How an institutional setting shape and limit the mitigation of accidents in complex work settings

Research suggests that accidents due to failed coordination arising from the disruption of everyday activity can be mitigated by empowered employees through sensemaking activities: observing or recognizing cues, voicing concern, and considering alternative perspectives. Unfortunately, the literature also observes limits to such activities due to the influence from technology, power, and language. However, there is negligible understanding of the mutual influence of these phenomena on (the failure of) sensemaking to prevent escalation.

Using an institutional and sociomaterial approach to sensemaking, we integrate the influence of technology, power, and language to investigate accident commission data (e.g., talk between different actors and interviews), from a railway accident in Sweden in 1987, showing how a minor disruption in everyday work escalated into a situation that exceeded the limits for effective sensemaking.

Technology, power, and language in institutional settings, expressed through actors' habitual repertoire, influence sensemaking and its outcomes. The findings indicate that actors' habits encourage the continuation of immanent sensemaking and that it takes strong, specific, cues to shift to deliberative sensemaking. Moreover, also deliberative sensemaking is influenced by actor's habitual repertoire, limiting its quality.

The efforts to mitigate the escalation to tragedy in this case failed because of the mutual influences of technology, power and language operating within an institutionalized and heavily regulated work environment. This resulted in fragmented or minimal sensemaking that, in hindsight, did not match the complexity in the accident and the response that would have been required.

To enable sufficient articulation of concerns and collaborative problem-solving in complex safety-critical systems, there is a need to break with hierarchical relations, to create a shared language, and employees should be made aware of the potential misleading signals from technologies designed to ensure safety.