A Report of Working with Unmanned Aerial Vehicles

Safety management within Task Force Uruzgan: A report of working with Unmanned Aerial Vehicles

Matthijs Moorkamp & Eric-Hans Kramer Netherlands Defense Academy, Breda, The Netherlands Coen van Gulijk & Ben Ale Safety Science, Delft University of Technology, The Netherlands

ABSTRACT: In this paper we present a conceptualization of safety management that is based on the cybernetic concepts of “controllability” and “control capacity”. In particular, we explore what this conceptualization means for safety management of the Dutch Army’s UAV unit that was part of Task Force Uruzgan (TFU) in the years 2006–2007 and 2008–2009. In this research we applied a qualitative research strategy. We conducted 20 interviews, 13 with employees of the UAV unit and 7 with key TFU-partners with whom the unit had to cooperate. We analyzed the interviews by means of the concepts developed in the theoretical framework. By going back and forth between theory and practice, we show that it was rather problematic for the unit to develop controllability and operate safely. We conclude with a reflection on a safety management strategy for this particular unit and the relevance of our conceptualization for other organizations.

1 Introduction Unmanned Aerial Vehicles or UAV’s. Within TFU they flew with the Sagem-Sperwer UAV in the Recently, the Dutch Defense organization has periods 2006–2007 and 2008–2009. In this period conducted a comprehensive expeditionary mission the unit conducted three tours within TFU. We aim in Uruzgan, Afghanistan. From 2006 until 2010 to reconstruct 107’s experiences on operating safely Task Force Uruzgan (TFU) was responsible for with UAV’s in TFU’s expeditionary organizational reconstruction and security duties in the Uruzgan network. This paper presents the study in several province. TFU was part of NATO’s ISAF forces. steps. Firstly, we construct a theoretical framework Next to the 1500 Dutch soldiers, the Task Force that aims to depict our perspective on the concept consisted of Australian troops. The Dutch of safety management for organizations such as the government depicted the mission in Uruzgan as military expeditionary organization. Secondly, we a reconstruction mission. However, over the four introduce the methodology that we employed to years of its deployment TFU has engaged in study 107’s experiences. Thirdly we will present our numerous combat activities with opposing parties results and analysis. Fourthly, we will reflect on a in the Uruzgan province. possible safety management strategy and the study’s Although the Dutch Ministry of Defense relevance for organizations with similar challenges. excludes operations that are related to enemy activ- ity from its safety management system (ministry of Defense, 2010), we argue that managing safety of 2 Theoretical Framework operations is particularly relevant for the expeditionary organization. Recent friendly-fire acci- This section will present our theoretical perspective dents highlight this relevance. on the concept of safety management that forms The study reported in this paper is to be regarded a framework for studying the experiences of as a first step in developing an understanding of 107 Aerial Systems battery. safety management in expeditionary conditions. The traditional safety management concept We studied one particular unit within TFU, the is mainly originating from so-called high-risk 107th Aerial Systems battery. This unit is the only organizations (Hale, 2003). These organizations unit within the Dutch MoD that operates with produce or work with hazardous materials such

