O&MJournalDraft.MV.April08.1

RESILIENT DISTRIBUTED COGNITION IN U.S. COAST GUARD FLIGHT CREWS
Michael Valerio, The George Washington University
April 15, 2008
This paper was presented at the Eastern Academy of Management meeting, Washington, DC,
May14, 2008, and for inclusion in the Conference Proceedings. The contributions to the study by
dissertation committee members Andrea Casey and David Schwandt (The George Washington
University) are greatly appreciated.

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ABSTRACT
Researchers in the emerging field of high-reliability organizations (HROs) have shown
the importance of resilient distributed cognitions in the prevention, management, and resolution
of organizational catastrophes. However, scholars have yet to agree on how resilient distributed
cognition (RDC) can be characterized, and under what conditions it is activated and then
transferred to others and manifested as highly reliable actions or behaviors. Understanding RDC
cognition in HROs offers the potential promise of avoiding disaster. Our study of a military
HRO, more specifically a Coast Guard C130 Aircraft and Crew engaged in Law Enforcement
(LE) and Search and Rescue (SAR) concluded that resiliency and its subcomponent, reliability,
in organizations can be achieved by learning the language of congregation, that is, a specific
grammar and syntax to organizing. An underlying congregate cognitive map of an organization
is activated through language building that highlights the mechanism behind resilient distributed
cognition and how highly resilient and reliable actions among organizational members is
achievable despite changing membership or diversity of shared beliefs, values and motivations.

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Bigley & Roberts (2001) recently argued that Incident Command System (ICS)- based
organizations have the “structure to support constrained improvisation and manage cognitive
behavior of participants necessary for flexible and adaptable response to hazardous and volatile
situations” (p1282). More specifically, due to the highly structured standard operating
procedures, roles and associated training, the ICS structure is a ‘blueprint’ around which an HRO
continuously evolves in a disciplined manner according to prescribed functions and role
switching among participants as facilitated by a formal language of operations (p.1291).
However, we believe that such structural resiliency and operational reliability is a product of the
communications process, not the organizational structure, that is, resilient and thus reliant
communication is due to mastery of the grammar and syntax of congregation (Valerio, 2006).
Weick (1979) has repeatedly reminded us that the organization is not the “separate force or
agent” (p. 34) behind the HRO but the interlocked behaviors of the participants. Nearly three
decades ago Weick (1969) argued “it is not the tangible fixtures in an organization that are
crucial. These merely provide the media through which the (organizing) processes are expressed
(p.16).” We agree with Bigley & Roberts (2001) that successful HRO performance depend upon
“intense communications” but those communications are achieved by understanding a language
of congregation rather than one of structure.
Weick, Sutcliffe & Obstfeld (2005) reaffirmed that sensemaking depends on words and
typifications assembled through “language, talk and communications”; “organizing itself is
embodied in written and spoken texts” (P409), that is, it follows a grammar and syntax of its own
(emphasis ours). Following Weick’s (1969) notion that “organizing is the grammar by which the

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vocabulary of elements in an organization is made meaningful (p.62)”, Czarniawska (2006)
poses that organizing of human interaction “is clearly linguistic: it is a grammar, and the
behaviors must sensibly interlock” (p.1666); however, she concluded that organizational
researchers have failed to describe the actual grammar itself: “But how do they connect cued
events into interlocking structures? What logics, what grammars, what plots are used to build
such connections?” (p1670). Similarly while Eisenberg (2006) reinforces Weick's perspective
that language is both central to the social construction of realities and the role of cognition
(p1693), he too asked: “Where was one to look for the ‘double-interacts’ that were purported to
characterize organizational communication?” (p1697). This study purposefully sought to resolve
this gap in theory by attempting to accurately describe the mechanism of interlocking behavior.
The language of specialized collective action characterized as heedful interrelating
(Weick & Roberts, 1993) and made possible by the language of congregation (Bougon, 1992,
Valerio, 2006) creates a reliable property of the whole system of actors, its technology and
artifacts (Hutchins, 1996a/b; Hutchins and Klausen, 1998; and Suchman, 1996). This language of
congregation is activated by precise congregating labels linked to congregating activities as
mastered through congregating roles among the cognitive maps of the members of the
organization (Bougon, 1992; Valerio, 2006). Weick (1969) had suggested that such
congregation among organizational participants was the product of a “of endless dyads sitting
around the organization, waiting to be plugged into some process, after they will return to their
offices to await new inputs (p.75)”. Evidently, increasing resilient and reliable performance of
organizations occurs when members are socialized to those specific congregating labels, roles,
and activities associated with their highly reliable actions. The fact that these congregating roles
and activities can be described as functions within organizations should not lead researchers to

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confuse the process of organizing for resiliency and high reliability and the associated highly
resilient and reliable actions due to the imposition of structure rather than as a communicative
achievement.
THE RESEARCH AGENDA
This research involved a U.S. Coast Guard C130 Aircraft and crew based in Elizabeth City,
North Carolina conducting maritime law enforcement and search and rescue operations in the
Caribbean Sea in 1999. The research questions that we pursued included:
(1) How do resilient cognitions in a crew or team operate? In other words, how is
requisite variety created and sustained in HROs (Conant & Ashby, 1970; Orton, 1988);
(2) How does a collectivity with ever changing individual membership maintain and
transfer resilient distributed cognition? That is, what processes in organizations create
"heedful interrelating" (Weick & Roberts, 1993) and how doe these processes allow for
the emergence of innovative solutions, specifically "bricolaged" or recombinant-
innovative solutions (D. Chales Galunic & Rodan, 1998; D. Charles Galunic & Weeks,
2002), to unexpected and potentially catastrophic situations (Weick & Sutcliffe, 2001;
Weick, Sutcliffe, & Obstfeld, 1999).
Evidence suggests that resilient cognition, a learned behavior, can be achieved:
1) By defining Resilient Congregating Activities;
(Resilient <---> Learning and Enforcement Mechanism)
2) By creating Resilient Congregating Labels for these Resilient Congregating Activities;
(Resilient <---> Learning and Enforcement Mechanism); and by
3) By creating Cognitive Congregants Roles i.e. one Congregant Cognitive Role = one
idiosyncratic Cognitive Map + At Least Two Resilient Congregating Activitiess.

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Figure 1 illustrates the relationship between resilient congregating activites, resilient
congregating labels and resilient cognitive congregants’ roles.
[INSERT FIGURE I HERE]
Resiliency is achieved by socializing each congregant into a Cognitive Congregant Role.
That is, by learning and enforcing of the Resilient Congregating Action/Activity, and by learning
and enforcing of the Resilient Congregating Labels, that is a Lexicon of Labels.
The problem or interchanging membership and sustainability of resilient distributed
cognition is achieved by introducing or “plugging in” congregate cognitive roles into a new
congregate cognitive map.. A congregate cognitive map and its congregate cognitve roles are
mutually self-defining. A missing congregate cognitive role will be immediately spotted by the
congregant cognitive roles that have an resilient congrating activity in common with the missing
congregant cognitive. Such a blatantly missing congregate cognitive role will call for immediate
correction. Because a congregant cognitive role is an interchangeable for congregate cognitive
maps, it is thus easy to form additional congregations as enough congregants become available
(who have been socialized in existing congregations) to populate a new congregation.
Consequently, random rotation of the congregant congregating roles s into the existing
congregations is a central technique for the over-learning and enforcement of the congregating
roles and activities..
A congregate cognitive map is a syntax/grammar for composing a Congregation. Like
syntax/grammar, a congregate cognitve map is content-free (and both can be diagrammed). One
does not need to know the meaning of the words(cognitive congregating lables) to recognize that
the syntax/grammar(congregate cognitive map) is flawed. In syntax/grammar, a verb links

