Loss of Defensive Capacity in Protective Operations: The Implications of the Überlingen and Linate Disasters

References

• ANSV . 2004a . Final report: Accident involved aircraft Boeing MD‐87, registration SE‐DMA and Cessna 525‐A, registration D‐IEVX, Milano Linate airport, October 8, 2001. N.A/1/04 , Rome, , Italy : Agenzia Nazionale per la Sicurezza del Volo .
   Google Scholar
• ANSV . 2004b . Press release 23 September 2004: ANSV investigates a traffic conflict at Milan Malpensa airport , Rome, , Italy : Agenzia Nazionale per la Sicurezza del Volo .
   Google Scholar
• ATCEUC . 2004 . Press release 20 April 2004: “Call for a fair ruling!” , Brussels : Air Traffic Controllers' European Unions Coordination .
   Google Scholar
• Airwise News (2004a) Prosecutors seek prison sentences for Milan crash. 8 March . Available at http://news.airwise.com/stories/2004/03/ (accessed 29 July 2006).
   Google Scholar
• Airwise News (2004b) Court jails four over Italy's worst air disaster. 16 April . Available at http://news.airwise.com/stories/2004/04/ (accessed 29 July 2006).
   Google Scholar
• Ashby , W. R. 1956 . An Introduction to Cybernetics , London : Chapman and Hall .
   Google Scholar
• Beck , U. 1992 . Risk Society: Towards a New Modernity , London : Sage .
   Google Scholar
• Bennett , S. A. 2004 . The 1st July 2002 Mid‐air collision over Überlingen, Germany: A holistic analysis, . Risk Management: An International Journal , 6 (1) : 31 – 49 .
   Google Scholar
• Bierly , P. E. and Spender , J.‐C. 1995 . Culture and high reliability organizations: the case of the nuclear submarine, . Journal of Management , 21 : 639 – 656 .
   Web of Science ®Google Scholar
• Blockley , D. I. 1996 . “ Hazard engineering, ” . In Debates in Risk Management , Edited by: Hood , C and Jones , D. K. C . 31 – 39 . London : UCL Press .
   Google Scholar
• Bogdanowicz, T. (2001) SAS backs Linate over safety. Available at http://cnn.worldnews.printthis.clickability.com/ (accessed 29 July 2006).
   Google Scholar
• Bott , M. and Paterson , T. 2005 . Father of air‐crash victims guilty of revenge killing, . The Independent , : 24 – 25 . 27/10/05
   Google Scholar
• BFU . 2004 . Investigation report: AX001‐1‐2/02 May 2004 , Braunschweig, , Germany : Bundestelle für Flugunfalluntersuchung .
   Google Scholar
• Burns , R. B. 2000 . Introduction to research methods , Thousand Oaks : Sage .
   Google Scholar
• CNN (2001) Human error kills 114 in Milan crash. 9 October. Available at http://www.cnn.com/2001/WORLD/europe/ (accessed 29 July 2006).
   Google Scholar
• Flight International . 2001 . Fatal assumption, . Flight International , : 5 16–22 October
   Google Scholar
• Flight International . 2002 . Basic instinct, . Flight International , : 1 16–22 July
   Google Scholar
• Flight International (2004) Rough justice, Flight International , 27 April. Available at http://www.atceuc.org/ (accessed 18 August 2006).
   Google Scholar
• Freudenberg , W. R. 2003 . “ Institutional failure and the organizational amplification of risk: the need for a closer look, ” . In The Social Amplification of Risk , Edited by: Pidgeon , N , Kasperson , R. E and Slovic , P . 102 – 120 . Cambridge : Cambridge University Press .
   Google Scholar
• Gephart , R. P. 1993 . The textual approach: Risk and blame in disaster sensemaking, . Academy of Management Journal , 36 : 1465 – 1514 .
   Web of Science ®Google Scholar
• Grabowski , M. and Roberts , K. H. 1996 . Human and organizational error in large scale systems, . IEEE Transactions on Systems, Man, and Cybernetics, Part A , 26 : 2 – 16 .
   Web of Science ®Google Scholar
• Grabowski , M. and Roberts , K. 1997 . Risk mitigation in large scale systems: lessons from high reliability organizations, . California Management Review , 39 : 152 – 162 .
   Web of Science ®Google Scholar
• Heizer , J. and Render , B. 2004 . Principles of Operations Management , Upper Saddle River, NJ : Pearson . (5th Ed.)
   Google Scholar
• Hill , T. 2005 . Operations Management , Basingstoke : Palgrave . (2nd Ed.)
