Failure to Mobilize in Reliability‐Seeking Organizations: Two Cases from the UK Railway*
基于英国铁路两起灾难性碰撞的定性分析，研究了强烈追求可靠性却最终遭遇灾难性失败的组织，发现其无法将已知风险转化为系统性改革。
abstract There is a considerable line of research on organizations dealing with large scale, intrinsic hazards. We know a good deal, as a result, about both the causation of catastrophic failure and its avoidance. Past work has explained failure in terms of (for example) structural vulnerabilities and organizational degradation – and reliability in terms of collective mindfulness, rigorous enculturation and high levels of social redundancy. This paper presents a study, based on a qualitative analysis of two disastrous collisions on the UK railway, of organizations that are strongly reliability seeking yet ultimately experience catastrophic failure. It argues that these cases implicated an organizational incapacity to mobilize systemic reform. The possibility of the two failures had been well‐known in the organizations before their occurrence, but this knowledge could not be converted into modification. A model is presented to explain how processes of systemic reform co‐exist with a set of phenomena that tend to undermine them. It is these that need to be the principal focus of efforts at managing catastrophic failure risks.