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subject to object. In a cognitve congregating map (CCM), an reslieint congregating activity
(RCA) is linking a giver to a taker.
With Congregating Activities (CA)s and Congregating Labels (CL) we have
the components of a grammar/syntax to compose a "Congregating Sentence", as follows:
English Grammar: English Sentence --
Subject (sender) --------> Verb (action) --------> Object (receiver)
CCM Grammar: Congregating Sentence --
Sender CL ---------------> CA (action) ----------> Receiver CL
Finally, language use was critical to organizing highly resilient and reliable activities.
The crew navigator/radio operators [NAV/AV (radio)] position acted as “keeper of the
language”, that is, they enforced the “R” in HRO. They controlled the language codes for all
potential labels around which crewmembers congregated their highly resilient and reliable
activities.
There was constant “idle chatter” over the course of the flight; in fact, most of the crew
conversation was social in nature. As a researcher (first author) new to use of headgear and the
monitoring of radio frequencies, the cognitive effort to listen was extremely fatiguing. If this
researcher (first author) “deselected” channels or unplugged his headset, he became more
anxious, that is insecure, and was not able to rest. Unplugging meant total isolation in flight.
This idle chatter seems to serve the purpose signaling: “I am here, I am listening.” And out of
the constant stream of words and phrases, certain keywords can be heard which cue and narrow
attention and trigger actions. Even when other crewmembers were in a state of “rest”, that is,
with their eyes closed and reclined, they wore their headsets with specific channels open. This

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idle chatter was a feature of crewmembers’ cosmological security (Weick, 1993a). The truly
important keywords expected to cue action must necessarily remain rigid and inflexible. It
would seem that these keywords operate within cognitive and cognitive congregate maps as a
largely rigid shared meaning pointing to clearly understand congregating actions; that is words
to serve as a mechanism to detect a wrong label or propagate the use of a novel more useful
label. And while these keywords appear to compose a highly reliable system of meaning, there
are agents i.e. the RAD/NAV positions, which have the authority to introduce change to adapt to
a dynamically changing environment.
The elusive double - interact manifest aspects of the cognitive congregate map (CCM).
For example, there is a “template” for take-offs, landings, vessel search and intercept, or air-
dropping supplies. These templates of action represent various slices of one whole CCM. The
one truly common linkage among all of the crewmembers is the internal communication system
and key words activate these various templates of the CCM. And once activated, like an array of
lights, the various positions with shared actions become activated. Furthermore, longitudinal
comparisons of the individual cognitive maps elicited for the members at the start and at the end
of the 5 day trip showed little or no change in content over time. The ability to switch templates
is a feature of high reliability operations. The template brings up a self-reinforcing cognitive
package that is multi-sensory in nature. The map itself is not the schema, but rather activates the
schema in the head of the interacting individuals.
The CCM in actuality is the map of the territory (Bougon, 1992). It seems to go beyond
the metaphorical level such as Morgan’s (1986) mind metaphors including a psychic prison,
machine, organism and all of the limitations associated with one imprecise metaphor. The CCM
captures all of these metaphors under one real thing. The metaphor we have chosen to best

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represent the CCM is the skin of the squid. Those regions of the skin illuminated are therefore
temporal regions of local centrality (LCoCCM)1
of the CCM where the density of causal
linkages is very strong. More specifically, these LCoCCMs once fully identified can be used to
the highlight crew behaviors (training) necessary to maintain crew resiliency or crew
effectiveness or improved crew cooperation. Each of the LCoCCMs represents different
activations among the CCM and not all crewmembers are active for all congregating actions at a
given time.
C130 HRO Case Study: Context for Organizing Highly Resilient and Reliable Actions
Hurricane Katrina was an organizational catastrophe that will be studied for years.
Relying on the embedded knowledge i.e. geography, typography, facilities, utilities, etc., within
Geographic Information Systems maps, the U.S. Coast Guard was able to rescue thousands of
people during Hurricane Katrina. In our study of U.S. Coast Guard C130 flight crews in 1999,
we found intriguing parallels between the precursor event, Hurricane Floyd (1999), and the artful
construction of air navigation maps of Greensboro, North Carolina and the catastrophic Katrina
event (2006). In the study, we specifically followed the conversation with a radio technician on a
Search and Rescue mission, in which he referred to the improvisational creation of maps during
the flooding of Greensboro, North Carolina, during Hurricane Floyd, September 14-18, 1999.
High-reliability researchers will see parallels to the Katrina and Floyd mapping cases and
Karl Weick's (1995) discussion of the importance of minimal structures in the creation of action.
Weick tells a story about a small Hungarian reconnaissance detachment lost in the Alps who
managed to find their way back to the rest of their army by use of a map of the Pyrenees. A poor
map became the organizing process around which the group was able to notice and extract the
environmental cues necessary to create a more useful course of action that led to their escape. In
1
A term coined by Dr. Michel Bougon

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the Hurricane Floyd case, though, the map was enacted, or "bricolaged," during a series of Coast
Guard sorties. Transcribed from a portion of a crew interview during the development of
individual cognitive maps as prescribed by Bougon (1983), the researcher (R) probes the radio
operator (RAD)’s recollection of the map construction:
RADIO OPERATOR (RAD): Well a recent incident, of course, you know with the
flooding there around the Tarborough Area, like it was mentioned, I think, you were
talking about it on the way down how -- we're not trained for ground, you know, over
ground type situations like that. We do all of our rescues on the high seas and here we
had a situation where it's over land and then--.
RESEARCHER (R): Momentarily, though, it was flooded.
RAD: That's not something that we train for like getting helicopters down there amongst
the power lines, towers, but you don't deal with a whole lot out on the open water other
than, you know, masts on a ship or antennas and whatnot and the middle of the night on
top of that and I just thought that when that alarm went off and they came over the
intercom saying there's 300 people stranded in the Tarborough area, need an evacuation
and they started sending helicopters out that way and then they put the C130 in the air to
kind of maintain the overall on the Commander--.
R: Coordination?
RAD: Well, they had a guy on the ground getting reports from the Sheriff's Department
and Highway Patrol… hey; we got people stuck here, there and whatnot. He would call
up to us and--it almost seemed like the whole mission evolved as it went along. We had
no game plan to speak of getting out there, what exactly are we going to do and it just
seemed like with the people that we had and the discussions that occurred that the plan
just worked itself out and it worked for the most part, it may not have been the best plan,
but we had nothing to refer to. I think Mr. Bills (P)ilot said, the way it evolved, nobody
had -- nobody had any kind of action plan to refer to. What do you do in this situation?
Well, you set up this, that and the other.
R: There was a navigator (NAV) I talked to on a SAR duty night who was in one of the
first crews on the scene and he said all they had was a street map and he said it was
miserable. I mean he couldn't find anything because he had no points of reference.
RAD: We had no charts!
R: And then he said what he did the first night they came in, he put LON (gitude) and
LAT (itude) s all over this street map and he passed it to the next crew.

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RAD: Right, he was there the second day. It was myself and Bart Fellow (NAV), they
had it the first night, you know, we had nothing!
R: OK, so maybe--.
RAD: We had nothing!
R: So what actually evolved as a tool? Was it the street map that they kept modifying?
RAD: Well, I think after that first night, we started looking to see what better resources
they could use, OK, so somebody might have gotten a more detailed chart of that area
from some other way, some other source. But the first night was nothing absolutely. But
it all worked.
This story from our research is a good introduction to the problem that was considered
during this research project. U.S. Coast Guard flight crews have used the C130 aircraft for
nearly 30 years, with a loss rate of < 1% compared with Department of Defense (30%) and other
nations (40%) in non-combat accidents (Bowman, 1999; Canton, 1999; Gero, 1999; Job, 1994)
using the same aircraft over a 45 year period. We believe one key ethnographic finding that
accounts the significant difference between the Coast Guard operations and others mirrors
maintenance policies. Whereas the Department of Defense and other nations have policies that
separate the maintenance of the aircraft from the operation of the aircraft, with a more rigid
specialization of flight crew roles, the Coast Guard has a culture referred to as "fix-and-fly," and
has a tradition of members of the flight crews being cross-trained and capable of moving
between specific flight crew roles over a career, between sorties, and even within an operation.
Our study – like Weick and Roberts' (1996) research on aircraft carriers – involves the
potential interaction of several catastrophic domains: the dangers of natural disasters such as
hurricanes, the dangers of operations at sea, the dangers of aviation operations, and the dangers
of interacting with criminal activities such as drug smuggling and human trafficking.

