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

References

• Adams MJ, Tenney YJ, Pew RW (1995) Situation awareness and the cognitive management of complex systems. Human Factors: J. Human Factors Ergonom. Soc. 37(1):85–104.Crossref, Google Scholar
• Alvesson M, Spicer A (2012) A stupidity-based theory of organizations. J. Management Stud. 49(7):1194–1220.Crossref, Google Scholar
• Amalberti R (1998) Automation in aviation: A human factors perspective. Wise JA, Hopkin VD, Garland DJ, eds. Handbook of Aviation Human Factors (CRC Press, Boca Raton, FL), 173–192.Google Scholar
• Amalberti R (2001) The paradoxes of almost totally safe transportation systems. Safety Sci. 37(2–3):109–126.Crossref, Google Scholar
• Ashby WR (1958) Requisite variety and its implications for the control of complex systems. Cybernetica 1(2):83–99.Google Scholar
• Bainbridge L (1983) Ironies of automation. Automatica 19(6):775–779.Crossref, Google Scholar
• Beer S (1981) Brain of the Firm: The Managerial Cybernetics of Organization (J. Wiley, New York).Google Scholar
• Belcastro CM (2012) Loss of control prevention and recovery: Onboard guidance, control, and systems technologies. AIAA Conf. Guidance, Navigation Control (American Institute of Aeronautics and Astronautics, Reston, VA).Crossref, Google Scholar
• Belcastro CM, Groff L, Newman RL, Foster JV, Crider DA, Klyde DH, Huston AM (2014) Preliminary analysis of aircraft loss of control accidents: Worst case precursor combinations and temporal sequencing. Proc. AIAA Guidance Navigation, Control Conf., National Harbor, MD.Crossref, Google Scholar
• Boeing (2016) Statistical summary of commercial jet airplane accidents 1959–2015. Accessed May 31, 2017, http://www.boeing.com/resources/boeingdotcom/company/about_bca/pdf/statsum.pdf.Google Scholar
• Boin A, Schulman P (2008) Assessing NASA’s safety culture: The limits and possibilities of high-reliability theory. Public Admin. Rev. 68(6):1050–1062.Crossref, Google Scholar
• Brooks RL (2010) Loss of control in flight. European Airline Training Sympos., Istanbul.Google Scholar
• Brown AD (2000) Making sense of inquiry sensemaking. J. Management Stud. 37(1):45–75.Crossref, Google Scholar
• Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile (BEA) (2012) Final report on the accident on June 1, 2009, to the Airbus A330-203 registered F-GZCP operated by Air France flight AF447 Rio de Janeiro–Paris. Accessed May 31, 2017, https://www.bea.aero/docspa/2009/f-cp090601.en/pdf/f-cp090601.en.pdf.Google Scholar
• Carr N (2015) The Glass Cage: Where Automation Is Taking Us (Random House, London).Google Scholar
• Child J (1984) Organization: A Guide to Problems and Practice (Sage, London).Crossref, Google Scholar
• Coombs WT (2007) Protecting organization reputations during a crisis: The development and application of situational crisis communication theory. Corporate Reputation Rev. 10(3):163–176.Crossref, Google Scholar
• Dekker S (2012) Just Culture: Balancing Safety and Accountability (Ashgate Publishing, Farnham, UK).Google Scholar
• Dismukes K, Berman BA, Loukopoulos LD (2007) The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents (Ashgate Publishing, Farnham, UK).Google Scholar
• Dunbar RL, Garud R (2009) Distributed knowledge and indeterminate meaning: The case of the Columbia shuttle flight. Organ. Stud. 30(4):397–421.Crossref, Google Scholar
• Endsley MR (1996) Automation and situation awareness. Parasuraman R, Mouloua M, eds. Automation and Human Performance: Theory and Applications (Lawrence Erlbaum, Mahwah, NJ), 163–181.Google Scholar
• Federal Aviation Administration (FAA) (2013) Safety Alert for Operators—Manual Flight Operations (Federal Aviation Administration, Washington, DC).Google Scholar
• Farjoun M (2010) Beyond dualism: Stability and change as a duality. Acad. Management Rev. 35(2):202–225.Crossref, Google Scholar
• Farjoun M, Starbuck WH (2007) Organizing at and beyond the limits. Organ. Stud. 28(4):541–566.Crossref, Google Scholar
• Galbraith JR (1974) Organization design: An information processing view. Interfaces 4(3):28–36.Link, Google Scholar
• Garud R, Dunbar RL, Bartel CA (2011) Dealing with unusual experiences: A narrative perspective on organizational learning. Organ. Sci. 22(3):587–601.Link, Google Scholar
