Cognition, Technology, and Organizational Limits: Lessons from the Air France 447 Disaster

• 成果类型: Article
• 署名作者: Oliver, Nick; Calvard, Thomas; Potocnik, Kristina
• 署名单位: University of Edinburgh
• 刊物名称: ORGANIZATION SCIENCE
• ISSN/ISSBN: 1047-7039
• DOI: 10.1287/orsc.2017.1138
• 发表日期: 2017
• 页码: 729-743
• 关键词: managerial and organizational cognition; interpretation and sense making; decision making; complex systems analysis; ambidextrous organizations

摘要

Organizations, particularly those for whom safety and reliability are crucial, develop routines to protect them from failure. But even highly reliable organizations are not immune to disaster and prolonged periods of safe operation are punctuated by occasional catastrophes. Scholars of safety science label this the paradox of almost totally safesystems, noting that systems that are very safe under normal conditions may be vulnerable under unusual ones. In this paper, we explain, develop, and apply the concept of organizational limits to this puzzle through an analysis of the loss of Air France 447. We show that an initial, relatively minor limit violation set in train a cascade of human and technological limit violations, with catastrophic consequences. Focusing on cockpit automation, we argue that the same measures that make a system safe and predictable may introduce restrictions on cognition, which over time, inhibit or erode the disturbance-handling capability of the actors involved. We also note limits to cognition in system design processes that make it difficult to foresee complex interactions. We discuss the implications of our findings for predictability and control in contexts beyond aviation and ways in which these problems might be addressed.