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In the conversation reported above, the flight crew members in Hurricane Floyd were
well-trained and skillful enough at the navigation role to improvise a solution to a new problem,
which can be framed as a requisite variety solution to the problem. The radio technician often
acted in multiple roles in the flight crew and thus was able to participate in the creation of a
series of increasingly useful maps, which can be framed as a process that created heedful
interrelating to resolve the emergent problem. On a larger scale, the rise of an "unexpected"
problem was resolved through the capacity of members of the "fix-and-fly" culture of the Coast
Guard to take materials at hand and combine them in innovative solutions during a crisis.
POSITIONING THE STUDY IN HUMAN AND ORGANIZATIONAL LEARNING
Research Findings on Distributed Cognitions in Loosely Coupled Networks
Weick (1987) suggested that the term organization “implies more orderliness,
coordination, and systemization than is commonly discovered when people look closely at joint
action” (p. 10). An organization, Weick (1993) further stated, is simply a “role structure of
interlocking routines” (p. 633). Weick (1969, 1979) argued that organizational networks can be
depicted graphically through cognitive maps (CMs). Bougon (1992) argues more specifically
that congregate cognitive maps (CCMs) define that organization. The concept of resilient
distributed cognition is derived from research on organizational structuring and organizational
learning.
Organizational Structuring
Organizational structuring has been defined as “a process of generating and recreating
meanings” among the members of an organization (Ranson, Hinings, & Greenwood, 1980p. 4).
Specifically, it is an emergent and unpredictable process shaped by the interplay of “prior social

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relations conditioned by an antecedent structural context” and mediated though the activities of
individuals (Archer, 1995, p. p. 165). Bougon (1992), Schwandt (1995, 1997), and Bradley
(1998) all posit that beneath these action-structures rests a deeper congregate cognitive structure
with its own ontological and emergent properties that frames and shapes (though not necessarily
pre-determines) collective behavior (Archer, 1995).
Rules and resources of social systems (Giddens, 1984) are re social structures, which
become causally efficacious through agency (Archer, 1995). These structures include memory,
norms, roles, leadership policies and procedures, rules, scripts, schemas, and values (Schwandt,
1995, 1997; Schwandt, Casey, & Gorman, 1999). Methodologically, these social structures can
be represented by CCMs depicting thinking and acting collectively in a particular action domain
(Bougon, 1992), such as aerial law enforcement.
Social realists view pre-existing collective cognitive structures as having the potential to
influence behavior, but that behavior is often unpredictable following the emergent nature of
human agency (Archer, 1995). Giddens (1976, 1979, 1984), Goffman (1967, 1974), and Archer
(1995, p. 165) argue that the resources of social collectives are spatial and physical as well as
human. Suchman (1987) demonstrated that physical workspaces are composed of equipment,
action, and spatiotemporal orders produced and informed by the work practices of situated
members. Lave and Wenger (1991) argued that actors, work activity, and the world mutually
constitute each other into "communities of practice" (p. 98). And finally, Suchman (1996),
Hutchins (1996a, 1996b), Hutchins and Klausen (1998) and Goodwin and Goodwin (1998)
demonstrated that workspaces, technology, and activities are mutually constituted in ship
bridges, airline cockpits, and air terminals. Work practice is pivotal to the activations of the
generative social structures of collective action (Archer, 2000).

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Organizational Learning
An adaptive and resilient structure of cognitions in a collectivity is a product of learning
collectively (Balaji S. Chakravarthy & Doz, 1992; Schwandt, 1995, 1997; Spender, 1996; Weick,
1996). Schwandt’s (1997) dynamic social Model of Organizational Learning holds that
“organizational learning,” that is, learning collectively, is a dynamic ability to continuously
generate equilibrating collective mental frameworks vital to organizational resiliency, threat
recognition, and the retention and creation of new knowledge necessary to enact contextual
sensemaking (Schwandt & Marquardt, 2000). Spender (1996) emphasizes that any useful theory
of organization must simultaneously rely on an integrative theory of learning, knowledge and
memory. A genuinely useful operational understanding of resilient distributed cognition would
also explain “collective memory,” learning collectively, collective decision-making, and
collective problem solving (Graesser, Gernsbacher, & Goldman, 1997).
Weick (1979) and Luhmann (1993) argue that the choices involved in the attention and
selection of information entering the collectivity cannot be overemphasized. Collective action
and reflection (Schwandt, 1997) enables the collective action learning required to develop
transferable goal-oriented knowledge competencies, or "interactional competence" (Cicourel,
1972). It is through communicative action that these competencies necessary for resiliency and
continuous learning are diffused throughout the organization (Schwandt, 1997).
Resilient Distributed Cognition
Many researchers have postulated the existence of resilient distributed cognition as a
unique phenomenon (Walsh, Henderson, & Deighton, 1988) often referred to as “shared
representations” or “team models” (Johnson, 2000). However, these researchers have not
reached a consensus concerning how cognitions in a collectivity can be characterized in terms of

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content and structure and under what conditions this collective structure emerges, is activated,
maintained, and shared.
"Distributed cognition," as a descriptor of cognitions within a collective, is defined here
as a socio-cultural process which organizes participants’ acts of perceiving, attending,
classifying, assigning meaning, remembering, and time reckoning (Hutchins, 1996a, 1996b;
Zerubavel, 1997), the outcome of which is the enactment of social practice (Hutchins, 1996a,
1996b). Distributed cognition is thus a process wherein participants organized around a specific
action domain assisted by technology and cultural artifacts, act relatively autonomously while
recognizing their interdependencies to make, exchange and sustain a coincident interpretation of
that environment so they can act collectively with understanding (Boland, Tenkasi, & Te'eni,
1994; Gray, Bougon, & Donnellon, 1985). It is important to keep in mind that while cognition is
an individual sensory phenomenon, distributed cognition occurs when “coincident interpretations
of reality are created, transmitted and sustained (Gray et al., 1985, p. p. 85).
"Coincident meaning” occurs when HRO participants favor one subjective interpretation
over others resulting in coincident expectations and reciprocal actions (p. 88). Such distributed
cognition is dependent on the connections between organizational participants (Weick, 1969,
1979).
"Cognitive Maps" are a visual representation describing the configuration of rules and
resources, or more specifically the concepts and relations associated with organizational
situations through which a person makes sense of his or her environment is known as a cognitive
map (Axelrod, 1976; Baird, 1994; Bougon, 1992; Bougon, Baird, Komocar, & Ross, 1990;
Bougon, Weick, & Binkhorst, 1977; Eden, 1994; Huff, 1990; Kaplan & Kaplan, 1982; Tegarden
& Sheetz, 2003; Weick & Bougon, 1986).

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"Collective Cognitive Maps" (CCMs) are the socio-culturally organized set of participant
cognitions within an action domain where this socio-cultural organizing of knowledge relies
upon a structure of cognitions in a collectivity that recognizes publicly held concepts used to
depict concepts, events and actions (Bougon, 1992). CCMs are collectively shared cognitive
structure that are relied upon to interpret, frame, simplify, and make sense of complex problems
encountered in collective goal accomplishment and threat adaptation (Norem & Cantor, 1992).
The manner in which individual CMs and a collective’s CCM are recursively constructed
and shared is critical to understanding organizational resiliency. Spender suggests that
distributed cognition and organizational learning -- learning collectively -- are two facets of the
same phenomenon (Spender, 1996).
One research tool common to explicating the nature of individual cognition and learning
is the cognitive map and by extension, the tying of individual cognitive maps through
congregating actions (Bougon, 1992) into congregate cognitive maps (CCMs).. The CCM is the
portal to collective sensemaking as a recursive process of distributed cognition and learning
collectively.
A number of researchers (Bougon, 1980, 1983, 1992; Bougon et al., 1990; Eden &
Ackerman, 1998; Eden, Ackermann, & Cropper, 1992; Kaplan & Kaplan, 1982; Spender, 1998;
Weick & Bougon, 1986) have suggested that interlocking role structures or collective structures
(Allport, 1962; Weick, 1969, 1979) can be described empirically through cognitive mapping
methods ultimately yielding a deeper CCM (Bougon, 1992). A CCM is a visual representation
of a collective’s experiences and knowledge in a specific action domain (Bougon, 1992).
Bougon (1992) stated that, structurally, a CCM binds the individual CMs of the social system’s
participants, not by shared meanings regarding perceptions and understandings of the

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environment, but by socially constructed and shared “cryptic” labels. "Cryptic Labels" are
publicly held concepts shaped by uniquely private personal meanings, or coincident meanings
(Donnellon, Gray, & Bougon, 1986).
Research streams associated with ethnomethodology, ethnography and linguistics have
demonstrated that the cognitions in a collectivity springs from talk in situ (Boden, 1994;
Garfinkel, 1967; Psathas, 1995; Sacks, 1972, 1995) wherein intersubjectivity is built by the
orderly structuring of turn taking in conversation (Boden, 1994; Leiter, 1980; Sacks, 1972), and
an embodied kinesthetic participation with artifacts and technology (Engestrom & Middleton,
1998; Hutchins, 1996a, 1996b). Organizations then arise “through the laminated sensemaking
activities of members, endlessly negotiated” (Taylor & Van Every, 2000, p. 33) (p. 33).
An effective operational understanding of resilient distributed cognition which addressed
theories of learning collectively and “collective memory” (Spender, 1998) must also link the
cognitive orientations of idiosyncratic participants to social interaction with their mutually
recognized displays of in interactive competence (Cicourel, 1964, 1972, 1981, 1992; Clayman &
Maynard, 1995; Leiter, 1980). While the collective characteristics of memory retention and
information sharing and new knowledge generation are fundamental to such an understanding,
the psychology of individual competencies and how they enter into distributed cognitions cannot
be ignored (Salomon, 1997). Qualitative but discernable differences associated with HRO
resiliency in “collective memory” and learning collectively become embedded in the structure of
cognitions in the collectivity of an HRO. This research specifically explored the structuring of
emergent cognitions in a collectivity realized by the participants of one high-risk HRO, a Coast
Guard C130 aircraft and its crew engaged in a routine LE patrol.

