Normal Accidents
"Normal" accidents, or system accidents, are so-called by Perrow because such accidents are inevitable in extremely complex systems. Given the characteristic of the system involved, multiple failures which interact with each other will occur, despite efforts to avoid them. Perrow said that operator error is a very common problem, many failures relate to organizations rather than technology, and big accidents almost always have very small beginnings. Such events appear trivial to begin with before unpredictably cascading through the system to create a large event with severe consequences. Perrow identifies three conditions that make a system likely to be susceptible to Normal Accidents. These are: • The system is complex • The system is tightly coupled • The system has catastrophic potential [Wikipedia]
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What Hacker News says
- I love reading, here's a few meatier books I've read recently:
* Seeing Like a State - great overview of how states (and corporations) lose visibility into reality due to the abstraction levels they operate at
* Normal Accidents - all about how things like nuclear reactors, ships and large systems naturally have accidents
* Managing the Unexpected: Resilient Performance in an Age of Uncertainty - great easy read about how high reliability organizations manage complexity and dangerous, high tempo situations.
- "Normal Accidents" is a profound, mind-bending book. I lectured on it during Anesthesiology Grand Rounds [University of Virginia School of Medicine], using it as an armature with which to view the making of disasters in the OR.
- You should read Normal Accidents. "Human error" is an excuse. It isn't really actionable. Instead of trying to fix the "human error", you must design the system such that it does not permit life-threatening errors.
Sometimes that means a tradeoff in terms of efficiency, cost, or something else. Often this tradeoff is not one that people in charge of the system are willing to make, unless they are forced to do so by a larger institution or force.
To really drive this home:
1. What steps did Flock Safety take to ensure this warrant was valid and current, and that the plate number was correctly entered?
2. What steps did the police officers take to validate the warrant against the APB hit from the camera?
3. What process is in place to ensure incorrect warrants are not entered or mistakenly kept live for longer than intended?
My guess is that the answer to all three of these is basically "none".
- Another case study to add to the maritime chapter of this timeless classic: https://www.amazon.com/Normal-Accidents-Living-High-Risk-Tec...
Like you said (and illustrated well in the book) it's never just 1 thing, these incidents happen when multiple systems interact and often reflect a the disinvestment in comprehensive safety schemes.
- Both unsophisticated lay observers and capital/owners tend to fault operators ... for different reasons.
Accident studies and, in particular, books like _Normal Accidents_[1] push back on this assumptions:
"... It made the case for examining technological failures as the product of highly interacting systems, and highlighted organizational and management factors as the main causes of failures. Technological disasters could no longer be ascribed to isolated equipment malfunction, operator error, or acts of God."
It is well accepted - and I believe - that there were a multitude of operator errors during the Air France 447 flight but none of them were unpredictable or exotic and the system they were tasked with operating was poorly designed and unhelpfully hid layers of complexity that suddenly re-emerged during tremendous "production pressure".
But don't take my word for it - I appeal to authority[2]:
"Automation dependent pilots allowed their airplanes to get much closer to the edge of the envelope than they should have ..."[3].
or:
@ 14:15: "... we see automation dependent crews, lacking confidence in their own ability to fly an airplane are turning to ther autopilot ..."[4].
[1] https://en.wikipedia.org/wiki/Normal_Accidents
[2] Captain Vanderburgh
[3] Children of Magenta: https://www.youtube.com/watch?v=dTwB94yOrRQ
- For a deeper dive there’s a somewhat old but excellent book on most of these points called Normal Accidents. [0]
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