   Google Scholar
• Hopkins , A. 1999 . The limits of normal accident theory, . Safety Science , 32 : 93 – 102 .
   Web of Science ®Google Scholar
• IFATCA . 2004 . Second Air Traffic Controller Attacked! , Montreal : International Federation of Air Traffic Controllers' Associations . Press Release 17 April 2004:
   Google Scholar
• Horlick‐Jones , T. 1996 . “ The problem of blame, ” . In Accident and Design: Contemporary Debates in Risk Management , Edited by: Hood , C and Jones , D. K. C . 61 – 71 . London : UCL Press .
   Google Scholar
• Hutter , B. and Power , M. 2005 . “ Organizational encounters with risk: an introduction, ” . In Organizational Encounters with Risk , Edited by: Hutter , B and Power , M . 1 – 32 . Cambridge : Cambridge University Press .
   Google Scholar
• Jasanoff , S. 1993 . Bridging the two cultures of risk analysis, . Risk Analysis , 13 : 123 – 129 .
   Web of Science ®Google Scholar
• Kasperson , R. E. , Renn , O. , Slovic , P. , Brown , H. S. , Emel , J. , Goble , R. , Kasperson , J. X. and Ratick , S. 1988 . The social amplification of risk: a conceptual framework, . Risk Analysis , 8 : 177 – 187 .
   Web of Science ®Google Scholar
• Klein , R. L. , Bigley , G. A. and Roberts , K. H. 1995 . Organizational culture in high reliability organizations: an extension, . Human Relations , 48 : 771 – 793 .
   Web of Science ®Google Scholar
• La Porte , T. R. 1996 . High reliability organizations: unlikely, demanding and at risk, . Journal of Contingencies and Crisis Management , 4 (2) : 60 – 71 .
   Google Scholar
• La Porte , T. R. and Consolini , P. M. 1991 . Working in practice but not in theory: theoretical challenges of high‐reliability organizations, . Journal of Public Administration Research and Theory , 1 : 19 – 47 .
   Google Scholar
• La Porte , T. R. and Thomas , C. W. 1995 . Regulatory compliance and the ethos of quality enhancement: surprises in nuclear power plant operations, . Journal of Public Administration Research and Theory , 5 : 109 – 137 .
   Google Scholar
• Learmount , D. 2002 . Inquiry details disaster timeline, . Flight International , 3–9 September
   Google Scholar
• Macdonald , K. and Tipton , C. 1993 . “ Using documents, ” . In Researching Social Life , Edited by: Gilbert , N . London : Sage .
   Google Scholar
• Milde , M. 1977 . “ Aviation law, ” . In The International Encyclopaedia of Aviation , Edited by: Mondey , D . London : Octopus .
   Google Scholar
• Mitre Corporation (2003) Traffic Alert and Collision Avoidance System . Available at http://www.mitre.org/ (accessed 27 May 2006).
   Google Scholar
• Neighbour , M. 2004 . Russian admits he may have killed air traffic controller, . The Scotsman , 17 March
   Google Scholar
• Paton‐Walsh , N. 2004 . Revenge suspected as motive for killing of air controller, . The Guardian , 26 February
   Google Scholar
• Patterson , J. W. , Fredendall , L. D. and Craighead , C. W. 2002 . The impact of non‐bottleneck variation in a manufacturing cell, . Production Planning and Control , 13 : 76 – 85 .
   Web of Science ®Google Scholar
• Perrow , C. 1984 . Normal Accidents , New York : Basic Books .
   Google Scholar
• Perrow , C. 1999 . Normal Accidents , Princeton, NJ : Princeton University Press . reprint
   Google Scholar
• Ramanujam , R. and Goodman , P. S. 2003 . Latent errors and adverse organizational consequences: a conceptualization, . Journal of Organizational Behavior , 24 : 815 – 836 .
   Web of Science ®Google Scholar
• Rasmussen , J. 1990 . The role of error in organizing behaviour, . Ergonomics , 33 : 1185 – 1200 .
   Web of Science ®Google Scholar
• Rasmussen , J. 1997 . Risk management in a dynamic society: a modelling problem, . Safety Science , 27 : 183 – 213 .
   Web of Science ®Google Scholar
• Reason , J. 1990 . Human Error , Cambridge : Cambridge University Press .
   Google Scholar
• Reason , J. 1997 . Managing the Risks of Organizational Accidents , Aldershot : Ashgate .
   Google Scholar
• Roberts , K. H. 1990 . Some characteristics of one type of high reliability organization, . Organization Science , 1 : 160 – 176 .
