Artefacts, sensemaking and catastrophic failure in railway systems

Complex socio-technical systems rely extensively on organisational artefacts - such as rules, procedures and authority structures -for their protection. These artefacts help coordinate the cognitions of people designing, operating and maintaining such systems. Nonetheless, people continuously engage in processes of sensemaking that can undermine the coordinating function of organisational artefacts. A set of accidents on the UK railway was analysed in order to reveal the way in which artefacts and sensemaking combined to cause catastrophic failure. The main advantage of studying such failure is that is has helped reveal what is sometimes taken for granted in organisational cognition, and sometimes neglected in the design of systems.