3127 as in the process industry, mining and utilities. 2.1 Conceptualizing safety management In our interpretation, these traditional high-risk by using the “controllability” concept organizations, however, predominantly operate Operating safely in a dynamically complex envi- in a relative stable operational environment that ronment is problematic because the nature of presents the organization with a fixed set of the mission area is characterized by the presence familiar problems. Consequently, the logic of the of opposing forces. Therefore, the mission area is traditional concept safety management is mostly inherently unsafe. However, fighting that results defined in terms of creating stability. For exam- in wounded or killed Dutch soldiers as a result of ple, Leveson, Marias, Dulac & Caroll (2009) Taliban fire cannot be qualified as a symptom of define ensuring safety (i.e. safety management) unsafe operations; these events are the unfortunate as a control problem. They argue that trying to but inherent results of the specific characteristics achieve safe operations is to be done by creating of the military job. Friendly fire that occurs while sufficient constraints in order to keep behavior fighting the Taliban can be qualified as unsafe of elements between predetermined boundaries operations. That is, the units of a particular mili- (p. 242). tary organization are not meant to interact in such Applying these premises to the expedition- a dysfunctional way. In our interpretation, safety ary organization is problematic for two reasons. management should not be directed at the prob- Firstly, the environment in which the expedi- lems associated with the inherently unsafe char- tionary organization operates can be defined as acteristics of the military job. Instead it should dynamically complex (Kramer, 2007). This means be aimed at the characteristics of the (military) that instead of providing the organization with organization in which unsafe dysfunctional inter- a stable flow of familiar problems, the operating actions take place. environment confronts the expeditionary organi- Christis (1998) distinguishes between definitions zation with a varying flow of unfamiliar problems. that are based on symptoms and definitions that Secondly, for each expeditionary mission, units are based on causal mechanisms. A definition of are selected and assembled from Army, Navy and safety management cannot be based on symptoms Air Force “parent” organizations to contribute to because the absence of a symptom of unsafety is expeditionary organizations (De Waard & Kramer, no reliable indicator for the absence its source, the 2008). Each expeditionary mission requires a spe- risk. Therefore we need to base our definition on a cific combination of functionalities, which leads causal mechanism that connects a source of risks to to expeditionary organizations that differ sub- consequences for safety. De Sitter (2000) provides stantially in organizational layout, tasks and goals. us with such a causal mechanism by explicating Even, within a particular expeditionary organiza- that characteristics of an organization represent an tion, the functional layout of patrol teams some- organization’s source for its successful adaptation times varied per assignment (Kramer, De Waard & to environmental variation. De Graaff, 2012). De Sitter defines the organization as a social Creating safety, in the dynamically complex mis- interaction network. In that network the activities sion area, therefore, cannot be about creating pre- are grouped and coupled, or structured, to determining boundaries of safe behavior because particular workstations such as P in Figure 1. the underlying organizational configurations for In order to match variance in the environment which such boundaries should be defined are con- with variance in the organizational network, the tinuously changing. Consequently, we need to base our definition of safety management on an understanding of organizational control for the dynamic complex environment. Following Ashby (1956), control in highly vari- able (i.e. dynamic complex) environments can be interpreted as: the more options an organization has to come up with varying activities, the better it will be at operating in and adapting to a dynamically complex environment. De Sitter (2000) refers to this ability as “controllability”. The next section will explicate our definition of safety management by means of the concept of controllability. Firstly however, we will elabo- rate on safety because especially for the military expeditionary organization, operating “safely” is rather problematic. Figure 1. De Sitter’s model of interference (2000, p. 82).