• Grose VL (1988) Coping with boredom in the cockpit before it’s too late. Risk Management 35(8):30–35.Google Scholar
• Harris D (2011) Human Performance on the Flight Deck (Ashgate Publishing, Farnham, UK).Crossref, Google Scholar
• Harris D (2014) Improving aircraft safety. Psychologist 27(2):90–94.Google Scholar
• Haunschild PR, Polidoro F Jr, Chandler D (2015) Organizational oscillation between learning and forgetting: The dual role of serious errors. Organ. Sci. 26(6):1682–1701.Link, Google Scholar
• Holweg M, Oliver N (2016) Crisis, Resilience and Survival: Lessons from the Global Auto Industry (Cambridge University Press, Cambridge, UK).Crossref, Google Scholar
• International Air Transport Association (IATA) (2015) Loss of Control In-Flight Accident Analysis Report, 2010–2014, 1st ed. (International Air Transport Association, Montreal).Google Scholar
• Karasek RA, Jr (1979) Job demands, job decision latitude, and mental strain: Implications for job redesign. Admin. Sci. Quart. 24(2):285–308.Crossref, Google Scholar
• Lawrence PR, Lorsch JW (1986) Organization and Environment: Managing Differentiation and Integration (Irwin, Homewood, IL).Google Scholar
• Lazarus RS, Folkman S (1984) Stress, Appraisal, and Coping (Springer Publishing Company, New York).Google Scholar
• Learmount D (2011) AF447. full.mov. Accessed June 1, 2017, https://www.youtube.com/watch?v=ARybu2kHeZ8.Google Scholar
• Leveson N, Dulac N, Marais K, Carroll J (2009) Moving beyond normal accidents and high reliability organizations: A systems approach to safety in complex systems. Organ. Stud. 30(2–3):227–249.Crossref, Google Scholar
• March JG (1999) The Pursuit of Organizational Intelligence: Decisions and Learning in Organizations (Blackwell Publishers, Hoboken, NJ).Google Scholar
• March JG, Simon HA (1958) Organizations (Wiley, Oxford, UK).Google Scholar
• Mintzberg H (1989) Mintzberg on Management: Inside Our Strange World of Organizations (Simon and Schuster, New York).Google Scholar
• Ocasio W (1997) Towards an attention-based view of the firm. Strategic Management J. 18(Summer):187–206.Crossref, Google Scholar
• Ocasio W (2005) The opacity of risk: Language and the culture of safety in NASA’S space shuttle program. Starbuck W, Farjoun M, eds. Organization at the Limit: Lessons from the Columbia Disaster (Blackwell Publishing, Oxford, UK), 101–121.Google Scholar
• Ocasio W (2011) Attention to attention. Organ. Sci. 22(5):1286–1296.Link, Google Scholar
• Palmer B (2013) Understanding Air France 447 (Publisher: Author).Google Scholar
• Parasuraman R, Wickens CD (2008) Humans: Still vital after all these years of automation. Human Factors: J. Human Factors Ergonom. Soc. 50(3):511–520.Crossref, Google Scholar
• Perrow C (1984) Normal Accidents: Living with High-Risk Technologies (Basic Books, New York).Google Scholar
• Plant KL, Stanton NA (2012) Why did the pilots shut down the wrong engine? Explaining errors in context using schema theory and the perceptual cycle model. Safety Sci. 50(2):300–315.Crossref, Google Scholar
• Reason J (1997) Managing the Risks of Organizational Accidents (Ashgate, Farnham, UK).Google Scholar
• Reason J (2000a) Human error: Models and management. British Medical J. 320(7237):768–770.Crossref, Google Scholar
• Reason J (2000b) Safety paradoxes and safety culture. Injury Control Safety Promotion 7(1):3–14.Crossref, Google Scholar
• Richardson B (1995) Paradox management for crisis avoidance. Management Decision 33(1):5–18.Crossref, Google Scholar
• Roberts KH (1990) Some characteristics of one type of high reliability organization. Organ. Sci. 1(2):160–176.Link, Google Scholar
• Roberts KH, Rousseau DM (1989) Research in nearly failure-free, high-reliability organizations: Having the bubble. Engrg. Management, IEEE Trans. 36(2):132–139.Crossref, Google Scholar
• Rochlin GI (1993) Defining “high reliability” organizations in practice: A taxonomic prologue. Savendy G, ed. New Challenges to Understanding Organizations (Wiley, Oxford, UK), 11–32.Google Scholar
• Rochlin GI (1997) Trapped in the Net: The Unanticipated Consequences of Computerization (Princeton University Press, Princeton, NJ).Google Scholar