   Web of Science ®Google Scholar
• Roberts , K. H. and Rousseau , D. M. 1989 . Research in nearly failure‐free, high‐reliability organizations: having the bubble, . IEEE Transactions on Engineering Management , 36 : 132 – 139 .
   Web of Science ®Google Scholar
• Roberts , K. H. , Stout , S. K. and Halpern , J. J. 1994 . Decision dynamics in two high reliability organizations, . Management Science , 40 : 614 – 624 .
   Web of Science ®Google Scholar
• Rudolph , J. W. and Repenning , N. P. 2002 . Disaster dynamics: understanding the role of quantity in organizational collapse, . Administrative Science Quarterly , 47 : 1 – 30 .
   Web of Science ®Google Scholar
• Ruitenberg , B. How a nightshift became a nightmare in just 20 minutes., . Paper presented at the Australian Aviation Psychology Symposium, . 2003 .
   Google Scholar
• Sagan , S. D. 1993 . The Limits of Safety: Organizations, Accidents and Nuclear Weapons , Princeton : Princeton University Press .
   Google Scholar
• Sagan , S. D. 1994 . Toward a political theory of organizational reliability, . Journal of Contingencies and Crisis Management , 2 : 228 – 240 .
   Google Scholar
• Schulman , P. R. 1996 . Heroes, organizations and high reliability, . Journal of Contingencies and Crisis Management , 4 (2) : 72 – 82 .
   Google Scholar
• Slack , N. , Chambers , S. and Johnston , R. 2004 . Operations Management , Harlow : Pearson . (4th Ed.)
   Google Scholar
• Snook , S. A. 2000 . Friendly Fire: The Accidental Shootdown of US Black Hawks Over Northern Iraq , Princeton : Princeton University Press .
   Google Scholar
• Sochor , E. 1991 . The Politics of International Aviation , London : Macmillan .
   Google Scholar
• Starbuck , W. H. and Milliken , F. J. 1988 . Challenger: fine‐tuning the odds until something breaks, . Journal of Management Studies , 25 : 319 – 340 .
   Web of Science ®Google Scholar
• Svenson , O. 1991 . The accident evolution and barrier (AEB) model applied to incident analysis in the processing industries, . Risk Analysis , 11 : 499 – 507 .
   PubMed Web of Science ®Google Scholar
• Taylor , L. 1988 . Air Travel — How Safe Is It? , Oxford : BSP Professional .
   Google Scholar
• The Guardian (2004) Four jailed for Milan air disaster, 17 April. Available at http://www.guardian.co.uk/print/ (accessed 23 July 2006).
   Google Scholar
• Toft , B. and Reynolds , S. 1994 . Learning from Disasters , Oxford : Butterworth‐Heinemann .
   Google Scholar
• Turner , B. A. 1976 . The organizational and interorganizational development of disasters, . Administrative Science Quarterly , 21 : 378 – 397 .
   Web of Science ®Google Scholar
• Turner , B. A. 1978 . Man Made Disasters , London : Wykeham .
   Google Scholar
• Weick , K. E. 1987 . Organizational culture as a source of high reliability, . California Management Review , 29 : 112 – 127 .
   Web of Science ®Google Scholar
• Weick , K. E. 1990 . The vulnerable system: an analysis of the Tenerife air disaster, . Journal of Management , 16 (3) : 571 – 593 .
   Web of Science ®Google Scholar
• Weir , D. T. H. 1996 . “ Risk and disaster: the role of communications breakdown in plane crashes and business failure, ” . In Debates in Risk Management , Edited by: Hood , C and Jones , D. K. C . 114 – 126 . London : UCL Press .
   Google Scholar
• Wicks , D. 2001 . Institutionalized mindsets of invulnerability: differentiated institutional fields and the antecedents of organizational crisis, . Organization Studies , 22 (4) : 659 – 692 .
   Web of Science ®Google Scholar
• Willan, P. (2001) Shambles at Milan airport led to jet disaster. 15 October. Available at http://www.guardian.co.uk/print/ (accessed 11 August 2006).
   Google Scholar
• Woo , D. M. and Vicente , K. J. 2003 . Societechnical systems, risk management, and public health: comparing the North Battleford and Walkerton outbreaks, . Reliability Engineering and System Safety , 80 : 253 – 269 .
   Web of Science ®Google Scholar
• Zohar , D. and Luria , G. 2003 . Organizational meta‐scripts as a source of high reliability: the case of an army armoured brigade, . Journal of Organizational Behavior , 24 : 837 – 859 .
   Web of Science ®Google Scholar