3128 workstations of that network are confronted Safety management by using the controllability with requests for interaction that challenges, and concept is therefore defined as creating safety interferes with, the way work is done until that by reducing the structural causal potential for moment. This is referred to as disturbance. disturbance. For absorbing a particular disturbance, the workstations within the organizational network need to possess “control capacity” in order to 3 Methodology develop controllability (De Sitter, 2000). This means that the workstations need to have the In the previous section we conceptualized safety options to solve a particular problem internally or management as the ability of an organization to pass the problem on to other workstations in the develop controllability in its particular operating network that on their turn have to solve the prob- environment. We argued that this ability is charac- lem either internally or externally. De Sitter (2000) terized by the capacities of workstations to absorb therefore distinguishes between internal and exter- disturbance. In this section we will describe how nal control capacity for a particular workstation. this conceptualization is operationalized to study When a disturbance cannot be dealt with on the the experiences of 107 ASbt. basis of internal control capacity, controllability requires coordination with other workstations, 3.1 Research strategy hence employing the workstation’s external control capacity. Depending on the ability of other work- According to Yin (2009), our research strategy stations in the network to deal with the distur- can be defined as a single case embedded strategy, bance, the disturbance might be passed on through which means that although 107 ASbt is our unit of the organizational network. Therefore, a distur- study, the concepts of external control capacity and bance in a particular workstation may eventually disturbance widen our perspective to other units result in organizational behavior that threatens the within the Task Force. Recognizing this means coherence of the organizational network. that our analysis will be able to shift organizational Consequently, De Sitter defines the following levels—or system boundaries—in order to explain causal mechanism: the more the workstations in the controllability issues of 107 ASbt. a particular organizational network possess con- We conducted 20 “open” interviews. 13 trol capacity, the more the network will be able to with employees of 107 ASbt and 7 with key absorb disturbances and attain controllability in its TFU-partners, such as an Apache pilot, air traf- environment. fic controllers and a commanding officer of TFU. The way in which activities are grouped and cou- These interviewees ranged between the opera- pled in the organization’s structural design, influ- tors at the “sharp end” of the unit and the com- ences the amount of internal and external control manding officer at the “blunt end” of the units. capacity of its workstations (De Sitter, 2000). For The military ranks the interviewees hold ranges example, designs with a high degree of functional between Sergeant for the operators of the UAV specialization and differentiation of operational and Major General for a commanding officer of and control functions, such as bureaucracies, are the Task Force. The interviews were “open” to the prone to have little internal and external control degree that the employees could talk freely about capacity within workstations. Bureaucratic struc- their work in Afghanistan. However, the reason we tural designs, therefore, predominantly rely on placed open between quotation marks is that our environmental stability to avoid disturbance and theoretical premises on safety management guided remain controllable. the interviews. That is, the interviews were steered This implies that there are better and worse in the direction of getting information on the con- ways to designing a structure that can cope with cepts we introduced in the previous section. This environmental variation in a controllable manner. resulted in an interview process that, along the way, However, although structure influences control came to a “saturated” understanding of the con- capacity and control capacity influences the pos- trollability issues of the particular unit of study, sibility for solving disturbances, it depends on the 107 ASbt. That is, we continued our interviews particular structural characteristics of the organi- until the point that we did not find any new issues. zation, the specific environmental circumstances at a certain point in time and sheer chance whether 3.2 Methodological premises an unsolved disturbance will result in an accident at a particular workstation or the network. Con- The methodology that we applied in this study can sequently, by building on work by Christis (1998), be described as “systematic combining” (Dubois & we argue that an organization’s structural design Gadde, 2002). This methodology: “builds more on possesses a causal safety potential. refinement of existing theories than on inventing

