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On 23 June 1998, the Norwegian national football team played a World Cup match in Marseille against multiple-times world champions Brazil. Only a win would be enough to secure further participation in the tournament for Norway. With 15 minutes to go, the match was scoreless. The Norwegian coach, Egil Olsen, decided to make a substitution. He wanted to bring on Egil Østenstad, the fastest player in the team, to make runs in the space behind the tired Brazilian defenders. After 78 minutes, Østenstad stood on the sideline with his tracksuit off, ready to enter the game. Then Brazil scored, and Norway suddenly needed to score two goals to remain in the tournament. Coach Olsen was still intent on bringing Østenstad on, despite the dramatic change in circumstances. The Brazilians would now most likely retreat further back on the pitch, leaving less space for Østenstad to make fast runs behind them. Even so, it looked like the planned substitution would go ahead.

Suddenly, one of the Norwegian substitutes shouted, “You should bring on Jostein Flo now.” Coach Olsen listened and realised the wisdom in that advice. At the last moment, he changed his mind and brought on the slower but taller forward Flo instead of Østenstad. Norway could now hit high and long balls for Flo to head on to teammates. Flo turned out to make a significant contribution in the final minutes of the match, when Norway scored the two goals they needed to beat Brazil.

Critical quality moments are situations where the communication climate in an organisation is put to the test (Kvalnes 2017, 2022). The next event to happen will affect whether the outcome will be good or bad. On a June evening in Marseille, Coach Olsen and his team experienced a critical quality moment. He was about to make the wrong tactical move by bringing on Østenstad. Olsen was known to be a meticulous tactical planner but also to be slow in responding to sudden disruptions and changes in matches. This time he was saved by a quick thinker on the bench. The substitute was Ståle Solbakken, who has gone on to become a merited football coach and is currently (i.e., in 2022) the national coach of Norway. His initiative changed the course of events and paved the way for a win. Had he remained silent, Brazil likely would have won the match. Olsen showed exemplary leadership in listening to the substitute and following his advice. In retrospect, he also praised Solbakken for his intervention and gave him the full credit for the sudden change of plan.

Critical quality moments can occur in a range of organisational settings. They take place when individuals within the organisation face a situation where they must decide whether to speak up or remain silent. The junior doctor Ida in the previous chapter was the central actor in a critical quality moment. She had important reflections to convey to her colleagues at work, input that was likely to improve patient safety at the hospital. Ida could have held back due to a fear of repercussions or doubts about how it would affect her career. This was a critical quality moment in the common history of the surgical and medical units at the hospital, and one that led to a significant breakthrough in their patient services.

A senior engineer told me about the critical quality moments that can occur in the projects in his organisation, which constructs bridges and other installations for traffic infrastructure. The safety of travellers depends on high-quality groundwork and execution from the organisation. In one instance, they were preparing the final drawings and specifications for a bridge leading traffic over a wide river. Everything looked fine, and the senior engineer was ready to send the material to the production unit. In a meeting with 15 colleagues, he laid out the calculations and drawings one final time to obtain confirmation that it was safe to bring the project forward. Most people around the table nodded and seemed satisfied with what they saw, but one newcomer had doubts and asked questions about a specific part of the construction. Is that part sufficiently robust to hold the pressure from heavy vehicles? The rest of the team now inspected that detail in the plan and realised simultaneously that the answer to the newcomer’s question was no. They had overlooked a significant weakness in one part of the construction. On closer inspection, it was clear that the bridge would hold only 26% of the weight of expected traffic and would have collapsed under the pressure from a heavy vehicle. The specifications had to be revised before production could proceed.

A debrief showed that one engineer had made a calculation mistake during the planning. It had gone unnoticed by his colleagues. This was an experienced and trusted professional, with a history of being correct. Why had his colleagues not spotted the mistake earlier? This was a group with a high level of psychological safety, so it seemed that fear of repercussions for speaking up was not the issue. So how could the mistake go undetected for so long?

Reason’s (1990) barrier model can shed some light on events such as these. It distinguishes between

  • a mistake that sets a causal chain of events in motion;

  • barriers to stop that chain of events from continuing; and

  • the negative outcome that occurs if the barriers fail.

Humans are fallible beings, so mistakes will happen, no matter how experienced or well-trained people are. We thus depend on barriers to detect mistakes and stop them from causing harm. The communication climate in an organisation is normally a crucial part of the barrier system. Technological features may also be in place to stop a chain of events from causing harm. For example, an alarm might go off whenever someone has forgotten to close the door or regulate the heat properly. However, human intervention in the shape of speaking up and using one’s voice to draw attention to a mistake will often be the most important barrier component.

Solbakken performed important barrier work in the events that unfolded in the football match in Marseille. Coach Olsen had decided to bring on Østenstad, who was not the optional substitution under the circumstances. Solbakken intervened and stopped that chain of events from continuing.

One common mistake in the evaluation of barrier quality is to think that the more individuals who are involved in critical scrutiny of the processes, the better. This turned out to be a key factor in the bridge example and the reason no one identified the mistake earlier. In the engineering organisation, they were highly conscious of human fallibility and adhered to Reason’s barrier framework. Fifteen engineers were supposed to keep a critical eye on the processes and speak up when they spotted irregularities or weaknesses. The idea was that by mobilising so many skilful people to do barrier work, a mistake would be noticed. However, what appears to have happened was that the high number of individuals involved weakened rather than strengthened the barrier system. One by one, each of the 15 were able to think that he or she was very busy, but that fortunately 14 other colleagues would keep an eye on the processes. When everyone in a group thinks like that, no one takes proper barrier responsibility.

