Normal Accidents Buchzusammenfassung - das Wichtigste aus Normal Accidents

Zusammenfassung von Normal Accidents

Name: Normal Accidents
Author: Charles Perrow

Charles Perrow

Living with High-Risk Technologies

18 Min.

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Normal Accidents
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What’s in it for me? Learn how safety is just a matter of perspective.

Flying in a plane is safe, right? Every day, thousands of aircrafts take off from runways and arrive safely at their destinations and nobody worries about them.

Decades of research into safety mechanisms, safeguards, and updated procedures mean that flying today is safer than it has ever been.

But air travel, like many of the potentially disastrous systems that are part of our social and economic fabric, is highly complex – when something does go wrong, it goes very wrong indeed.

Normal Accidents tells the story of these rare incidents and their impact.

First published in 1984, the book warned against the further adoption of nuclear power. Nuclear power plants, like flight, carry risks that are often mitigated by safety precautions, but can cause unparalleled damage thanks to something as trivial as a loose screw.

The author’s assertion that these accidents can and will happen despite our best efforts to contain them has been sadly vindicated by the 1986 Chernobyl and 2011 Fukushima nuclear disasters, as well as numerous major oil spills and two space shuttle tragedies.

In these blinks, you will discover how these highly complex systems work, and how certain systems are more prone to terrible catastrophe than others. In addition, you will learn to assess the inherent risks of systems, and end up asking yourself whether it might not be better to simply abandon some systems altogether!

After reading these blinks, you’ll find out:

how two ships about to safely pass each other on the Mississippi River ended up in a non-collision course collision,
how “papering over the cracks” near the Grand Teton Dam cost eleven people their live, and
how three astronauts narrowly avoided suffocating to death in space.

Some disasters are both inevitable and unpredictable.

Imagine you have an important job interview. Preoccupied, you step out the door without your keys, and the door locks behind you. That’s OK – you keep a door key hidden nearby.

Wait, you forgot – your friend has it, and he lives across town. So you ask your neighbor for a lift, but his car won’t start.

You rush to the bus stop only to discover that there’s a bus drivers’ strike, and all the taxis are occupied. Disparaged, you cancel the interview.

Sometimes it just works out that way: rare sequences of events thwart precautions, such as safety devices, workarounds and backups.

For example, your hidden key was a backup, but failed because you changed your plan and gave it to a friend. The bus system wasn’t a workaround because its drivers were on strike, and the resulting lack of cabs show how dependent, or coupled, the two transport systems were to one another.

None of these errors would be a problem on their own. However, when they all interact with each other unexpectedly, they cause the entire system – and in this case your job interview – to fail.

System accidents, where multiple failures result in disaster, are often so complicated that we can neither foresee nor comprehend them in real time.

System accidents arise from a range of errors: in Design, Equipment, Procedure, Operator, Supplies and an unpredictable Environment – or DEPOSE, for short.

The door-locking mechanism and lack of emergency taxi capacity, for example, were design errors. When the neighbor’s car failed to start, it was an equipment error. Not allowing extra time for delays on the way to your interview was a failure in procedure.

The bus strike and the taxi shortage were failures in the environment. And finally, absent-mindedly leaving the house without your keys was an operator error.

Of course, a system accident in which you miss an interview isn’t the end of the world. But what happens when one occurs at something like a nuclear or chemical plant?

A system may be simple to understand, but that doesn’t make it dependable.

Why is it that some complex organizations or technologies succeed, while simpler ones fail spectacularly at the first hurdle? To answer this, we’ll need to take a look at the characteristics of systems.

Systems can be categorized both by their complexity, and the flexibility of their processes.

The Three Mile Island nuclear accident showed the precariousness of high-risk industries.

So what do system accidents actually look like? In 1979, the core at the Three Mile Island (TMI) nuclear power plant partially melted and came close to releasing massive amounts of radioactive material into the environment.

In a complex and tightly coupled system like TMI, where interactions are often unpredictable yet also unable to handle delays, trivial and unrelated failures can interact to cause a system accident.

The safety of some complex and tightly coupled systems, like air travel, improve over time, but disasters still happen.

You often hear that it’s safer to fly than to drive a car. And truly, flying is relatively safe.

Over the years, repeated flight trials and experiences with error management have all inspired better designs and safety measures, which have in turn resulted in fewer and fewer crashes per number of flights.

Petrochemical plants suffer from system accidents, but rarely from unpreventable catastrophes.

The dangers of nuclear power are well known, but the risks involved in petrochemical plants pass largely under our radar. However, they are considerable, and we should be informed.

The petrochemical industry – like the nuclear business – employs transformative processes, whereby new products are created from raw materials that are often toxic or explosive. In spite of this, the chemical industry has been in business for over a hundred years and has suffered few catastrophic accidents. There have been relatively few unpreventable system accidents resulting in high casualty figures, but they do indeed occur.

Sometimes safety devices and automation actually increase the likelihood of a system accident.

Have you ever been under so much pressure at work that, in a frantic haste to finish, you ended up making some little mistakes? Something similar happens in systems, too.

System accidents usually don’t happen because of production pressures, but these pressures do increase the likelihood of small errors, which can cascade into something uncontrollable.

While the best designs may be flawed, and management impotent, recovery from failure is possible.

Although the Apollo 13 space mission was en route to a moon landing, the ship never touched its dusty surface. Instead, the crew almost suffocated in the vacuum of space.

Why?

Our intuitions can deceive us and cause accidents.

One day on the Mississippi River, two ships, the Pisces and the Trade Master, were on course to safely pass one another. Yet, at the last minute, they turned into each other’s paths and collided. How on Earth did this happen?

Partly it’s a matter of intuition. Since we cannot pore over all possible outcomes when making a decision, we base our judgements on hunches and rules of thumb, and while these intuitions are convenient, they’re also sometimes flat-out wrong.

Risk assessment isn’t just about the numbers.

Do you know anyone who smokes cigarettes and at the same time condemns nuclear power? Though it might sound strange, such contradictions are natural, as we tend to minimize some dangers and maximize others.

For example, risk assessors, engineers and economists tend to employ precise and quantitative goals, facilitated by mathematical models. This absolute rationality ignores the social or cultural aspects of risk and safety.

We must reorganize some systems and abandon others altogether.

If we know that system accidents can be terribly disastrous, what can we do to balance their risks against the benefits that those systems bring to our societies?

One way to ease the risk of system accident is to centralize or decentralize the system, depending on its complexity and coupling.

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Worum geht es in Normal Accidents?

Normal Accidents delves into the accidents that can and have occurred in high-risk environments, like nuclear plants and dams, airplanes and even space. It shows us how mind-bogglingly complex modern systems have become, and that no one could possibly predict the trivial failures that cascade into catastrophe.

Bestes Zitat aus Normal Accidents

Fact:
In the 1920s, 31 out of the 40 Air Mail Service pilots died trying to meet schedules.

—Charles Perrow

Wer Normal Accidents lesen sollte

Anyone involved in complicated operations, like start-ups, research operations, or project management
Perfectionists or technological solutionists
Anyone who travels by plane or ship

Über den Autor

Charles Perrow is an emeritus professor of Sociology at Yale and a visiting professor at Stanford. Since its original publication in 1984, the award-winning Normal Accidents has been widely cited in academic indexes for both social science and science. Perrow has also written about organizational culture, juvenile detention systems and the treatment of AIDS.

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Technologie & Zukunft Wissenschaft

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