3129 new ones. One major difference, as compared with This means that claims made are internally valid both deductive and inductive studies, is the role of only when it regards normative claims with respect the framework. In studies relying on abduction, the to the causal mechanism explicated in our theoreti- original framework is successively modified, partly cal framework in relation to the particular unit of as a result of unanticipated empirical findings, but study during the particular periods in which the also of theoretical insights gained during the proc- interviewees developed their experiences. With ess. This approach creates fruitful cross-fertilization regard to generalizability, we claim limited external where new combinations are developed through a validity in this paper. The findings with regard to mixture of established theoretical models and new specific problems of the UAV unit are, quite under- concepts derived from the confrontation with real- standably, not generalizable beyond the UAV unit. ity.” (Dubois & Gadde, 2002, p. 559). However, we will conclude our paper with some This type of qualitative research can be charac- remarks on the potential similarity of safety man- terized by a number of research steps: exploration, agement issues within organizations that are con- specification, reduction and integration (Wester & fronted with adjusting to a dynamically complex Peters, 2004). The goal of this paper is not to report environment. on this entire process that, by following Dubois & Gadde’s proposed methodology, may result in the 3.4 Data analysis development of a formal theory on safety management. In this paper we will report on the exploration To develop an understanding of the controllability and specification phase. This means that in this study, issues and the unit’s control capacity we analyzed the “cross-fertilization” between empirical findings the interviews by means of creating categories. and theoretical constructs is emphasized by the fact These categories were identified using the phrase: that we are not particularly interested in “all” experi- “dealing with …”. Consequently the analysis ences of the unit, we are interested in a specific part resulted in categories that show how the unit dealt of the everyday experiences of 107 ASbt. That is, we with a particular problem. The phrase was chosen wanted to explore what, between the limits of our because “dealing with” implicates both a problem conceptual framework, safety management means and a solution. The problems were subsequently within the UAV unit. In particular we are interested interpreted as disturbances and the solutions were in disturbances and how these are absorbed at the interpreted as attempts to use either internal or operational level by means of the unit’s internal and external control capacity. external control capacity. As stated above, the analysis reported in this paper consists of two stages, the exploration and specification phase. The exploration phase con- 3.3 Reliability and validity sisted of analyzing the interviews and identifying Our research strategy has implications for the reli- the variety of problems every interviewee had to ability and validity of claims that we are able to deal with in their work. These problems resulted in make. Reliability, according to Yin (2009), refers categories that were subsequently listed in the data- to the possibilities to do the same case over again base. This procedure resulted in a list of 45 catego- and find similar results. In our case, reliability is ries. Due to space constraints, the categories from established in two ways. Firstly by explicating the the exploration phase are not listed in this paper. theoretical premises with which we conducted the A list can be requested for review by contacting the interviews. Secondly, according to Yin, document- first author. ing as many research steps as possible enhances In the specification phase, the categories were reliability. In order to ensure this criterion we analyzed on their commonality. That is, some cat- recorded every interview on a tape. Subsequently egories can be identified as sub-categories of an we transcribed the interviews word-by-word. Also, overarching “dealing with” category. For example, during the process of analysis these transcriptions dealing with a new communication device is the were used to categorize the interviews is a “case logical result of dealing with new airspace users. In study database”. This database contains all catego- line with the methodology of systematic combin- ries and accompanying pieces of text originating ing, identifying these “overarching categories” was from the transcriptions. done by going back and forth between our theo- Validity, according to Yin refers to the possi- retical framework and the interview data. After bilities to establish whether the causal claims made all, we were interested in not all, but particular are “correct” (internal validity) and whether the problems. The categories are presented in the next findings are generalizable beyond the actual unit section of this paper. It should be noted, however, of study (external validity). Our study aims to that the analysis of this study is still in progress, the ensure internal validity by explicating the causal results and analysis therefore are to be interpreted mechanism by which the analysis is conducted. as preliminary.

3130 4 Results determine whether the aircraft has to go to maintenance or only needs preparation for the next This section will present the categories that we iden- launch and flight. The whole process is directed by tified as disturbances that 107 attempted to solve the unit’s administrative office. in order to continue flying safely within TFU. Firstly, however, we will present a schematic 4.1 Dealing with new assignments overview of 107’s activities and its organizational structure in Uruzgan. Also, we will give a brief All interviewees of 107 mentioned the problem description of the activities at 107’s workstations. of dealing with new assignments. They reported In the sequence of getting an UAV in the air, the that their assignments differed substantially from activities are depicted schematically in Figure 2. the assignments they used to conduct in training Figure 3 shows 107 ASbt’s organizational struc- and exercises. They pointed out that the unit was ture in which the activities are linked to particu- used to train isolated from other military units. lar workstations. To be able to contribute to TFU After arriving in Uruzgan in both 2006 and 2008, with a flying UAV, the UAV has to be maintained the unit was confronted with the other members according to strict aviation rules. These rules deter- of TFU. Initially, these other members did not mine how the maintenance crew carries a partic- have the experience of operating with a UAV. This ular maintenance job. Next, the assembly crew resulted in an extensive “familiarization” effort. prepares the aircraft for flight by filling the aircraft Representatives of 107 ASbt presented themselves with fuel and carrying out pre-flight checks. After to other TFU units and TFU staff members to that, the aircraft is put on a launching device and explicate both what the UAV could do for them and the launching crew has—among other things—to what the limits of the UAV’s capabilities were. In make sure the aircraft is launched with a certain 2008, this resulted in an explosion of assignments, velocity. After that, the operating crew in a Ground ranging from patrolling routes, mapping domestic Control Station navigates the aircraft during its areas and patterns of civilian life to reconnaissance operations. When the assignment is complete, the missions for the Dutch Apaches. UAV lands by using its parachute and airbags. The The explosion of assignments resulted in transport crew then moves to the recovery site to disturbance within and between most worksta- bring the UAV back to the base. When returning tions of the unit. Operators had to change their from a particular assignment, post-flight checks work hours substantially and preparation and

Figure 2. Activities of 107 Aerial Systems battery.

