Air France 447 (AF447) was lost over the Atlantic in 2009 when, following a brief and transitory loss of speed indications, the crew lost control of the aircraft. Communication and coordination in the cockpit broke down and the crew was unable to comprehend what was happening in time to recover the situation. We analyze events in the final hour of the flight, observing many of the classic symptoms of a collapse of sensemaking. We note that AF447 is classified as a loss of control incident, currently the single biggest cause of airline fatalities. Within the aviation community, loss of control events have been partly attributed to a lack of manual flying and limited exposure of pilots to unusual aircraft behavior as a consequence of flight deck automation. We combine ideas from the literatures on sensemaking, automation and organizational limits to develop a conceptual model that links the ability of actors to make sense of unusual situations to the potentially insulating effect of automation and lack of exposure to situations that are close to, or beyond, normal limits. We argue that our findings help understand how the sensemaking capabilities of actors who oversee complex systems may be developed and maintained. We highlight the importance of two factors to sensemaking capability, namely a) experiences beyond normal limits and b) close, ongoing, active engagement between actors and the systems that they control.
|Publication status||Published - 5 Aug 2016|
|Event||Academy of Management Conference - Anaheim, United States|
Duration: 5 Aug 2016 → 9 Aug 2016
|Conference||Academy of Management Conference|
|Period||5/08/16 → 9/08/16|
- organizational limits