System Effects, Failure, and Repair: Two Cases

Abstract

This paper argues for the importance of studying the systemic causes of organization failures. Taking a systems approach calls for both a theoretical and methodological framing that examines system effects: the relation between conditions, actors, and actions in the institutional environment, as they affect organizations, changing them, and consequently changing the workplace, technology, tasks, and the actions and reactions of the people who work there. All organizations are vulnerable to system effects — competition for scarce resources necessary to achieving organization goals, including survival, status, and legitimacy in their organization field. Consequently, this research aims to fill gaps in what is known about failure by asking how and why, of two organizations with similar operations and under the same constraints, one is subject to repeat catastrophic failures, while the other has been able to maintain safety. To this end, this research is a cross-case comparative analysis based on historical ethnographies of two crises in large socio-technical systems, looking for analogies and differences. Both cases reveal the institutional constraints and internal responses to the liabilities of technological and organizational innovation: NASA’s decision to launch the Space Shuttle Challenger, and Air Traffic Control response to the intersection of a staffing shortage and automation. The conclusions have implications for both policy and for our understanding of institutional persistence, change, and agency.

Keywords

• boundary work
• ethnocognition
• heterarchy
• liabilities of technological and organizational innovation
• system effects