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Cognition, technology and organizational limits: Lessons from the Air France 447 disaster

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Original languageEnglish
Pages (from-to)1-15
Number of pages15
JournalOrganization Science
Volume28
Issue number4
Early online date9 Jun 2017
DOIs
StateE-pub ahead of print - 9 Jun 2017

Abstract

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 safe systems” (Amalberti 2001), 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” (Farjoun and Starbuck 2007; Starbuck and Farjoun 2005) 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.

Research areas

  • managerial and organizational cognition, interpretation and sense making, decision making, complex systems analysis, ambidextrous organizations

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