Figure 3. 107 ASbt’s organizational structure in Uruzgan.

3131 maintenance were stressing to get UAV’s ready in such as the navigators, the flight safety officer and time for launch in order to fly a next mission. The the LSO, were reporting difficulties in dealing with unit was truly working on, or sometimes beyond, these aircrafts. Flying in Uruzgan meant dealing its operational limits. This was expressed in the way with other aircraft and finding a way to not collide, employees sought to find solutions both internally or conflict, with them. Three major problems, or and externally. In terms of internal control capac- disturbances, were identified on this aspect: dealing ity, the unit aimed at doing “everything according with see-and-avoid, dealing with the air traffic con- to the rules”. However, these rules were created in trol tower and dealing with the difference between the isolated training situation and were character- operating with other TFU assets and operating ized by functionally specialized workstations and “on your own”. accompanying coordination procedures. During The UAV was tasked for two broad categories the terms of their tours in Uruzgan, the unit found of assignments, assignments that were the result ways to shortcut some of the procedures in order of immediate contact of ground troops with the to solve problems more quickly. For example, enemy (troops in contact, or TIC) and assignments maintenance personnel were known to accompany for which the UAV flew on its own to gather intelli- operators during their flight in order to detect gence. In the case of TIC, the UAV was part of a fire defects in an early stage instead of following the support chain, which is an organizational coordina- formal sequence of activities coordinated by the tion instrument that is developed to prevent friendly administrative office. troops from firing at each other. The fire support The units Liaison Officer (LSO) was a key player chain connects different parts of the Task Force such when it comes to external control capacity. Every as the Artillery, F16’s and ground troops. Through assignment had to be handled by the LSO who this chain, units are enabled to “de-conflict”: to on his turn took the assignment to the unit. With keep every unit informed on the whereabouts of regard to the amount of assignments, the interview- other units. For intelligence assignments, the main ees reported a substantial difference between 2006 way of de-conflicting with other units was to com- and 2008. In 2006, the LSO was known to filter- municate with the air traffic control tower. “TK out many assignments, which created some relief tower” controlled a range of 10 kilometers around for the unit. In 2008, the LSO had the intention to the airfield and was a key player in informing and fly the UAV’s as much as possible because the TFU directing aircraft in order to prevent collision. Ini- units were reporting that the UAV had become an tially 107 was not familiar with these de-confliction asset in their operations that they could not miss. procedures. Numerous existing ways of working Our interviewees reported that adjusting 107’s such as Local Operating Procedures and all kinds activities to the demands of working in TFU of checklists and communication skills had to be resulted in conflicts between maintenance, opera- changed which can be interpreted as 107 employing tions and the LSO. Also, adjusting the supply of its internal control capacity. spare parts to local demands resulted in shortage Next to the measures of de-confliction, military of some vital parts. For example, parachutes had aircraft are extensively trained to use the principle to be “recycled” multiple times beyond specified of see-and-avoid to prevent collision. In Uruzgan, maintenance intervals, which resulted in increasing this meant that seeing each other and taking sub- accumulation of sand and dust in these parachutes. sequent avoidance actions was used frequently This caused damage to the aircraft during landing when aircraft were tasked to the same piece of air- because these parachutes had a decreasing ability space. However, due to the technical characteris- to slow the aircraft’s landing velocity sufficiently. tics of the Sperwer UAV, the operator was not able This shows a failure to absorb a disturbance both to “see” around the aircraft. The problem of not internally within 107 and externally by coordinat- being able to “see” had consequences for the way ing with other units in the TFU network, which led the unit dealt with the problem of de-confliction. to safety issues within 107. During the interviews it became clear that for ad- hoc operations, such as in case of a TIC, the UAV was flying “blind” and relied heavily on its external 4.2 Dealing with airspace users control capacity: on the ability other aircraft to Next to 107’s UAV, Dutch Apaches and an Australian keep clear of the UAV. UAV were at TFU’s disposal. Also, Afghani, It took some time for the 107 to develop an American and commercial Russian airplanes were understanding of the de-confliction measures and flying in and out of Tarin Kowt (TK) airfield. procedures in TFU’s military aviation. During this Our interviewees reported that during training, process of “finding out”, our interviewees reported 107 never had to deal with other aircrafts because that two near misses had occurred: one while flying the exercise airspace was (and is) closed off for all with two Dutch Apaches and one while launching other aircraft traffic. The operational employees with an incoming transport helicopter.