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Collective cognitive structures help explain complex organizational processes (Archer,
1995; Bhaskar, 1979, 1989; Danermark, Ekstrom, Jakobson, & Karlsson, 2002; Sayer, 1992,
2000). Bougon (1992), for example, has suggested that the CCM is (emphasis Bougon’s) the
territory or the social structure of cognitions in a collectivity, that is, an ontological reality
(Sayer, 1992, 2000). Spender (1996) insists that reliance upon individual psychology alone in
collective theory is inappropriate. CCMs as emergent and pre-existing structures, culturally
imposes a sense of order and structurally condition organizing activity (Archer, 1995).
Research Findings on Human and Organizational Sensemaking Processes
Collective communication mechanisms resident within the organization’s congregate
(collective) cognitive structure of collective values, thinking, understanding and acting (Bougon,
1992; Krackhardt, 1987; Schwandt, 1995, 1997; Schwandt et al., 1999; Schwandt & Marquardt,
2000) aer manifested by socially constructed memory, norms, roles, leadership policies and
procedures, rules, scripts, schemas, and values (Schwandt, 1995, 1997; Casey, 1995, 1999). Yet,
researchers have not yet reached consensus concerning the sources of collective cognitive
structure (Johnson, 2000; Klimoski & Mohammed, 1994; LaPorte & Consolini, 1991; Tegarden
& Sheetz, 2003) for such sensemaking processes.
From a sociological perspective, the structure of cognitions in a collectivity is believed to
embody a process that accounts for knowledge generation, learning, and meaning-making within
specific domains of expertise as structured by culture (Cole & Zuckerman, 1975; Hallowell,
1951; Harris, 1994; Schwandt, 1997; Zerubavel, 1997). Researchers (Crossan, Lane, & White,
1999; Gioia, 1986, 1992; March & Olsen, 1975; Neuberg & Newsom, 1993; Vaughan, 1996;
Walsh et al., 1988; Walsh & Ungson, 1991) also broadly suggest that cognitive structure takes
the form of schemas of embedded patterns of social interaction between individuals and their

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environment. And, while few agree as to the nature of that structure (aspects such as the degree
of sociality, or the role of emotion and affect (Bradley & Pribram, 1998; Fineman, 1996; Hume,
1985; McDougall, 1973; Thelen & Smith, 1998; Weick, 1999; Weick & Roberts, 1993) or the
role of a collective unconscious (Cicourel, 1972; Colman, 1975; Freud, 1989; Hopkins, 1997,
1998; Jung, 1990), these structures do exist as ontologically separate realities with casual power
mediated by agency (Archer, 1995; Bhaskar, 1979, 1989, 1998; Layder, 1990, 1998; Popper,
1979). These configurations of culturally shaped social interactions embodied by a deeper
collective cognitive structure are believed to trigger patterns of sensemaking among
organizational participants.
As sensemaking follows a social process of inscribing these patterns (or structuring) of
thinking and acting in a particular action domain into the structure of cognitions in a collectivity,
it is also a process of creating order facilitated by collective cognitive structures capable of
recognizing differences within a complex environment which usually go unnoticed (Klimecki &
Lassleben, 1999). Such order is created through the reduction of equivocality (Weick, 1969,
1979, 1995, 2001), crypticality (Bougon, 1992) or complexity (Luhmann, 1995), depending upon
the strata (individual, collective or institutional) of social reality (Archer, 1995). Furthermore,
that order, cemented by collective concerns for survival or cosmological security (Weick, 1993)
is morally imposed by the collectivity (Clayman & Maynard, 1995; Garfinkel, 1967). Weick
(1995) similarly refers to the “visibility, volition and irrevocability” of public actions that
"commits" participants to each other -- imposing order (p. 157).
Following Garfinkel (1967), Cicourel (1972) argues that this sensemaking activity is
manifested by interpretive procedures that can be accounted for empirically in social interaction:
that is, by how members display their intersubjective orientation to common assumptions and

20
understandings of everyday work activity (Clayman & Maynard, 1995; Leiter, 1980; Moerman,
1988), however “it is impossible to understand fully the nature of social interaction in the
absence of a concern with system factors” (Layder, 1998p. 48) and their interplay with
intersubjectivity and reflexivity (Archer, 1995, 2003).
According to Neuberg and Newsom (1993), cognitive structuring or the “creation and use
of abstract mental representations e.g., schemata prototypes, scripts, attitudes, and stereotypes”
(p. 113), binds previous personal and group experiences with new information and collective
action to create new knowledge supportive of adaptation and resiliency (Schwandt & Marquardt,
2000); such a structuring of cognitions in a collective demands that “certain abilities or
resources”(Bar-Tal, Kishon-Rabin, & Tabak, 1997p. 1158) be available for effective
sensemaking or those socially described cognitive processes used by members to determine the
meaning and significance of situations and events (Weick, 1969, 1979) as new information is
processed through collectively shared memories (Schwandt, 1995, 1997; Schwandt et al., 1999;
Weber, 1995). Consequently, the resiliency of cognitions in a collective may demand unique
configurations of rules and resources necessary for the reduction of equivocality (Weick, 1969,
1979), collective equivocality or “crypticality” (Bougon, 1992), or environmental complexity
(Luhmann, 1995).
Research Findings on Distributed Cognition and Sensemaking Processes in High-
Reliability Organizations
Organizations involved in these devastating accidents, mishaps, or incidents such as the
Three Mile Island incident, the Chernobyl nuclear incident, the Bhopal chemical leak or the
Challenger explosing are but a few examples of high-risk organizations (HROs). HROs are
organizations involved in operations in which the slightest mistake can lead to catastrophe.
HROs operate in very strong cultures marked by custom and tradition that become cognitively

21
focused on performance and obsessed with reliability (Bierly & Spender, 1995). Operating
rooms, cockpits of jet transports, the control rooms of nuclear power plants and C130 aircraft
engaged in maritime law enforcement are all complex settings in which the crews of HROs
interact with each other and technology.
When the organization of a nuclear power plant, a rescue helicopter, an oil tanker, a fire
control command center, or a surgical ward fails to such an extent that a catastrophe ensues,
investigations tend to be searches for features of failure by individual members of the
organization (Richardson, 1994), rather than an investigation of failure trajectories within
interactively complex systems. Stated another way, some individual becomes the “ritual
sacrifice”: an event that allows the organization to “avoid having to learn from the unfortunate
course of events” (Luhmann, 1993, pp. 195-196) or having to decipher the nature of the
interactively complex “structural couplings” between technology, social structure (Luhmann,
1993p. 99) and participants within an action system.
The examples of organizational collapse or failure to adapt to threat, such as Mann Gulch
(Maclean, 1992) or South Canyon (Maclean, 1999), may appear less inexplicable if it is
considered that cognition infused with emotion is neither as rational nor as stable as many
researchers have assumed. Carley and Harrald (1997) suggest that HROs may have to learn one
disaster at a time.
Bougon and his colleagues (1990) suggested that instability in an HRO could result from
the seemingly innocuous addition or removal, by a participant, of a single connection in that
collective’s CCM. Instability in an HRO occurs when an organization can no longer maintain
the effective interlocking role relationship necessary to support collective sensemaking and
decision-making.

