Normal Accidents: Living with High-Risk Technologies (Paperback)

by Charles Perrow (Author) "Our first example of the accident potential of complex systems is the accident at the Three Mile Island Unit 2 nuclear plant near Harrisburg, Pennsylvania,..." (more)
Key Phrases: component failure accidents, system accidents, secondary cooling system, United States, Coast Guard, New York (more...)

Editorial Reviews

Amazon.com Review
Hang a curtain too close to a fireplace and you run the risk of setting your house ablaze. Drive a car on a pitch-black night without headlights, and you dramatically increase the odds of smacking into a tree.

These are matters of common sense, applied to simple questions of cause and effect. But what happens, asks systems-behavior expert Charles Perrow, when common sense runs up against the complex systems, electrical and mechanical, with which we have surrounded ourselves? Plenty of mayhem can ensue, he replies. The Chernobyl nuclear accident, to name one recent disaster, was partially brought about by the failure of a safety system that was being brought on line, a failure that touched off an unforeseeable and irreversible chain of disruptions; the less severe but still frightening accident at Three Mile Island, similarly, came about as the result of small errors that, taken by themselves, were insignificant, but that snowballed to near-catastrophic result.

Only through such failures, Perrow suggests, can designers improve the safety of complex systems. But, he adds, those improvements may introduce new opportunities for disaster. Looking at an array of real and potential technological mishaps--including the Bhopal chemical-plant accident of 1984, the Challenger explosion of 1986, and the possible disruptions of Y2K and genetic engineering--Perrow concludes that as our technologies become more complex, the odds of tragic results increase. His treatise makes for sobering and provocative reading. --Gregory McNamee

Review
"[Normal Accidents is] a penetrating study of catastrophes and near catastrophes in several high-risk industries. Mr. Perrow ... writes lucidly and makes it clear that `normal' accidents are the inevitable consequences of the way we launch industrial ventures.... An outstanding analysis of organizational complexity." -- John Pfeiffer, The New York Times

"[Perrow's] research undermines promises that `better management' and `more operator training' can eliminate catastrophic accidents. In doing so, he challenges us to ponder what could happen to justice, community, liberty, and hope in a society where such events are normal." -- Deborah A. Stone, Technology Review

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Product Details

• Paperback: 386 pages
• Publisher: Princeton University Press; Updated edition (September 27, 1999)
• Language: English
• ISBN-10: 0691004129
• ISBN-13: 978-0691004129
• Product Dimensions: 9 x 5.9 x 1.3 inches
• Shipping Weight: 1.4 pounds (View shipping rates and policies)
• Average Customer Review: 4.0 out of 5 stars See all reviews (29 customer reviews)
• Amazon.com Sales Rank: #182,219 in Books (See Bestsellers in Books)

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Customer Reviews

Most Helpful Customer Reviews

67 of 77 people found the following review helpful:

3.0 out of 5 stars Living With High-Risk Conclusions, January 29, 2004

By	Robert I. Hedges - See all my reviews (TOP 100 REVIEWER)    (REAL NAME)

I have been mulling over this review for a while now, and am still undecided on the correct rating to award this book. On the one hand Perrow offers some genuine insight into systems safety, but frequently does not understand the technicalities of the systems (or occasionally their operators) well enough to make informed decisions and recommendations. In more egregious cases he comes to conclusions that are guaranteed to reduce safety (as when he argues that supertankers should be run by committee, and the usefulness of the Captain is no more) or are merely the cherished liberal opinions of an Ivy League sociologist (he teaches at Yale) as when he argues for unilateral nuclear disarmament, government guaranteed income plans, and heroin maintenance (distribution) plans for addicts "to reduce crime." In the case of disarmament, remember this was written during the early 1980s while the Soviet Union was still a huge threat...complete nuclear disarmament would have resulted in fewer US nuclear accidents, but would NOT have made us safer as we would have been totally vulnerable to intentional nuclear attack. He has great personal animosity toward Ronald Reagan, and makes inflammatory statements in the mining section that mining safety regulations would surely be weakened by Reagan, causing many more accidents and deaths. Later in the same section, though, he concludes that mining is inherently dangerous, and no amount of regulation can make it safe. So which is it? Any of this is, at very best, folly, but regardless of political bent (he is a self avowed "leftist liberal") has absolutely no place in a book ostensibly on safety systems. As such I think portions of this book show what is so wrong in American academia today: even genuinely excellent research can be easily spoiled when the conclusions are known before the research is started. This is one of the many reasons that physical scientists scorn the social sciences, and it doesn't have to be this way.

Having said all that there IS a wealth of good information and insight in this book when Perrow sticks to systems and their interactions. The book contains the finest analysis commercially available of the Three Mile Island near-disaster, and his insight about how to improve safety in nuclear plants was timely when the book was written in 1984, though many improvements have been made since then.

Speaking as a commercial airline pilot, I feel his conclusions and observations about aircraft safety were generally true at the time of printing in 1984, but now are miserably out of date. (The same is true of the Air Traffic Control section.) I believe that he generally has a good layman's grasp of aviation, so I am willing to take it as a given that he has a knowledgeable layman's comprehension of the other systems discussed. As an aside, he never gets some of the technicalities quite right. For instance, he constantly uses the term 'coupling' incorrectly in the engineering sense; this is particularly objectionable in the aviation system where it has a very specific meaning to aeronautical engineers and pilots.

