certainty is having only one message possible, nochoice and predictability. Because of this, certaintycarries no information, creating an apparent paradox:uncertainty is information.We can resolve this paradoxif we follow Shannon’s approach – making a choice fromrandomness creates information and communication isthe act of resolving this uncertainty.Because of the largenumber of choices, the unexpected event has high infor-mation entropy.We gain information by making choiceswhen we engage the unexpected.

Physicists and chemists study the change of entropyin the system because it is the change in entropy thatdrives reactions. While information scientists studyentropy as a single variable, in crisis management we canstudy the change in information entropy as people makechoices over time to resolve uncertainty and ambiguity.Making choices creates information. Just as the changein thermodynamic entropy drives physical processes,the change in information entropy, giving meaning torandomness and uncertainty by choices, increases infor-mation. Ambiguity, when it drives engagement, cancreate reliable crisis management.

In these three forms of uncertainty, the dictionaryform describes states where information can decide thesituation. Heisenberg’s Uncertainty Principle refers toknowledge of either place or movement but never bothand the inability to know causation and prediction. Itapproaches ambiguity when we focus on momentum andprediction. Shannon’s Information Entropy describeshow choice creates information. For pragmaticpurposes, however, we face situations with multiplereasons for causation, multiple predictions and multipleresponses following each intervention. Uncertainty, as astatic state, is amenable to the collection of information.Ambiguity, as the temporal quality of uncertainty, hasmultiple possible causes, multiple possible futures andmultiple possible responses to each intervention.

Ambiguity creates the possibility for divergent viewson how best to act. Individuals select different interpre-tations or some people see ambiguity where others seesingle causation or a predictable trajectory. Focus onthe most frightening possibility in these discrepanciesmakes possible the use of fear to motivate others; focuson the most benign possibility or denial of alternativeviews, leads to dangerous complacency. Ambiguity, andthe sense of vulnerability it creates,may drive safety andreliability or create fear and panic. Ambiguity can alsolead to serious, intractable problems.

Operators who accept ambiguity and Wolfberg’smystery-solving are more likely to entertain doubtwhile expressing less confidence that they are right.They may actually be more accurate with predictionsthan those who deny uncertainty and ambiguity.Ambi-guity deniers tend to reduce the problem to some coretheoretical theme with which they feel comfortable,giving them exceptional confidence in the accuracy oftheir predictions (Watts & Brennan, 2011).The crowd ismore likely to follow the reductionist, ambiguity denierwho expresses great confidence than the operator whoaccepts ambiguity and the doubt that accompanies it.

A group may reduce the ambiguous situation to oneexplanation through which all perception is filtered.When the group’s beliefs co-opt newer members, notonly does groupthink develop but this shared beliefbecomes a self-fulfilling prophecy through enactment(Weick, 1979). Enactment prevents individuals fromacting on their sensemaking to engage the situation.Thegroup will ostracize the individual who acts contrary tothe groupthink, creating stagnation in the presence ofambiguity.

Rule-based decision-making relies on recognition ofthe situation and categorization together with rules foractions (Rasmussen & Lind, 1982). For such a rule-basedsystem to work, a certain level of fidelity must existbetween the chosen category and reality. In states ofuncertainty, one can collect more information tosupport the chosen category. Ambiguity in causation,however, clouds where to look to relieve the uncer-tainty, ambiguity in prediction clouds how to preparefor the outcome, and ambiguity of response to actionsclouds the ability to learn from the choices made.

When the rule does not perform well, enactment andcognitive dissonance may drive the individual, support-ive colleagues and organizations to continue using therule despite its failure. Reason (1990) described this asthe ‘strong-but-wrong’ rule.The application of discreteconcepts to ambiguous situations is problematic, muchas the difficulties that exist between discrete conceptsand continuous perceptions (Weick, 2011).

Ambiguity prevents us from making a direct linkbetween our actions and results.We cannot fully attrib-ute success to a specific intervention, a problem thathinders learning. In the same way, we may continue to

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Journal of Contingencies and Crisis ManagementVolume 23 Number 2 June 2015© 2015 John Wiley & Sons Ltd

fail without being able to identify the cause of ourfailure or the flaw in our reasoning.