22
Resiliency is an HRO's ability, despite changing membership, to reconstitute those
effective interlocking role structures. Chakravarthy and Kwun (1989) have described this
process of achieving resiliency as “strategy making” (p. 2). Weick (1995) has suggested that this
interchangeability of personnel necessary for resiliency follows pressures to “develop generic
subjectivity” (p. 170). Generic subjectivity is organized around congregating actions (Bougon,
1992) sustained by talk, mutual expectations and commitment. Commitment is created through
visible, volitional and irrevocable actions by the members of a collectivity (Weick, 1995).
Weick (1996) describes resiliency as an astonishing capacity for retrospective reflection
that not only recreates all of the harrowing performances that lead to failure, but also anticipates
and socially enacts (Weick, 1969, 1979) a definition of environment that conceptually avoids
disaster. Weick (1997) further suggests that learning resiliency is also one of recapturing the
emotion associated with the original vigilant cognitions that were hallmarks of successful HROs.
Left unattended -- that is, not actively reflected upon -- collective performance simply
degenerates into mindless heuristics or repetitive habits of thoughtless action (Spender, 1998).
Chakravarthy and Kwun (1989) also postulate that heuristics retained by only a few participants
working within collectives who do not share them among other HRO participants can neither be
validated nor developed into new knowledge; these few participants may contribute links that if
removed by their departure would destroy the stability of the CCM (Bougon, 1992).
In the fields of strategy, human resources, and organizational behavior, an operational
understanding of how a resilient structure of cognitions, that is RDC, in a collective is created,
sustained and transferred can afford researchers the power to explain theories of collective
performance and the management of environmental complexity (Klimoski & Mohammed, 1994).
Specifically, collective action can be explained by reference to their underlying generative

23
mechanisms and the conditions under which they are activated (Archer, 1995; Danermark et al.,
2002; Sayer, 1992).
The exponential growth in the complexity of high-risk organizational systems (Perrow,
1984) provides an important reason for developing an operational understanding of distributed
cognition. The increasing complexity of HROs puts their collective cognitive capabilities at
greater risk of collapse (Perrow, 1984). Dorner (1997) laments that this growth in system
complexity parallels a growth in the apprehension of failure that ironically acts to make failure
more likely. But we also know that often the root causes behind HRO failure are present within
the system long before the obvious cue is presented (Reason, 1998). Detection of these
technological cues is facilitated by the successful activation of distributed cognition obsessed
with reliability and characterized by what Weick and Roberts (1993) describe as “mindfulness.”
Mindfulness is described “preoccupation with mistakes, reluctance to simplify, sensitivity to
operations, commitment to resilience, and deference to authority" (p. 342).
Further, the economically constrained life extensions of the aging major platforms of
HROs are a risk factor. Beaty (1995) warns that half of today’s air passenger fleet is 50 years old
and what aviation engineers have referred to as BFOs (bits falling off) have increased in
frequency, including the most striking case of the Columbia Shuttle (Starbuck & Farjoun, 2005).
Recent warning signals of potential disaster involving the now 30-year-old, long-range C-130
aircraft fleet have surfaced in the news media (Cihelka, 2000). Such a preoccupation with aging
equipment undermines collective cognitive capability by diverting its attention away from the
focus on the HRO as a system of high reliability actors focused on mission performance as
opposed to equipment malfunction. More specifically, the crew becomes more focused on the
reliability of the aircraft rather than reliability of the mission. This is particularly insidious

24
because it plays on the culture of reliability baiting HROs to hunt for routine maintenance
problems instead of discovering the subtle cues of potential systems failures.***
Sensemaking Processes in High-reliability Organizations
LaPorte and Consolini (1991) have argued that the sensemaking patterns associated with
high-risk HROs are not well understood. Further, Weick, Sutcliffe, and Obstfeld (1999) have
suggested that there are specific processes in HROs associated with stability and resiliency,
including a preoccupation with failure, resistance to simplified interpretations, sensitivity to
operational context, and an under-specification of organizational structure.
Weick (1969, 1979, 1995, 2001) has argued that an organization must include a “mind”
capable enough of making sense of a variety of equivocal inputs. To survive, a resilient HRO (or,
at least those who manage HROs) must develop, share, and transfer the adaptive structuring
processes of the cognitions in a collectivity necessary to continuously make sense of its complex
environment among its changing membership. Resilient collective cognitive structure in an
organization is the product of intentional social learning processes that focus on knowledge
development (B. S. Chakravarthy & Kwun, 1989; Schwandt, 1997; Schwandt et al., 1999;
Schwandt & Marquardt, 2000; Spender, 1996, 1998). This intentionality can be operationalized
through the linking of CMs by strategic design (Eden & Ackermann, 1998) -- achieving
coincident meaning and expectations associated with the congregating actions essential to HRO
mission performance (Bougon, 1992; Gray et al., 1985). The failure of an HRO’s collective
cognitions (Schwandt, 1995, 1997) to make sense of “new information” and collectively
transform it into “goal-referenced” resilient behavior (Deevy, 1995; Weick & Roberts, 1993) can
lead to tragic ends.
Three prevailing factors put HROs at greater risk of breakdown of the structure of

25
cognitions in their collectivity: (a) the ever-increasing complexity of socio-technical
organizations; (b) the economically constrained life extensions of these aging major platforms of
HROs, i.e. ships and planes; and (c) a rapidly increasing reliance on technology. If we are to
take Luhmann’s (1993) sociological theory of risk seriously, a fourth factor, the failure to
consistently maintain a “second-order systems level observer” (one who can recognize
significant differences occurring within a system because of the ability to operate outside the
system i.e. an Inspector General) must be added. Such monitoring also occurs through collective
action and collective reflection (Schwandt, 1997) and the accounting of reflexivity, that is, the
rational features of socially organized and situated work (Cicourel, 1972; Garfinkel, 1967;
Goodwin, 1995; C. Goodwin & Goodwin, 1998; Leiter, 1980)
Perrow (1984) argues that these system complexities, involving the interaction of
economic constraints, people, and technology can overwhelm traditional organizational defenses
embodied by training, supervision, standards, practice, and redundancy. This leads the way to
serious incidents or “normal” accidents. In light of this rapidly escalating risk, how minimally
staffed HROs collectively make sense of these system complexities while operating safely and
effectively despite changing organizational participants is believed to be embedded in the
structure of cognitions in a collectivity and represented by the CCM (Bougon, 1992) of the HRO.
The HRO research, following Perrow's 1984 book, is traditionally sorted by catastrophic
contexts: e.g. fire-fighting, naval, space shuttle, and aviation.
RESEARCH METHODS
The purpose of our current study was to identify and describe the structuring of RDC in a
high-risk HRO in situ by extending Bougon’s (1992) theoretical construct of the CCM to
operational practice, that is, more specifically, to construct the first known CCM of an

26
operational HRO. To date, no researcher had attempted to develop an organization’s CCM, and
more specifically that of an operational HRO.
The HRO under study is the crew of a U.S. Coast Guard C130 aircraft deployed during a
routine law-enforcement patrol subject to any of a number of types of diversions, including
search and rescue (SAR), interdiction of drugs or aliens, fisheries patrols, ice patrols, or oil spill
response. In a recent study of Coast Guard aviation mishaps occurring between 1993 and 1998,
Canton (1999) discovered that Coast Guard C130s engaged in LE have the lowest odds of
mishap. He concluded, “Crews on LE missions looking for violators are more vigilant. This
hyper-vigilance may result in safer flight operations.” (p. 28).
The C130H aircraft HRO, the particular series of aircraft and crew involved in this study
is considered at high risk despite the Coast Guard’s remarkable record of safety, because the
Coast Guard continues to operate it well beyond its service life in extreme environmental
conditions. While a new HRO is believed to evolve during the course of each C130 LE flight
deployment because members of C130 aircrews are interchangeable and the crew membership is
reshuffled for each new deployment, the templates about which the HRO forms rest within the
structure of cognitions in a collective in that HRO than can be explicated via the CCM.
The primary products of examination are individual CMs, a CCM of the focal Coast
Guard C130 aircrew HRO and recorded crew conversations, supported by ethnographic
participant observation. Specifically, Bougon’s (1983) qualitative Self-Q methodology of
individual cause map (distilled CM showing means/ends causal attributions used to make sense
of bracketed environments) construction (Orton, 1996) was employed to construct the CCM
(Bougon, 1992). This study is specifically designed to capture the individual CMs of the
crewmembers and to construct the first CCM of an HRO crew (collectivity) engaged in a routine