• Roe E, Schulman PR (2008) High Reliability Management: Operating on the Edge (Stanford University Press, Palo Alto, CA).Google Scholar
• Rouse WB, Geddes ND, Curry RE (1987) An architecture for intelligent interfaces: Outline of an approach to supporting operators of complex systems. Hum.-Comput. Interact. 3(2):87–122.Crossref, Google Scholar
• Royal Aeronautical Society Flight Operations Group (RASFOG) (2010) Aeroplane Upset Recovery Training, History, Core Concepts and Mitigation (Royal Aeronautical Society, London).Google Scholar
• Sagan SD (1995) Limits of Safety: Organizations, Accidents, and Nuclear Weapons (American Association for the Advancement of Science, Washington, DC).Google Scholar
• Sarter NB, Woods DD, Billings CE (1997) Automation surprises. Savendy G, ed. Handbook of Human Factors and Ergonomics (Wiley, Oxford), 1926–1943.Google Scholar
• Sastry MA (1997) Problems and paradoxes in a model of punctuated organizational change. Admin. Sci. Quart. 42(2):237–275.Crossref, Google Scholar
• Simon HA (1972) Theories of bounded rationality. Decision Organ. 1(1):161–176.Google Scholar
• Simon HA (1982) Models of Bounded Rationality: Empirically Grounded Economic Reason (MIT Press, Cambridge, MA).Google Scholar
• Starbuck W, Farjoun M (2005) Organization at the Limit: Lessons from the Columbia Disaster (Blackwell Publishing, Malden, MA).Google Scholar
• Starbuck W, Stephenson J (2005) Making NASA more effective. Starbuck W, Farjoun M, eds. Organization at the Limit: Lessons from the Columbia Disaster (Blackwell Publishers, Oxford, UK), 309–335.Google Scholar
• Starbuck WH (2009) Perspective-cognitive reactions to rare events: Perceptions, uncertainty, and learning. Organ. Sci. 20(5):925–937.Link, Google Scholar
• Sutcliffe KM, Vogus TJ, Dane E (2016) Mindfulness in organizations: A cross-level review. Annual Rev. Organ. Psych. Organ. Behav. 3(March):55–81.Crossref, Google Scholar
• Syed M (2015) Black Box Thinking: The Surprising Truth About Success (John Murray, London).Google Scholar
• Vaughan D (1997) The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA (University of Chicago Press, Chicago).Crossref, Google Scholar
• Weick KE (1990a) Technology as equivoque: Sensemaking in new technologies. Goodman P, Sproull, eds. Technology and Organizations (Jossey-Bass, San Francisco), 1–44.Google Scholar
• Weick KE (1990b) The vulnerable system: An analysis of the Tenerife air disaster. J. Management 16(3):571–593.Crossref, Google Scholar
• Weick KE (1993) The collapse of sensemaking in organizations—The Mann Gulch disaster. Admin. Sci. Quart. 38(4):628–652.Crossref, Google Scholar
• Weick KE (2005) Making sense of blurred images: Mindful organizing in mission STS-107. Starbuck W, Farjoun M, eds. Organization at the Limit (Blackwell Publishing, Oxford, UK), 159–177.Google Scholar
• Weick KE (2010) Reflections on enacted sensemaking in the Bhopal disaster. J. Management Stud. 47(3):537–550.Crossref, Google Scholar
• Weick KE (2016) 60th Anniversary essay constrained comprehending: The experience of organizational inquiry. Admin. Sci. Quart. 61(3):333–346.Crossref, Google Scholar
• Weick KE, Roberts KH (1993) Collective mind in organizations—Heedful interrelating on flight decks. Admin. Sci. Quart. 38(3): 357–381.Crossref, Google Scholar
• Weick KE, Sutcliffe KM (2007) Managing the Unexpected: Resilient Performance in an Age of Uncertainty (Jossey-Bass, San Francisco).Google Scholar
• Weick KE, Sutcliffe KM, Obstfeld D (1999) Organizing for high reliability: Processes of collective mindfulness. Sutton RI, Staw BM, eds. Research in Organizational Behavior: An Annual Series of Analytical Essays and Critical Reviews, Vol. 21 (JAI Press, Stamford, CT.), 81–123.Google Scholar
• Weiner EL (1989) Human factors of advanced (“glass cockpit”) transport aircraft. Report, NASA, Ames Research Center, Moffett Field, CA.Google Scholar
• Young JP, Fanjoy RO, Suckow MW (2006) Impact of glass cockpit experience on manual flight skills. J. Aviation/Aerospace Education Res. 15(2):27–32.Google Scholar
• Yu T, Sengul M, Lester RH (2008) Misery loves company: The spread of negative impacts resulting from an organizational crisis. Acad. Management Rev. 33(2):452–472.Crossref, Google Scholar