Technology‐push, market‐demand and the missing safety‐pull: a case study of American Airlines Flight 587

• Date: 01 July 2015
• Published date: 01 July 2015
• DOI: http://doi.org/10.1111/ntwe.12050
• Author: Amy L. Fraher

Technology-push, market-demand and the

missing safety-pull: a case study of

American Airlines Flight 587

Amy L. Fraher

Through a critical case study of the crash of American Airlines

Flight 587, this paper draws upon ‘the Social Shaping of Tech-

nology’ (SST) approach to offer a reconceptualisation of the

technology-push and market-demand model for High-Reliably

Organisations (HROs), providing support for a third factor,

called here a ‘safety-pull’. A safety-pull is defined as

organisationally supported reflexivity in which technology

innovators and frontline operators collaborate to consider the

potential implications of adopting new technologies in HROs

and the complex ways this change may impact human opera-

tors’ work performance, often in risky and unanticipated ways.

In contrast to accidents occurring solely as the result of indi-

vidual operator error, analysing the safety-pull provides a way

to tease out the wide range of factors that can contribute to

HRO failures and offers a new SST perspective through which

to examine high-risk operations.

Keywords: the social shaping of technology (SST),

high-reliability organisation (HRO), airline pilots, clumsy

technology, flight simulation, automation confusion, high risk

operations, technology failure, technology push, market

demand.

‘An improperly trained pilot can break any airplane.’

Airbus Vice-President of Safety

(Air Safety Week, 25 October 2005)

‘Most pilots think that’ there are systems that ‘will protect the aircraft structurally’ or ‘there would

be a limitation or a warning’if parameters were being exceeded that might damage the plane.

American Airlines Captain, A300 Fleet Standards Manager

(NTSB, 2004: 24)

Dr. Amy L. Fraher (amylfraher@gmail.com) is a senior lecturer in the Department of Organisation,

Work and Employment (a.l.fraher@bham.ac.uk) at the Birmingham Business School, University of

Birmingham in the UK and a lecturer in the GraduateSchool of Management at University of California,

Davis,in the USA. A retired US Navy Commander and Naval Aviator, and former United Airlines pilot,

she has over 6,000 mishap-free flight hours in four jet airliners, five military aircraft and several types

of civilian airplanes. She has published widely including books such as The Next Crash: How Short-Term

Profit Seeking Trumps Airline Safety (2014, Cornell University Press) and ‘Thinking Through Crisis’:

Improving Teamwork and Leadership in High Risk Fields (2011, Cambridge University Press) and in

journals such as Human Relations and Journal of Management Studies.

New Technology, Work and Employment 30:2

ISSN 0268-1072

© 2015 John Wiley & Sons Ltd The Missing Safety-Pull 109

Introduction

How successful are high-risk industries such as aviation at technological innovation?

Given the sophisticated design of modern jetliners, extensive training of airline

employees and unforgiving operating environment, one might assume that air car-

riers are exemplary at developing new technologies and successfully integrating

them into the processes and procedures of frontline operators. This assumption

underpins research investigating several High-Reliability Organisations (HROs)

which, like airlines, involve high-risk professions that must consistently operate in

complex, dynamic and time-pressured environments in a nearly error-free manner

(Roberts, 1990; Weick and Sutcliffe, 2001). For example, studies from medicine

(Sexton et al., 2000; Makary et al., 2006), offshore oil (Flin, 1995; 1997), emergency

response (Flin, 1996) and nuclear power (O’Hara and Roth, 2006) cite aviation as a

performance model for their industries to emulate further perpetuating the view that

aerospace designers, airline managers and frontline operators have perfected their

collaboration processes. Yet, curiously, little empirical research has investigated this

assumption. By examining the ways one airline developed and integrated new tech-

nologies and how these technology decisions impacted the day-to-day work perfor-

mance of employees, this paper aims to challenge this assumption. It does so through

the case study of a fatal airline accident and, as a result, makes two theoretical con-

tributions. First, by examining the ways various stakeholders shaped the design and

implementation of new technologies at a US air carrier, this study makes an empiri-

cal contribution to a growing body of research that explores ‘the Social Shaping of

Technology’ (SST) in organisations (MacKenzie and Wajcman, 1985; Williams and

Edge, 1996; Howcroft and Light, 2010; Holmstrom and Sawyer, 2011). Second, by

analysing the emergent nature of technology in one high-risk profession, aviation,

this study identifies dynamics that could potentially undermine workplace perfor-

mance and threaten the reliability in a wide range of HROs. Little research to date

has applied SST in the empirical study of an HRO.

A considerable literature from a variety of fields suggests that in order for new

technologies to be successful there needs to be both a ‘technology-push’, supplying

innovations based on new scientific discoveries, and a market-demand, ‘pulling’ prod-

ucts to market to fill industry needs (Mowery and Rosenberg, 1979; Dosi, 1982; vanden

Ende and Dolfsma, 2005; Godin and Lane, 2013). In this paper, I suggest a

reconceptualisation of the technology-push and market-demand model for HROs by

providing support for a third factor, called here a ‘safety-pull’. I define a safety-pull as

organisationally supported reflexivity in which technology innovators and frontline

operators collaborate to consider the potential implications of adopting new technol-

ogies in HROs and the complex ways this change may impact human operators’ work

performance in ‘extreme contexts’ (Hannah et al., 2009). In contrast to accidents occur-

ring solely as the result of individual operator error, analysing the safety-pull provides

a way to tease out the wide range of factors that can contribute to HRO accidents and

offers a new SST perspective through which to examine high-risk operations. Through

the safety-pull lens, for instance, it becomes clear that HRO failuresoften result from a

complex, inter-organisational breakdown in collaboration that involves a variety of

people in different roles at several levels within their respective organisations.

This paper applies this push–pull framework in an analysis of the crash of American

Airlines Flight 587, an Airbus A300-600, which departedfrom New York City’s John F.

Kennedy International Airport en route to the Dominican Republic on November 12,

2001. Less than two minutes after takeoff, the aircraft encountered wake turbulence

from a previously departing airliner and disintegrated inflight, killing all 260 onboard

as well as five people on the ground (NTSB, 2004). After conducting a three-year study

the National Transportation Safety Board (NTSB), the US agency tasked with investi-

gating transportationrelated accidents, reported some surprising findings. In short, the

NTSB concluded that the well-trained and highlyexperienced American Airlines pilots

broke the airplane and their actions were caused in large part due to training they had

received in American’s state-of-the-art flight simulators.

© 2015 John Wiley & Sons Ltd110 New Technology, Work and Employment