27
LE flight.
The unit of analysis is the RDC between people, technology and artifacts in embodied
social interaction (Suchman, 1987; 1996; Hutchins, 1993, 1996a, 1996b; Rogers & Ellis, 1994;
Hutchins & Klausen, 1998; Goodwin & Goodwin, 1998). However, investigation of complex
phenomena such as organizational learning, action, and cognition necessarily involves the
individual, group, and organizational levels of analysis (Cicourel, 1958; Boden, 1994; Rogers &
Ellis, 1994; Brown & Starkey, 2000; Taylor & Van Every, 2000). Bougon (1992) has argued that
all levels of analysis are addressed simultaneously by the CCM, as a system of linking members
through publicly understood (congregating) actions, which bind the organizational participants
into a collectivity.
Assisted by observation and audio-recorded individual and group interviews, and in-flight
crew conversation, the CMs (more specifically dominant cause and influence maps) of each
crewmember and the CCM of the crew were developed. Observations served as a means to
gather data on the nature and relationships of the cryptic labels used in the HRO organizing
process (Bougon, 1992) and to help understand how a structure of cognitions in a collectivity in
an HRO is created and reproduced over time. Proper elicitation of interactional competence
requires an understanding of the socio-technical context (Cicourel, 1972, 1992; Suchman, 1987;
Moerman, 1988; Hutchins, 1993; Boden, 1994) afforded through participant-observation and
interviewing. Crewmembers were interviewed to identify the network of mental labels pertaining
to their collective action domain. At the congregate level, these labels became keywords that
signaled to reciprocal actions between the crewmembers engaged in collective sensemaking and
collective decision-making activities and collective actions or activities.

28
Congregating labels (CLs) either can be found through focused interviews, in the analysis
of crew conversation in situ, the Self-Q Interviews (Bougon, 1983), or through the development
of unique but commonly understood thematic statements which the researcher can attribute to
each participant following the analysis of CMs (Kennedy, 1993). Bougon’s (1980, 1983) and
Bougon et al.’s (1990) Self-Q Interview technique was used to construct individual idiosyncratic
CMs and the HRO CCM. Cognitive mapping elicits individually held assumptions and beliefs
regarding action domains that can facilitate a reduction of equivocality (Lee, Courtney &
O’Keefe, 1992); that is, the CCM adds meaning to equivocal environmental cues allowing the
collectivity to achieve the situational awareness necessary to define and sustain joint action
(Weick, 1969; 1979; Bougon, 1992). Consequently, sharing CM/CCMs should increase
intersubjectivity (Weick & Bougon, 1986; Eden & Ackermann, 1998a, 1998b; Tegarden &
Sheetz, 2003). Such a process is necessary to facilitate the collective self-reflection required for
threat-adaptive learning (Schwandt, 1997).
Research Site
Built in 1938 under the Lend Lease Act, Air Station Elizabeth (AIRSTA) City is the only
Coast Guard air station originally designed and built specifically for the Coast Guard. AIRSTA
Elizabeth City is one of several operational Coast Guard commands co-located on an 800 acre
site along the Albemarle Sound in the city of Elizabeth City, North Carolina.
The C-130H High Reliability Organization
During this study, 226 men and women assigned to the Air Station operated and
maintained five (5) HC-130s (long-range cargo aircraft) and three (3) HH-60 helicopters. The
High Reliability Organization (HRO) studied was the C-130 “H” model, or C-130H aircraft and
its seven member crew. AIRSTA Elizabeth City missions include search and rescue (SAR),

29
enforcement of laws and treaties (LE) including drug and alien interdiction, international ice
patrol operations, training and the maintenance of Aids to Navigation (AToN) for shipping. The
focus of this study centers on the work activities of aircrew operating the C130H aircraft in
support of SAR and LE between the months of September through October of 1999.
With the exception of two air crewmembers, all were married and with children. Not
including the researcher (first author), the average age of the crew was 31.25 years. Average
tenure with the Coast Guard was 6.5 years. Average education was 2.9 years beyond the high
school level (and that includes journeyman work in specialty skills such as electronics, simulator
training and chief petty officer’s academy). Average operating time in the air with the C130H
aircraft was 1015 hours. The average age of the active duty Coast Guard C-130H fleet (1999)
was over 25 years old, among the oldest flying C-130H aircraft in service today.
In 1999, the Air Station C130s flew 5847 hours of flight time amounting to 1136
“sorties”, the majority of which supported LE, SAR and training. The researcher (first author)
observed and participated as a “basic” air crewmember during a Law Enforcement (LE) patrol of
the Caribbean. Despite the excessive hours and age of these aircraft, non-combatant or
peacetime operations of Coast Guard operated C-130s (<1%) is dramatically less than combined
Department of Defense (30%) and other country (40%) operations (Bowman, 1999; Gero, 1999;
Reed, 1999).
Constructing Congregate Cognitive Maps (CCMs)
The Self-Q Interview Process (Bougon, 1982) was used to develop the individual
cognitive maps (CMs) and the Congregate Cognitive Maps (CCMs) of a SAR duty crew (pilot
study) and then of an LE crew performing over the course of a 5-day patrol in the Caribbean.
The action labels tying the individual cognitive maps of the HRO can be established by

30
identifying the shared actions (interacts) among the members in cooperation. These double
interacts (defined as the behavior of one participant being contingent upon the behavior of
another (Weick, 1979) manifest aspects of the CCM. For example, there is a “template” for
take-offs, landings, vessel search and intercept, or air-dropping supplies. These templates of
action represent various slices of one whole CCM. Individual cognitive maps between
crewmembers are linked by “keyword’, rigidly enforced words or word phrases which activate
these various templates of the CCM. And once activated, like an array of lights, the various CAs
and CLs become activated. Furthermore, longitudinal comparisons of the individual cognitive
maps elicited for the members at the start and at the end of the 5 day trip showed little or no
change in content over time. The ability to switch templates is believed to a feature of high
reliability operations. The template brings up a self-reinforcing cognitive package that is multi-
sensory in nature. The map itself is not the schema, but rather activates the schema in the head
of the interacting individuals.
Congregating Actions (CAs) and Congregating Labels (CLs) evolve from being
introduced, utilized/adopted i.e. becoming coincident until they are finally institutionalized
(culturally defined as CG “keywords” i.e. "Search/Presearch Checklist", or "Before Take-Off
Checklist," etc). Part of training for reliability is to adopt a term or phrase and then over-learn
the word or phrase in the context of role-training so that it ultimately becomes institutionalized.
CAs or CLs for this study emerged following Kennedy’s (1993) theme analysis. In the case of
the C130 crew for example, terms become repeated and reinforced by the radio operator, the
keeper of the language. CLs and keywords are not necessarily the same thing. For example, the
term, "Search/Patrol Checklist", is a "keyword" (institutionalized by the Coast Guard); in this
situation, it also happens to be the CL. Hence, a "keyword" (or a part of it) may be a "CL” or it

31
may not, and conversely, a CL may yet have no corresponding (CG-institutionalized) "keyword".
Figure 2, A Partial CCM drawn to illustrate the layout of the congregating of the SAR Duty
Crew. This CCM also shows a Congregating or Organizing Loop (Weick, 1969) going through
the two Congregating Actions and through the two causemaps (correspondence with Bougon
2005).
[INSERT FIGURE 2 HERE]
Data Collection
Data collection took place at the AIRSTA and on board the aircraft while on patrol in the
Caribbean. A combined qualitative methodology relying on the use of several opportunities to
triangulate for meaning and understanding (Tashakkori & Teddlie, 1998; Danermark, et alii,
2002) was used to investigate how the crew of an operational aircraft observed in real time
collectively makes sense of their aerial and marine environment. Such triangulation broadly
embraces the use of compatible methodologies, which operating in isolation; fail to fully
explicate collective behavior. Overall research design was based upon the elicitation of
cognitive maps (Bougon, et alli., 1977; 1990; Bougon, 1974-1995; 1980; 1983; 1992; 1990;
Kennedy, 1993; Baird, 1994; Weber, 1995; Valerio, 2006) supported by ethnography to properly
key the meanings displayed by interactants in conversation and/or validate or meaningfully edit
missing or incomplete segments in recorded data (Moerman, 1988). Cognitive mapping is a
qualitative research approach directed toward understanding, in particular, how individuals in
organizations make sense of events and situations (Jenkins, 1998). The unit of analysis is the
distributed cognition between people, technology and artifacts in embodied social interaction
(Suchman, 1987; 1996; Hutchins, 1993, 1996a, 1996b; Rogers & Ellis, 1994; Hutchins &
Klausen, 1998; Goodwin & Goodwin, 1998).