When people identify themselves as highly expertand experienced, they risk the effects of cognitive dis-sonance – the painful inconsistency that forms betweenreality and the person’s self perception. The logicalresponse, in their mind, is to believe their own percep-tion over reality (Tavris & Aronson, 2008).The nature ofambiguity enables the individual to select informationsupporting their perception while furthering their iden-tity. Cognitive dissonance, reinforced by ambiguity,makes some people resistant to reality.

The dynamic, multifaceted event, rich with paradoxi-cal meanings, contributes to errors and disagreement,confounding efforts to explain the cause of actions. Inthe causation–action–justification linkage, causation ishidden and justification is suspect.Ambiguity allows theselection of information that, retrospectively, supports aparticular view and we can see how easy it is to commitan error, criticize others or blame the individual.This isrelated to the availability heuristic and confirmationbias, along with individual prejudices and attitudes.

Another way to use ambiguity in a positive sense is toassume ‘People in these situations do the right thing;they do what I would do.’ This drives us to look at thecircumstances from the individual’s perspective withthe goal of understanding what would cause the personto act in the manner they did.This begins a search forsignals and meaning from the environment that woulddrive specific actions, opening up new possibilities ofunderstanding.

The papers in this Special Issue can be assembled andconsidered in multiple ways. At the risk of oversimpli-fying, I have placed them in an order that emphasizes adiscussion of ambiguity followed by responses to ambi-guity and finally the role of organizations in handlingambiguity.

My co-author (Thomas A. Mercer, RAdm, USN,retired) and I write about ambiguity as experiencedwhile creating new programmes (van Stralen & Mercer,2015).RAdm Mercer describes his experience assumingcommand of the US Navy aircraft carrier Carl Vinsonwith the ambiguity of a novel communication system.Karlene Roberts, from the University of California,Berkeley, studied his command philosophy and thecrew’s performance in her work on High ReliabilityOrganizing (Rochlin, LaPorte, & Roberts, 1987) and myexperience in a paediatric intensive care unit (Roberts,Madsen, Desai, & van Stralen, 2005). Our articledescribes the effect ambiguity has, at the levels of theindividual and leader, on creation of our respectiveprograms.

John Carroll (2015) focuses on functional types ofambiguity and their effect on safety. Fundamental ambi-guity is experienced as the lack of categories; causalambiguity is from cause–effect relationships; and role

ambiguity of who is accountable.This is what people facewhen they stand alone at the beginning of a crisis and towhat the organization responds.Weak signals of unsafepractices tend to be ambiguous and easy to ignore.As inWolfberg’s mystery-solving and full spectrum analysis,we do not know what information may be relevant.Carroll describes the effect of information entropy onbad news as it is reframed to become less threateningand also less meaningful and less urgent. More success-ful strategies involve seeking multiple perspective andinnovative suggestions, which contributes to learning bydoing.

Bea (2015) creates a typology of ambiguity anduncertainty for assessment and management. He iden-tifies ambiguity inherent to the system, Intrinsic Uncer-tainty, comprising a natural part of the environment orthe result of analytical modelling. Ambiguities fromoutside the environment, Extrinsic Uncertainty, arisefrom human and organizational test performance or thedevelopment and utilization of information. Engineeringapproaches do not address extrinsic uncertaintieswhere high reliability leadership and management havegreater importance. Proactive management requiresanticipation and a robust system that can tolerate thedamage and defects of the adverse effects from extrin-sic uncertainties. Reactive assessment managementrelies on the premise that systems can fill in the goals tominimize consequences of failures. Engagement, a nec-essary component of working with ambiguity, occursthrough interactive assessment and management func-tions, a form of real-time crisis management. Becauseambiguity cannot be reduced to zero, the managementof ambiguity is a continuous process, a constant struggleto make sense of what is happening to a complexsystem.