The number of people in the barrier system also caused trouble in a critical quality moment for an organisation investing money in developing countries. Hackers had infiltrated their system and had managed to steer 100,000,000 NOK to their bank account, rather than to the designated account of another company in a different country. In this case, five people were supposed to scrutinise payment documents critically ahead of the transaction. In this case, a high level of psychological safety was also in place. The employees had no reason to expect repercussions if they raised a critical concern. They would be worse off not voicing a concern when in retrospect they should have done so. Each of the five people involved seems to have thought, “I am very busy, but four others will look closely at the documentation, so everything will be fine.” This mentality meant none of the five studied the facts and figures carefully enough to detect the red flags that could have alerted them to the fraud.

With shared responsibility for speaking up comes the danger of passivity due to bystander effects. Bystanders tend to make what philosopher Parfit (1984) called a “mistake in moral mathematics.” Five people who all have a responsibility for monitoring a particular process can each mistakenly believe that in this setup they only have one-fifth of the responsibility. They count the number of people involved and treat responsibility as one unit that can be spread evenly and fairly among them. The higher the number of people, the less individual responsibility exists. This is a flawed way of thinking about responsibility, but it often occurs in a group setting. We will discuss it more closely in the next chapter, which is dedicated to bystander effects and how group thinking can cause passivity and weaken barriers.

In organisational settings, it makes sense to identify critical quality moments in advance and collectively decide upon a way to cope with them. Consider the following situation that can occur in a concert hall.

The choir is on the podium, ready to sing Mozart’s Requiem. The conductor enters the stage and appreciates the applause from the audience. He turns to the singers and provides them with the tone from which they are supposed to start. It is the wrong tone, too deep. Unease spreads among the singers. The conductor is unaware of his mistake. Will any of the singers take an initiative to correct him?

A musicologist and conductor explained that this kind of situation occurs very rarely, but is every conductor’s nightmare (Kvalnes 2017):

A performance of Mozart’s Requiem is all about collective precision. The choir and their conductor have spent hundreds of hours practicing together to get the details exactly right. They are supposed to breathe, move, and sing together as one entity. The conductor needs to be sensitive to what happens among the choir members and should be able to note signs among them that something is wrong. When that does not happen, it can create a musical crisis.

How should the singers respond in such cases? The conductor may be reluctant to bring up the possibility at all because it may weaken his or her authority. It should never happen, but can do so, even with the most experienced conductors.

Authority can also be under threat in critical quality moments in aviation. The situation can be one where a senior employee commits a mistake, witnessed by a junior employee who is in a position to intervene.

The pilot is about to taxi the airplane out on the runway, although the copilot believes that he has not received the clearance signal from the control tower to do so. He can express his concern to the pilot or remain silent. The pilot is the most experienced and highly regarded professional in the company, so perhaps they have received a clearance signal from the tower after all. It would be embarrassing to sound a false alarm. What should the copilot do?

In aviation, the message is that the copilot should voice his or her concern, even if he or she may have misinterpreted the situation. When in doubt, speak up. That is the core norm drilled into the staff working together to create safety in this area. The description above was the situation at Tenerife airport on 27 March 1977, when two Boing 747 jets collided on the runway and 583 people died. The copilot was concerned and tried to hint that the signal to enter the runway had not come. It was a wakeup call for international aviation and led to systematic and sustained efforts to strengthen communication climate (Weick 1990; Stoop and Kahan 2005).

The critical quality moments outlined so far have each been about the possibility of harm and negative outcomes. Another set of such moments occurs when an opportunity exists to do good by speaking up. A vocal initiative in this instance can generate pride, joy, and higher motivation, whereas silence can have the opposite effect. A team of colleagues has just done a tremendous job in manoeuvring the organisation out of a difficult situation. A meeting immediately after the achievement seems the time to appreciate that effort because everyone is present and can take in the praise.

Normally, the leader of the unit is the one who should take the opportunity to thank the colleague and express gratitude. What if the leader is not in the habit of doing so? Should another member of the group step forward and do it instead? Whether the meeting ends in silence or with applause for the effort can make a significant difference to the motivation and further efforts in the group, not only from the colleagues who have shone this time but to others who will witness how efforts of this kind are appreciated, or not. Celebrating efforts and wins can energise the whole group (Dutton 2003; Amabile and Kramer 2011). The critical quality moment for doing so is now, and it may last for five seconds and be gone.

One final observation regarding critical quality moments is that the optimal way to respond can be to do nothing. Action bias, an irrational preference for doing something over doing nothing, is a phenomenon noted in a range of contexts (Patt and Zeckhauser 2000; Bar-Eli et al. 2007; Paukku and Välikangas 2021). Action bias can occur both on an outcome level (i.e., people tend to consider an outcome of action to be more positive than the same outcome brought about through inaction) and on an intention level (i.e., people tend to consider an action to be more purposeful and intentional than inaction (Sunderrajan and Albarracín 2021). In a communication context, action bias leads us to think that speaking up is preferable to remaining silent. As Edmondson and Besieux (2021) noted, the voice option can be less productive than saying nothing. People’s tendency to speak up rather than remain silent—to detrimental effect—in critical quality moments can be a feature of the communication climate in organisations. A critical quality moment can be one where a junior employee attempts to find a solution to a challenge at work, and a senior employee can choose between intervening to explain how to move forward or remain silent and let the other figure out what to do. In a communication climate favouring voice over silence, the senior is likely to speak up and spoil the opportunity for the junior to master the situation and learn.

The main purpose of this chapter has been to introduce the concept of critical quality moments as a label for situations where the communication climate in an organisation is put to the test. In a critical quality moment, the next event to happen will critically affect the quality of the delivery from the group or organisation. People may have assumptions about how well functioning the communication climate is and the likelihood that someone will address an issue. Whether they are right in their assumptions can be exposed in critical quality moments, which may come and pass, with or without a significant vocal intervention.