32
A portable Sony (ICM-5000EV) tape recording unit plugged into the aircraft internal
communication system (ICS) was used to record crew conversation. Personal follow on
interviews with the participants probing “labels” in their cognitive maps were also
recorded. Due to the presence of classified electronic equipment on board the aircraft,
videotaping was prohibited. Limited photography with a SLR 35mm camera was allowed.
Instrumentation
For the interview phase of this study, the Self-Q interviewing technique (Bougon, 1983;
Bougon et alli, 1990; Kennedy, 1993; Baird, 1994; Weber, 1995) was used. This instrument
consists of four interviews of 40 to 90 minutes each. For this study, personal and group Self-Q
Interviews were conducted (a) with participants of a SAR HRO (the pilot study), and with an LE
HRO (the actual dissertation study).
[INSERT TABLE I HERE]
The interviews and observations of the intact crew’s interactions took place during the 5-
day LE deployment in August of 1999. These interviews and observations focused on the
development and maintenance of the distributed cognitions in the HRO
collective. These interviews served three objectives: (1) Documenting the characteristics of the
structure of distributed cognitions in an HRO collective; (2) Exploring and evaluating averted
"near misses" or aviation incidents to understand how catastrophes were avoided; and (3)
Developing an ethnographic account of the C130 HRO. The entire data generation and
collection process is summarized by Table 1, Summary of Data Generation Procedures.
Additional sources for the exploration of scenarios of potential near misses as
documented by the Aviation Safety Reporting System (ASRS, 2000) self-reporting database on

33
similar C-130 aircraft, was used to add an institutional context to the everyday activities of
aircrews as well as help with some gray areas in the ethnographic interviews.
Analysis
Table I also demonstrated that data collection and analysis is a qualitative iterative
process that required detailed analysis of all 5 days of cockpit recordings of crew interactions.
The researcher (first author) followed Kennedy’s (1993) thematic analysis based on the
meanings of the labels as determined by semi-structured interviewing and ethnographic
observation (Moerman, 1988).
The output from the CMA computer-based analysis of the Self-Q Interview data
(Bougon, 1974-2005) was used to prepare first the individual and then the congregate three
cognitive maps. Semi-structured group and individual interviews were used to amplify Self-Q
data, collect demographic and past performance and experience information.
Collective cognitive structure emerges when two requirement are met (Weick, 1979;
Kennedy, 1993):
(1) Two similar notions be present in both cognitive maps; and
(2) A double-interact between two participant’s maps.
Double-interacts are essential to establishing interdependence among the participants
(Kennedy, 1993. Interdependency is the term which best describes how “the actions of
participants in different roles and with different responsibilities fit (Kennedy, 1993, p. 166) into
an interlocking role pattern for collective goal action and ultimately collective goal attainment.
Following Weick and Bougon (1986), Kennedy (1993) used three criteria to identify mutual
interdependency among cognitive maps:
Criterion 1. The content of two labels has common relevance for both participants.

34
Criterion 2. The direction of the relationships as indicated by the arrows connecting the
two linking labels is in the same.
Criterion 3. Two or more labels of both participants are casually related to provide what
is required to enable each participant to fulfill mutual role tasks and expectations.
Theme statements which characterize dominant role behavior then emerge as the pattern
of potential independencies are identified. Theme statements for the LW Crew are shown in
Table II.
[INSERT TABLE II HERE]
Finally, Table 3 demonstrates that while a single CCM exists for the LE Crew, at least
twelve (12) variations of that CCM or localized congregations (Local Centralities of the CCM)
emerged as linked by at least twelve congregating actions and three congregating labels which
also happened to institutionalized Coast Guard keywords/phrases.
[INSERT TABLE III HERE]
Assumptions of the Study
The primary assumption of the current study was that collective cognitive structures, that
is, structures of cognitions in a collectivity both exist and influence collective action. This is a
social realist assumption (Archer, 1995). Organizational participants are socialized into these
collective cognitive structures and often take them for granted (Cicourel, 1972; 1981;
Krackhardt, 1987; 1992).; however, and while these cognitive structures as represented by the
congregate cognitive map of the HRO (Bougon, 1992) are not the same thing as tangible what
researchers typically label as organizational structures as manifested by organizational charts and

35
the like, they are real, if not properly understood. Social realism assumes that (1) the world
exists independently of knowledge, (2) that knowledge is fallible and theory-laden, even if it is
idiosyncratic and in the minds of individuals (Hume, 1985), (3) the world is differentiated and
stratified by events, objects and structures which possess emergent powers and that such
mechanisms are ontologically separate and analyzable, (4) that social phenomena are concept-
dependent requiring both explanation and interpretation, that is, that unlike the natural sciences,
social science possesses hermeneutic conditions, (5) that knowledge is linguistic or expressible
linguistically, and (6) social explanation is critical of commonsense understandings of events and
the generalizability of social mechanisms (Archer, 1995) (Sayer, 1984/1992; Layder, 1990;
Danermark, et alli, 1997/2002).
From the social realist perspective, structure and agency are ontologically distinct strata
of reality, each having its own causally efficacious powers and not reducible to each other
(Archer, 1995). These cognitive structures, it was assumed, can be described through
configurations of rules, human resources, and material resources. Further, these knowledge
structures or “typifications” (Schultz, 1964, 1971) can be visually represented via CCMs
(Bougon, 1992). Cognitive interpretive frameworks associated with sensemaking are assumed to
be both produced and reproduced by organizational structures such as leadership, roles, policies
and directives, collective norms (Goffman, 1967; Parsons, 1951; Giddens, 1984; Archer, 1995;
Schwandt, 1997) standards generated by communities of (aviation) practice (Lave, 1988) (Lave
& Wenger, 1991), and member "background expectancies" (Garfinkel, 1967, p. 37).
CCMs encompass collectively stored beliefs, knowledge, and experiences (collective
action domain) that enable and constrain perception, interpretation, and action (Jelinek, Smircich,
& Hirsch, 1983; Giddens, 1984; Gioia, 1986). As such, it was also posited that an HRO’s

36
distributed cognitive or sensemaking abilities, as well as the dynamics of learning and transfer
(Weick, 1993b)(1997), can be captured and analyzed by congregate cognitive mapping (Bougon,
1992; Eden & Ackermann, 1998b). Expanding on the Schultz’ ( 1964, 1971) concept of the
reciprocity of perspective, the heedful interlocking, double-interacts associated with HRRAs
manifested by the CCM is a reciprocity of cognitions (actions) focused on purposeful and
heedful behavior in the high reliability domain.
Finally, the use of language, words, and dialogue offers evidence of the structuring of
cognition and action (Pierce, 1955; Vygotsky, 1997; Riegel, 1973; Sayer, 1992; Layder, 1990;
Weick, 1995; 1996b; 1999 and Pennebaker & Francis, 1999). The cryptic words or labels in the
CCM may point to the “the knowing system” (Pinker, 2000 of organizing for high reliability and
the assembly rules behind the double-interacts which interlock congregant behaviors (Weick,
1969; 1979; Bougon, 1992) may point to the “knowing how system” (Pinker, 2000) of
accomplishing HRRAs. Social constructions of reality as “thought by organizational thinkers”
(Weick, 1979, p. 2) are made possible through structures of cognitions in collectivities that are
recursively created between language and cognition (Riegel, 1973; Cicourel, 1964, 1972; 1981;
Layder, 1990). As such, this sensemaking or RDC can be highlighted through the screening of
linguistic cues for utterances, speech acts or talk tied to specific contexts and action domains
(Cicourel, 1964, 1972; 1981; Predmore, 1991; Bougon, 1992; Symer, 1998). Furthermore, “talk
creates its own logic, turn by turn. At the same time, everyday interaction creates the contexts
and interprets the contingencies out of which next actions spring” (Boden, 1994, p. 215). This is,
in fact, the linguistic organizing of human interaction (Czarniawska (2006) which affords “a
glimpse of the psychic unity of humankind (Pinker, 2000, p. 239). There is a grammar to this

