Charles Perrow > Quotes

“Unfortunately, most warning systems do not warn us that they can no longer warn us.)”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“Organizational theorists, at least since Burns and Stalker, 1961 and Joan Woodward, 1965 in what came to be called the contingency school, have recognized that centralization is appropriate for organizations with routine tasks, and decentralization for those with nonroutine tasks.”
― Charles Perrow, Normal Accidents: Living with High-Risk Technologies

“Unfortunately, the technological fixes have frequently only enabled those who run the commercial airlines, the general aviation community, and the military to run greater risks in search of increased performance.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“Engineers speak of a “control loop,” in which the “man in the loop” is the problematical element. This is the human component in a series of sequentially interacting pieces of equipment that control or adjust a function. But when the pilot is suddenly and unexpectedly brought into the control loop (in other words, participates in decision making) as a result of (inevitable) equipment failure, he is disoriented. Long periods of passive monitoring make one unprepared to act in emergencies. The sudden appearance of several alarms, all there for safety reasons, leads to disorientation.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“Accidents can be the result of multiple failures. Our example illustrated failures in five components: in design, equipment, procedures, operators, and environment. To apply this concept to accidents in general, we will need to add a sixth area—supplies and materials. All six will be abbreviated as the DEPOSE components (for design, equipment, procedures, operators, supplies and materials, and environment).”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“It is the interaction of the multiple failures that explains the accident.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“Equally frightening is the section in this chapter on gene splicing, or recombinant DNA. In this case, in the unseemly haste for prizes and profits, we have abandoned even the most elementary safeguards, and may loose upon the world a rude beast whose time need not have come.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“This interacting tendency is a characteristic of a system, not of a part or an operator; we will call it the “interactive complexity” of the system.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“we must add organizational contradictions to our list of problems.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“Most high-risk systems have some special characteristics, beyond their toxic or explosive or genetic dangers, that make accidents in them inevitable, even “normal.” This has to do with the way failures can interact and the way the system is tied together.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“the Nuclear Regulatory Commission issued a report”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“If interactive complexity and tight coupling—system characteristics—inevitably will produce an accident, I believe we are justified in calling it a normal accident, or a system accident. The odd term normal accident is meant to signal that, given the system characteristics, multiple and unexpected interactions of failures are inevitable.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“The argument is basically very simple. We start with a plant, airplane, ship, biology laboratory, or other setting with a lot of components (parts, procedures, operators). Then we need two or more failures among components that interact in some unexpected way. No one dreamed that when X failed, Y would also be out of order and the two failures would interact so as to both start a fire and silence the fire alarm.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“Edwards continues by arguing that all this automation has not reduced the workload of the pilot a great deal; instead, it has increased the operational effectiveness of the system.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“Their training never imagined a multiple accident with a stuck PORV, and blocked valves.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“It is normal not in the sense of being frequent or being expected—indeed, neither is true, which is why we were so baffled by what went wrong. It is normal in the sense that it is an inherent property of the system to occasionally experience this interaction.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“We might put this quarrel down to the traditional rivalry between these two universities and treat it as insignificant, except that the latter, scoffing, scientist turned out to be the advisor on nuclear power production to Governor Thornburg of Pennsylvania, and was in the thick of the expert advice at TMI.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“In complex industrial, space, and military systems, the normal accident generally (not always) means that the interactions are not only unexpected, but are incomprehensible for some critical period of time. In part this is because in these human-machine systems the interactions literally cannot be seen. In part it is because, even if they are seen, they are not believed.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“workload has become more “bunched,” with long periods of inactivity and short bursts of intense activity. Both of these are error-inducing modes of operation.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“This will give us the necessary tools, in the form of ideas or concepts, to enter, in later chapters, the world of other high-risk systems that someone has decided we cannot live without.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“The subsequent investigations and law suits disclosed a seemingly endless story of incompetence, dishonesty, and cover-ups before, during, and after the event;”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“example of a phenomenon that will concern us in this chapter: production pressures in this high-risk system.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“The nuclear power industry, for example, lacks a strong union, has random public victims with delayed effects, has no safety board that is independent of licensing and regulatory functions, and does not see an immediate effect on its profits if safety flags (though a far more severe incentive exists to avoid a catastrophic accident which could shut down the industry).”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“Of such complexities is the normal accident made. For all but one operator, presumably, and for all the experts, the pressure spike and the hydrogen bubble were incomprehensible.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“Patient accident reconstruction reveals the banality and triviality behind most catastrophes.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“suppose the system is also “tightly coupled,” that is, processes happen very fast and can’t be turned off, the failed parts cannot be isolated from other parts, or there is no other way to keep the production going safely. Then recovery from the initial disturbance is not possible; it will spread quickly and irretrievably for at least some time. Indeed, operator action or the safety systems may make it worse, since for a time it is not known what the problem really is.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“no matter how effective conventional safety devices are, there is a form of accident that is inevitable.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“Time and time again warnings are ignored, unnecessary risks taken, sloppy work done, deception and downright lying practiced. As an organizational theorist I am reasonably unshaken by this; it occurs in all organizations, and it is a part of the human condition. But when it comes to systems with radioactive, toxic, or explosive materials, or those operating in an unforgiving, hostile environment in the air, at sea, or under the ground, these routine sins of organizations have very nonroutine consequences.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition

“Shoddy construction and inadvertent errors, intimidation and actual deception—these are part and parcel of industrial life. No industry is without these problems, just as no valve can be made failure-proof. Normally, the consequences are not catastrophic. They may be, however, if you build systems with catastrophic potential.”
― Charles Perrow, Normal Accidents: Living with High-Risk Technologies

“That accident had its cause in the interactive nature of the world for us that morning and in its tight coupling—not in the discrete failures, which are to be expected and which are guarded against with backup systems.”
― Charles Perrow, Normal Accidents: Living with High Risk Technologies - Updated Edition