3132 The near misses show that a disturbance within disturbance of the TFU network that manifests in 107 was not solved internally or externally, which uncontrolled and unsafe behavior of 107. subsequently led to disturbance of the TFU network. Fortunately, these disturbances did not 4.4 Dealing with constantly changing personnel manifest as an accident, however, near misses can be interpreted as a similarly dysfunctional interac- During their deployment in Uruzgan the inter- tion because only sheer luck seems to distinguish a viewees reported that the TFU-units with which near-miss from an accident. they had to cooperate changed frequently and rather independently from each other. This meant that 107 ASbt had to cooperate with a number 4.3 Dealing with physical environmental of different infantry battalions, Apache detach- circumstances ments, control tower personnel, TFU-staff and Operating in Uruzgan also meant an entirely dif- reconnaissance units. Also, the unit rotated inter- ferent operating area regarding the weather, height nally because the period for which 107 ASbt was above mean sea level and local air density. assigned to TFU entitles individual soldiers to The interviewees reported that these circum- some holiday time. This meant that these soldiers stances particularly implicated maintenance, were sent back home for three weeks. During that launching and flying activities of the unit. For time they had to be replaced or tasks had to be car- example, due to temperature and the height above ried out by somebody else. mean sea level air density was significantly lower These internal and external rotations challenged when compared to circumstances during training. the unit’s internal and external control capacity. This had implications for the “lift” characteris- The interviewees reported that again and again they tics of the UAV, lower air density means less lift. were confronted with TFU-units that were unfa- Therefore the unit had to figure out how these miliar with working with a UAV. Again and again, lift characteristics might be improved. They had the unit had to restart its familiarization process to “experiment” with the weight, fuel load and with these other parties within TFU. Being unfa- launching velocity of the UAV until satisfactory miliar with the UAV also meant that these TFU- results were reached. units were unfamiliar with its possibilities and its Also, temperatures in Uruzgan were significantly limitations. At the one hand, this led to assign- higher during the summer period when compared ments that the UAV was incapable of conducting, to training circumstances. Higher temperature has such as determining the depth of certain rivers or an effect on the UAV’s lift characteristics but it also scouting for a red pickup truck while the UAV was meant that the engine of the UAV ran hot more only equipped with a black-and-white camera. On quickly when idling during the launch procedure. the other hand, this led to assignments that were Therefore, a short launch time window bound the challenging the UAV’s technical limits, such as fly- unit during daytime operations. Experimenting and ing with fog, ice and during daytime. Also, it was changing the units launch procedures are examples reported that unfamiliarity led to problems of of the unit using its internal control capacity. TFU-units in understanding a “no” from 107 at a However, the unit also tried to solve these prob- particular request for assignments. These rotation lems by using its external control capacity. For issues decrease 107’s external control capacity and example, the unit’s LSO limited operations to the increases internal disturbance due to increasing morning and evening, when temperatures were amount of operations that have to be conducted. lower. Also, the unit informed the air traffic con- Also, the interviewees reported that rotating inter- trol tower of its problems with the overheating nally sometimes led to “doing more than one job”. engine. They told the tower that when the UAV was Individual rotations were accompanied by a period idling on the launcher, it had to be launched within of two weeks of handing over the job to another ten minutes. The tower was then requested to keep person. Because soldiers rotated frequently, these the local airspace clear of other airplanes for that “hand over-take over” processes were constantly particular timeframe. This solution however was present. Subsequently these internal rotation issues prone to miscommunication between 107 and the led to fewer available resources for the particular tower: 107 and the tower used the word “within” in job one was supposed to do and therefore impacts an entirely different manner. In the perspective of the internal control capacity of the unit. the tower, “within” meant: exactly over 10 minutes whereas 107 were under the impression they could use the entire 10-minute timeframe for launching. 5 Conclusion This resulted in unexpected launches of the UAV from the perspective of the tower. This, again, Based on the analysis in the previous section and shows that a disturbance within 107 may result in the causal mechanism presented in our theoretical