37
organizing, that is a “rule system… which are combinatorial and recursive that allow us to reason
about an unlimited range of cases, often far from our experience (Pinker, 2000, p.285)”.
Delimitations of the Study
The study was delimited to a single HRO, which was specifically examined to investigate
how, that HRO made sense of its daily operational environment. As such, conclusions drawn in
this study are particularistic rather than generalizable (Miles & Huberman, 1994). The purpose is
to explain rather than predict (Sayer, 1992). The primary sources of data were a case study of an
HRO, interviews with the HRO’s participants, observation of these participants, cockpit
recordings of these participants’ on-the-job conversations, and available mishap records
involving similar types of aircraft. The study was also bounded by a discrete five-day time period
and by a unique aviation culture operating within a larger traditional naval organization, the
United States Coast Guard. Finally, the study was conducted by an “insider,” that is, a
researcher whose organizational perspective was informed by a 27-year career in the U.S. Coast
Guard, the same organization that supported the interpretive perspective of natural inquiry in the
current study (Schultz, 1995). The biases of the present researcher are somewhat tempered by
the fact that this researcher is not part of the unique aviator subculture and has never been
formally “indoctrinated” into that subculture.
Limitations of the Study
The study was delimited to U.S. Coast Guard air crewmembers during a routine five-day
LE patrol. To afford a richer understanding of how a unique aviation subculture structures
cognitive capability, an operational C130 aircraft was observed during a routine LE patrol

38
specifically towards eliciting collective cognitive structuring processes. This purposeful
sampling limits the generalizability of the findings, which may not be transferable to commercial
or non-aviation HROs (Sayer, 1984/1992; Eisenhardt, 1989; Miles & Huberman, 1994). The
causal powers of these collective cognitive structures are generalizable only to the extent that the
contexts of these structures are similar as they are necessarily embedded within a cultural context
(Sayer, 1984/1992). And, Lincoln and Guba (1985) claim that no subjective methodology or
interpretation can completely eliminate “misconstruction” and distortion on the part of the
researcher, whether this distortion is “perceptual,” “selective,” or “retrospective” (pp. 298-294).
SIGNIFICANCE OF THE STUDY
The current study has significance from both practical and theoretical perspectives. From
a practical perspective, this study enriches our understanding of how an HRO makes sense of and
collectively avoids potentially disastrous situations. Weick (1993a) stated that the emergence of
collective senselessness (or “absent-mindedness” (Beaty, 1995) or “mindlessness” (Spender,
1998)) is tied to the manner in which a collective is organized and how the meaning frameworks
of the collective’s participants are constructed, sustained, and reproduced. By observing crew
interactional behavior and capturing their thinking and action relationships (CCM) over a five
day period, this study may offer insight into how the fragile networks that often comprise critical,
high-reliability, or otherwise accident-prone organizations can manage failure, enhance
resilience, and detect and avoid disaster.
From a theory of action perspective (Parsons, 1951), in other words, one which
recognizes that resilient HROs “adapt to their environments through changes that emanate from
both performance and learning actions” (Schwandt, 1997, p. 341), the results of this study may
offer insight into the mechanism or structure of cognitions in a collectivity through which an

39
operational and testable construct of RDC for HROs may be pursued. As argued in this paper, we
are pursing a theory of RDC that is linguistic in nature but embedded within a larger theory of
organizational communication (Eisenberg, 2006).

40
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FIGURES AND TABLES
Figure 1, A Congregate Cognitive Map Showing Congregating Labels (CLs) and
Congregating Activities (CAs)

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Figure 2, A Partial CCM drawn to illustrate the layout of the congregating of the SAR Duty
Crew.

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Procedure Description of Activity Data Generated
Phase One
Semi-Structured Group
Interview
Conduct semi-structured interviews of SAR
and LE crewmembers specifically engaging
in discourse about mission role, experiences
and associated stories.
Interview Transcript
Group Format Self-Q
Interview
The Self-Q Interview was used to encourage
the participants to describe their mission role
performance in practice.
Set of Labels for each participant
with respect to performing SAR or
LE
Phase Two
1. Preparation/statement
identification
Analysis of interview transcripts and Self-Q
questions, to prepare a set of declarative
statements about the mission/role
performance of each participant.
For each participant, sets of index
cards, each with a declarative
statement or phrase which reflected
the specific participant’s role
performance.
2. Structured Interview.
Content review, importance
and influence sorting.
During the second Self-Q interview, a
structured sequence of sorts accomplished by
the participant to determine content
comprehensiveness, importance, and
influence rankings of the declarative
statements (the labels).
Ten cryptic "labels", that
are perceived by a participants as
most important in his mission/role
performance with respective to
either the prosecution of SAR or
LE.
3. Completion of MB-
Matrix/Relationship
Questionnaire.
The completion of a participant-specific
questionnaire in which each label (in his
CM) was examined in relation to every other
label in terms of the existence of an influence
link, the direction and magnitude of co
variation, and equivocality. Participants
completed this questionnaire during the
second interview within 1 to 3 days after the
second interview (independently).
After coding (i.e., a strong positive
link = 21, a moderate positive link =
2, no link = 0), an MB-Matrix with
11 rows and 11 columns reflecting
the participant’s perceptions of the
nature of the direct relationships
between the major labels (of his
CM) of interest.
Semi-structured Fifth but non
Self-Q Interview, clarification
of ten most important labels
The coded labels were reviewed with each
participant independently to explore the
meanings of words and phrases behind the
labels and to collect personal experiences and
stories related to mission performance as
well as demographic information.
Interview Transcripts
Phase Three
1. Construction of Participant
Cognitive Maps.
One output file of the CMA analysis program
(Bougon, 1974—2005) was used as input to
the Decision Explorer (DE) Program to
generate graphical displays of cognitive
maps.
Graphical Cause and Influence Maps
for each participant showing labels,
relationships, causality flows,
indegree and outdegree values, and
map shape/organization.
2. Participant Validation of
participant cognitive maps, the
Fourth Self-Q Interview.
Each participant was shown all cognitive
maps of the crew.
Participants correctly identified their
own maps from the collectivity of
maps Participants correctly
identified their own maps from the
full collection of maps.
Table I. Summary of Data Generation Procedures

49
Participant* Theme Statement (Constructed by the Researcher)
P Fly the Plane. Focus on getting the plane to the mission site.
CP Validate the Mission Site. Ensure the plane gets to the right mission site.
FE1 Manage Teamwork. Ensure everyone works together to fly the plane.
FE2 Maintain the Plane. Manage the aircraft endurance.
NAV/RAD1 Anticipate SAR. Search/Scan environment for suspicious activity.
NAV/RAD2 Guide the Plane. Plot the course. Define the location of the plane.
DM Anticipate and for Suspicious Activity.
LM Search/Scan for Suspicious Activity.
BA Learn the Job.
*Participant/Role: Pilot (P), Co-Pilot (CP); Flight Engineer (FE); Navigator/Radio Operator
(NAV/RAD); Drop Master (DM); Load Master (LM); Basic Aircrew (BA).
Table II, LE Crew Theme Statements

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Possible Congregations
*(LCoCCMs)
(Congregate Roles )
Common Relevance
(Frequency of Shared
Label Use)
Possible
Congregating
Actions
(Researcher’s
Interpretation of
Labels Convergence)
Congregating Label
(Official Keywords or
Public Labels used
among
crewmembers)
P/CP/NAVRAD2 location flight planning Flight Phase: Cruise
“Operational Descent
Checklist”
“Search/Patrol
Checklist”
“Presearch/Patrol
Checklist”
P/FE2/NAVRAD1 lodging/supplies sustainment
P/CP/NAVRAD1 weather flying
P/CP/FE1/NAVRAD1/NAVRAD2
/LM/DM
mission scenario mission planning
P/CP/FE1/NAVRAD1/NAVRAD2 a/c (aircraft) readiness a/c performance
monitoring
P/FE1/FE2/NAVRAD2/DM a/c readiness repair operations
P/CP/LM required fuel fuel monitoring
P/NAVRAD2/LM a/c control unit tasking management
CP/NAVRAD2 alternate airports contingency planning
FE1/NAVRAD2/LM crew fatigue safety monitoring
FE1/FE2/NAVRAD1/LM cooperation crew facilitation
NAVRAD2/DM/BA personal learning On-the-Job training
*Local Centrality of the CCM – congregations or participants with labels strongly linked around
specific LCoA (clusters of CAs/Activities/Tasks).
Table 3. Possible Crewmember Congregations (LCoCCMs) Once Common Relevance
(Criterion 1), Causal Directionality (Criterion 2) and Mutual Interdependencies (Criterion
3) are identified.

O&MJournalDraft.MV.April08.1

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