The section on maritime accidents and safety is superbly written. Here I am not an expert, but there seems to be a high degree of correlation with the aviation section. His section on "Non Collision Course Collisions" by itself makes this book a worthwhile read. He presents very compelling information and reasoning until the very end of the section, at which point he suggests that since ships are now so big, large ships (especially supertankers) essentially should have no Captain, but should be run by committee. This is an invalid conclusion, and he offers no evidence or substantial argument to support that idea. Clearly, it is an idea hatched in his office and not on a ship (or plane.) There always needs to be a person in a place of ultimate authority in fast moving, dynamic systems, or the potential exists to have crew members begin to work at direct odds with each other, making a marginal situation dangerous. Ironically, in the very same part of the discussion where he concludes that there should be no Captain, he has hit upon the key to the problem. He mentions that he was pleased to see that some European shippers were now training their crews together as a team, and that he expected this to lower accident rates. He is, in fact, exactly right about that. Airlines now have to train crews in Crew Resource Management (CRM) in which each member of the crew has the right and obligation to speak up if they notice anything awry in the operation of their aircraft, and the Captain makes it a priority to listen to the input of others, as everyone has a different set of concerns and knowledge. In this way, the Captain becomes much less dictatorial, and becomes more of a final decision maker after everyone has had their say. It IS critical, though, to maintain someone in command, as there is no time to assemble a staff meeting when a ship is about to run aground, or a mid-air collision is about to occur. Many other well documented studies and books have come to this conclusion, and in the airline industry since CRM was introduced the accident rate has decreased dramatically.

Overall, if you have a desire to understand high risk systems, this book has a lot of good information in it; however it is woefully out of date and for that reason among others, I can only recommend it with reservations. A better and much more contemporary introductory book on the subject is 'Inviting Disaster' by James R. Chiles. Remember, this book was written over twenty years ago, and much has changed since then. There is knowledge to be gleaned here, but you have to be prepared to sort the wheat from the chaff.

12 of 13 people found the following review helpful:

5.0 out of 5 stars Of Lasting Value, Relevant to Today's Technical Maze, January 27, 2003

By	Robert D. Steele (Oakton, VA United States) - See all my reviews (TOP 50 REVIEWER)

Edit of 2 April 2007 to add link and better summary.

I read this book when it was assigned in the 1980's as a mainstream text for graduate courses in public policy and public administration, and I still use it. It is relevant, for example, to the matter of whether we should try to use nuclear bombs on Iraq--most Americans do not realize that there has never (ever) been an operational test of a US nuclear missile from a working missle silo. Everything has been tested by the vendors or by operational test authorities that have a proven track record of falsifying test results or making the tests so unrealistic as to be meaningless.

Edit: my long-standing summary of the author's key point: Simple systems have single points of failure that are easy to diagnose and fix. Complex systems have multiple points of failure that interact in unpredictable and often undetectable ways, and are very difficult to diagnose and fix. We live in a constellation of complex systems (and do not practice the precationary principle!).

This book is also relevant to the world of software. As the Y2K panic suggested, the "maze" of software upon which vital national life support systems depend--including financial, power, communications, and transportation software--has become very obscure as well as vulnerable. Had those creating these softwares been more conscious of the warnings and suggestions that the author provides in this book, America as well as other nations would be much less vulnerable to terrorism and other "acts of man" for which our insurance industry has not planned.

I agree with another review who notes that this book is long overdue for a reprint--it should be updated. I recommended it "as is," but believe an updated version would be 20% more valuable.

Edit: this book is still valuable, but the author has given us the following in 2007:
The Next Catastrophe: Reducing Our Vulnerabilities to Natural, Industrial, and Terrorist Disasters

15 of 18 people found the following review helpful:

3.0 out of 5 stars Where are all the catastrophes he talks about?, June 26, 2002

By	voracious reader "One Reader's Opinion" (Oakland, CA USA) - See all my reviews

It's a good and interesting theory motivated by a desire to do away with nuclear power. Fine and dandy, but the problem is that while we can tick off a few major disasters: Chernobyl, Bhopal, possibly the intelligence failure leading up to September 11th, the truth is, all his doomsday prophecies have yet to come true. Maybe Perrow is a Cassandra, unlistened to and unappreciated until his prophecies come true. There are a variety of managers who have taken up the task of managing their complex, tightly coupled systems for reliability. Perrow addresses some of them in the afterword to the 2000 edition, but he gives them short shrift. No doubt Perrow touched off a flurry of new research on organizations and this book has, thus, become a classic. But some classics have to be update4d, rethought, and evaluated once again with the searching spotlight of new knowledge. The fact is, at a major weapons lab in the southwest there will be on the order of 1000 fatalities in 1000 years from traffic accidents and only 5 in 1000 years from nuclear related disaster. While traffic movement is complex and tightly coupled, it is probably not a system as he defines it. My suggestion is to read Perrow with Sagan, grasp the underlying theory behind Normal Accident Theory and then read the work of the Berkeley High Reliability Organizations group (Rochlin, LaPorte, Roberts, Weick--at Michigan) etc. THis will give a more well-rounded picture.