Barton et al. (2015) studied how wildland firefightersreduce ambiguity with improved sensemaking and lead-ership.This is enabled by a two pronged set of practicesenacted by leaders and frontline workers that includesactively searching for discrepancies and actively seekingdiverse perspectives.Wildland fire culture accepts real-time experimentation and improvisation. The authors’use of Bertrand Russell’s concept of ‘Knowledge byacquaintance and knowledge by description’ to explainleadership in dynamic states is of good use and longoverdue for complex organizations that rely on highlyexperienced personnel. The closer one comes to theevent, the greater the influence of ambiguity. Theauthors’ clear explanation of anomalizing and proactiveleader sensemaking can easily translate to otherindustries.

Flin and Fruhen (2015) defined ambiguity morebroadly to encompass vague probabilities and lack ofclarity. They focus on senior managers and ambiguousthreat with problem solving as a management behav-iour. Flin and Fruhen’s description of problem solving as



a behavior is similar to the principle of engagement andWolfberg’s mystery-solving and full spectrum analysis.This correlates closely to emergency responders whoroutinely encounter novel situations, which may explainthe insightful conclusion that, with problem-solvingstrategies, managers ‘gain a closer estimate of the risksthey are dealing with’.This point will benefit any discus-sion of how to create a safety culture.The concept thatcalm is a source of chronic unease in operators is veryreal, not because operators want to act, but because thecalm may be due to missing an early herald of failure.Chronic unease in managers influences how they reactwith subordinates, but it also presents the opportunityto model behaviour and thinking for ambiguity. Con-flicted decision-making, from Janis and Mann, is a mostuseful explanation of the response to uncertainty andambiguity under stress, including many of my experi-ences that became an integral part of what I taught foremergency management.

Meshkati and Khashe (2015) used the US AirwaysHudson River landing and the Fukushima Daini NuclearPower Station earthquake response to show how ambi-guity can act as a source of resilience through improvi-sation. In each of these situations the operatorsremained engaged to enact a response that lessened thedamage that could have occurred.To do this, people hadto move from routine operations to non-routine, emer-gency operations quickly and with minimal discussionamong themselves. Using Rasmussen’s skill-based, role-based, and knowledge-based framework, they demon-strate that independent, thinking people are the last lineof defense in a high risk, ambiguous situation.

Woods et al. (2015) discussed how organizationmanagers discount safety metrics and information whenfaced with uncertainty and ambiguity.With several real-life examples, they show that the deficit in ability for anorganization to assess incoming evidence of vulnerabil-ity can be measured.Their Q4-Balance framework pro-vides the analytic individual basis to assess balance andimbalance across the four classes that are formed. Safetyenergy comes from this framework; it looks at how theorganization consumes its ‘energy’, which is expertise,time and networking activities for safety personnel.Safety energy is a dynamic quantity expanding or con-tracting in the face of the organization’s reaction toever-changing goals and conditions of operation.

Vidal (2015) approaches ambiguity from the threestances of Thorngate (1976): simplicity, generality andaccuracy. We can have any two but not all three.Vidalexplains our choices with metaphors of the engineer,the craftsman and the gardener.The engineer metaphor(simple and accurate, local therefore not general)underscores our discussion of uncertainty with use ofdelegation of authority, protocol, and collection of facts.The craftsman (simple and general, ambiguous there-fore not accurate) aims for causation and uses creativity

to shape the world.The gardener (general and accurate,complex therefore not simple) can only respond to alimited number of things, ‘a figure who takes action onthe little things under his control, without expecting tocontrol nature, and who contemplates the beauty of aworld within his comprehension’.

Weick (2015) embraces ambiguity, describing thateven to reduce ambiguity you must initially increase it.Ambiguity becomes a moving target and acceptance ofavid unity as an expected part of the everyday marks anincrease in understanding from the level of the super-ficially simple and uncertain to the complex andambiguous. But it is through the engagement of thecomplex and ambiguous that we organize. Informationentropy is deeply embedded in his article as the activeengagement of ambiguity to create understanding,organization, and communication similar to Shannon’sstatement that when we make choices in uncertaintywe create information.Weick describes how we manageambiguity through experience. This is similar to ‘Youbecome part of the problem’, a phrase used to describeour experience as rescue ambulance paramedics in anarea of high crime gang activity.We could only solve theproblem by entering the crowd, but by entering thecrowd we might need rescue ourselves as we changethe immediate environment.