3133 framework, this section will present the conclusions projects, sometimes referred to as “mega-projects” with regard to safety management for 107 ASbt. (Flyvbjerg, Bruzelius & Rothengatter, 2003). The Also we will highlight the potential relevance of assembly of a temporary project organization from our study for other organizations. one or more stationary (i.e. stable) “parent” organi- The results and analysis showed that ASbt zations characterizes most of these temporary was prone to disturbance and had problems to project organizations (Modig, 2007). solve these either internally or externally, which It can be interpreted that these temporary challenged safety within both 107 and the TFU “project” organizations and their “parent” organi- network. zations are also faced with the problem of operat- In order to provide a statement on how these ing safely while adapting to variation in a dynamic safety problems might be improved (i.e. managed) complex environment. Consequently they also we turn to the mechanism provided in our theoreti- might be facing similar structural safety issues. cal framework, the potential of an organization’s structural design to be the source of successful adaptation and safety in a dynamic complex environment. References We conclude that safety management of Ashby, W.R. (1956). An introduction to cybernetics 107 involves structural design at three different (Vol. 80). London: Taylor & Francis. organizational levels: that of 107 ASbt, the expe- Christis, J. (1998). Arbeid, Organisatie en Stress. Een visie ditionary organization, and the Army “parent” vanuit de sociotechnische arbeids-en Organisatiekunde. organization. Our interviewees emphasized multiple Apeldoorn: Het Spinhuis. times that they were trained to operate in isolation De Sitter, L. (2000). Synergetisch produceren: Human with a sealed-off piece of airspace and few assign- Resources Mobilisation in de produktieeen inleiding ments. From this we infer that the way activities in structuurbouw. Assen: Van Gorcum. were grouped and coupled in 107’s organizational Dubois, A., & Gadde, L.E. (2002). Systematic combining: structure was most likely designed for environmental an abductive approach to case research. Journal of Business research, 55(7), 553–560. stability. The problems with regard to internal con- Flyvbjerg, B., Bruzelius, N., & Rothengatter, W. (2003). trol capacity can be interpreted as the logical con- egaprojects and risk: An anatomy of ambition: sequence of transplanting a similar organizational Cambridge University Press. structure to a dynamically complex environment. Hale, A. (2003). Safety management in production. With regard to the problems with 107’s external Human Factors and Ergonomics in Manufacturing & control capacity, it became clear that the differ- Service Industries, 13(3), 185–201. ent units within TFU had different time limits for Kramer, E.H. (2007). 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Hence, these issues might provide an argument Moving beyond normal accidents and high reliability for studying both the “mixing and matching” organizations: a systems approach to safety in complex systems. Organization Studies, 30(23), 227. (De Waard & Kramer, 2008) design philosophy Ministry of Defense. (2010).Veiligheidsmanagement bij behind the expeditionary organization’s structural defensie: een blauwdruk voor belegging en veranker- design and design of the Army’s “parent” struc- ing (in Dutch). ture in order to provide 107 with improved external Modig, N. (2007). A continuum of organizations formed control capacity. to carry out projects: Temporary and stationary Lastly, we address the relevance of our study for organization forms. International Journal of Project other organizations. We argue that our framework Management, 25(8), 807–814. may also be applied to organizations facing a Waard, E.J. de, & Kramer, E.H. (2008). Tailored task similar challenge as the Dutch MoD. 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