How Organizational Artefacts Fail to Protect Designed Systems

One of the main difficulties faced by designers of socio-technical systems is to understand how far they can rely on organizational, rather than physical, artifacts to protect such systems. Often it is not technically feasible or cost effective to devise purely physical protective measures. Organizational artifacts are entities such as rules, procedures, authority structures, records and so on that are artificial constructions, like physical equipment, but have organizational functions rather than physical ones. They typically work by providing constraints. For example, traffic rules constrain legitimate maneuvers, making the choice of maneuver simpler, and helping to protect the system against hazardous maneuvers. Nonetheless, these organizational artifacts are often implicated in failure, and a study was conducted to investigate what role they had played in the failure of maritime systems. This used the principle of distributed cognition as the theoretical starting point, and involved an analysis of 35 investigators’ reports of maritime accidents. For each case, an attempt was made to 1) identify organizational artifacts implicated in the accidents, 2) characterize the constraints they provided, and 3) describe their failure modes. From this analysis, several inferences were made. First, people’s cognitions with organizational artifacts are influenced by their cognitions about artifacts in various ways, and it is important to analyze both when understanding systems of distributed cognition. For example, if we design operating procedures to protect systems we need to understand the cultural assumptions that are made about such procedures in the environment in question. Second, artifacts are typically introduced when systems are problematic because they are under-constrained; but, in dynamic systems, situations then tend to arise in which the system becomes over-constrained. For example, traffic rules provide constraints that are typically ignored when other constraints (such as maintaining movement schedules) attain higher priority levels. Third, the constraints provided by organizational artifacts generally reduce people’s choice sets, and this reduction has three functions: it makes a person’s problem solving more tractable, it makes a person’s subsequent actions more predictable to others, and it reduces the likelihood that these actions will be hazardous to the system. For example traffic rules reduce the predictions that the master of one vessel has to make about the intentions of another vessel’s master.