Mentioned in several of the articles were the earlyherald and anomaly, the presence of a time course, theneed for engagement or interaction, the need forcreativity and improvisation, and the importance ofleadership.

Anomalies, small deviations, early warnings, minorperturbations and weak signals are signs that thesystem is not working well and bring attention toevents that, if not engaged, can enlarge to cause majordisruptions.Anomalies as indicators ‘have the potentialto trigger re-evaluation and re-conceptualizationabout changing risks before serious incidents or acci-dents occur’ (Woods et al). ‘Among these emergingdisconnects and contradictions lurk the weak signals,the cues indicating a hazardous condition where addi-tional scrutiny is now merited’ (Flin & Fruhen). Ambi-guity and background noise make it easy to ignorethese signs (Barton et al., 2015; Carroll, 2015; Flin &Fruhen, 2015; Meshkati & Khashe, 2015; van Stralen &Mercer, 2015; Woods et al., 2015).

Shannon’s formulation of information entropy findsinformation in uncertainty and that we gain informationby the choices we make.Ambiguity, discrepancy and thecreation of discrepancy force us to make choices, cre-ating information

From our authors, discrepancy identifies the smalldeviation that may enlarge. Every experience createsdiscrepancies and, when we pay more attention to theseemingly subtle and insignificant, we experience moreambiguity (Weick, 2015). Discrepancy can come from

Ambiguity 51


people with different experiences or from people withthe same experience but difference sensemaking.Within ‘these emerging disconnects and contradictionslurk the weak signals, the cues indicating hazardouscondition where additional scrutiny is now merited’(Flin & Fruhen, 2015).

Barton et al. call the active search for discrepancy andoutliers anomalizing.The leader can then reflect on theharsh realities of multiple viewpoints (Carroll, 1995,2015; Barton et al., 2015; Bea, 2015; Flin & Fruhen, 2015;Weick, 2015).

Organizations that operate effectively will simulta-neously engage different parts of the system to main-tain balance (Barton et al., 2015). Carroll (2015)describes this eloquently as ‘acting into an ambiguoussituation’, capturing our feeling, as rescue ambulancemen, when we approached a hostile crowd. People areinvolved in dynamic and continuous interaction toprevent failure and hazard; touching the boundary ofloss of control is necessary during a crisis (Meshkati &Khashe, 2015). In this manner, several groups of heroicpeople engaged the crisis of an airplane landing on theriver and a nuclear power plant severely damaged byan earthquake and tsunami. Interactive approaches,interactive assessment and management of ambiguity,is performed during the operations conducted (Bea,2015). Safety energy reflects the resources devoted tosafety-oriented indicators for proactive safety manage-ment; the purpose of proactive safety metrics is forengagement (Woods et al., 2015). The Fog of Warcan only be managed by engagement (van Stralen &Mercer, 2015).

Weick describes how high reliability organizationsincreased ambiguity in the initial phase of engagement.‘To grasp ambiguity is to comprehend it adequately.’Weexperience ambiguity and we do this through engage-ment, always substituting, always interrupted, and alwaysrelational.To manage ambiguity we experience ambigu-ity and even that experience, because we see it new,allows us to see new things. Innovative suggestions andlearning-by-doing are significant contributors to successin ambiguous states (Carroll, 1995, 2015).

Ambiguity can enable collective action by numbingpotential conflicts of interest; it can trigger explora-tion and learning. In the gardener’s stance,Vidal (2015)evocatively describes engagement with the Gardener’sStance; ‘take action on the little things under hiscontrol, without expecting to control nature, and whocontemplates the beauty of a world beyond his com-prehension’ (Carroll, 1995, 2015; Barton et al., 2015;Bea, 2015; Meshkati & Khashe, 2015; van Stralen &Mercer, 2015; Vidal, 2015; Weick, 2015; Woods et al.,2015).

