Adaptation failures that cause error in technical organizations

Article type: Research Article

Authors: Busby, J.S.

Affiliations: Department of Mechanical Engineering, University of Bath, Bath BA2 7AY, UK, Tel.: +44 1225826 588; Fax: +44 1225826 928; E-mail: j.s.busby@bath.ac.uk

Abstract: A study was conducted of 127 cases of organizational error in engineering companies, analysing in particular the adaptation failures they pointed to: that is, the reasons that adaptation to past error had not led to error-free performance. The cases were first categorised according to whether the failure was due to situational variety or shortcomings in learning. Shortcomings in learning were then differentiated according to whether the cause lay with individuals' inferences, the structure of the engineering task they were performing, characteristics of tools used during the task, or organizational-level phenomena. A detailed taxonomy was developed for the cases collected under these categories. An attempt was then made to find an over-arching explanation of these adaptation failures, most of which turned out to be cases where earlier adaptations had been too rapid and definitive. The individuals or organizations in question had taken account of historical experience, but had done so in a way that discounted the possibility that this experience was idiosyncratic or temporary. This was explained in terms of the reinforcing feedback that arises from a number of effects. The suggestion is also made that there are good reasons why reinforcing feedback is ultimately functional, even though it appears to underlie particular adaptation failures and errors.

Keywords: Human error, organisational learning, adaptation, feedback

DOI: 10.3233/HSM-2001-20403

Journal: Human Systems Management, vol. 20, no. 4, pp. 301-312, 2001