Ambiguity, by several authors, unfolds over time andwith it the context changes, which changes the meaningof observations and experience. As an unfolding

sequence of events, ambiguity threatens safety and reli-ability. Reactive management approaches, the premisethat systems can fail, seek to learn from near misses(Bea, 2015), events easily missed or disregarded in realtime. Safety energy is a dynamic quantity that contractsor expands in the face of the organization’s reaction toever-changing goals and conditions of operation (Bartonet al., 2015; van Stralen & Mercer, 2015; Weick, 2015;Woods et al., 2015).

The principle that organizations use creativity,improvisation and innovation as a response to ambigu-ity, surprised me the most about this project. Vidal(2015) describes the basis of innovation, ‘Organizationsare better prepared when their reservoir of ideas andactions is large enough, so that people can choose thosethat help them make sense of the situation at hand andrecombine behaviours to improvise ad-hoc solutions’.Meshkati and Khashe (2015) write, ‘Improvisation isconsidered as an engine of resiliency, improvisation insafety critical situation, which inhabits ambiguous infor-mation, could result in either mitigation or preventionof catastrophic system failures’. In the heroic responseto the nuclear power station damaged by an earthquakeand tsunami, they add that, ‘The improvised acts of thenuclear shutdown are too numerous to mention’. FromWeick, ‘Interruptions and improvisations seem to gotogether . . . one possibility of how organizations reactto ambiguity’. Flin and Fruhen (2015) write, ‘The abilityto imagine negative consequences is requisite imagina-tion.This is captured as flexible thinking’ (Carroll, 1995,2015; Flin & Fruhen, 2015; Meshkati & Khashe, 2015;van Stralen & Mercer, 2015; Vidal, 2015; Weick, 2015;Woods et al., 2015).

The authors who discussed leadership commonlydescribed elements of a bottom-up approach or, at theleast, transformative and supportive leaders at the top.Weick (2015) discusses the ‘group writ small’, which Ithink is critical as it describes the dynamics of abottom-up approach. It supports the idea that safetyand reliability are self-organizing responding to localcontext. ‘Empowering expert people closest to aproblem and shifting leadership to people who have theanswer to the problem at hand’ (Meshkati & Khashe,2015) is central to success.

Leadership in ambiguity also has a top-down element.Vidal urges caution with the Engineer’s Stance of lead-ership – ‘when lessons learned by organizations trans-late into the refinement of procedures, protocols, andthe proliferation of rules’. ‘Managing uncertainty by aninflation of rules is typical of the engineer’s stance.’Rather, successful leaders seek out diverse perspectivesand discrepancy (Barton et al., 2015), engage diverseparticipants from inside and outside the organization toprovide multiple perspectives and innovative sugges-tions that contribute to learning-by-doing (Carroll,1995, 2015), and a shuffling of power and influence to



those who can make sense of the ambiguous situation.Only the Captain of the ship could say no, giving a biasfor action to make the system work (van Stralen &Mercer, 2015). A deeper understanding of ‘only theCaptain can say no’ is the Captain sees a larger pictureof the events (Mercer, pers. commun.).Carroll describesthe CNO who reversed the firings of two contractworkers who voiced safety concerns.The CNO saw thelarger picture and, by acting into ambiguity, increasednot only safety in the program but transformed leader-ship in the ranks of management.

Bea described the importance of corporate leader-ship: when the leaders who developed the programmeretired, ‘the pipes started leaking again.’ (Barton et al.,2015; Carroll, 1995, 2015; Meshkati & Khashe, 2015; vanStralen & Mercer, 2015;Vidal, 2015;Weick, 2015).

When we assume uncertainty, we assume we havemissed information, that there is a correct hypothesisand outcome, and more information will bring us closerto reality. When we accept ambiguity, we accept thatthere are multiple interpretations, that system trajecto-ries and our conclusions will change, and that percep-tions have limited fidelity to reality.

How an organization responds to ambiguity is howthe organization maintains productivity, quality, resil-ience and safety in a changing, hostile and ambiguousenvironment.

Daved van Stralen*,***Department of Pediatrics, Loma Linda UniversitySchool of Medicine, Loma Linda, CA 92350, USA.

**Riverside County EMS Agency, Riverside, CA 92503,USA. E-mail: [email protected]

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Ambiguity, Guest Editorial

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