#normal accidents

[eightyonekilograms]

The captain decided to pass through the Scilly Islands, a rash of sand-spits and rocks comprising forty-eight tiny islands. Four are inhabited, mostly by fishermen, and there have been 257 wrecks there between 1679 and 1933. Tales of false lights and plundered ships abound. Edward Cowan, in his lively tale Oil and Water, notes that the following petition has been attributed to the Reverend John Troutbeck, a chaplain in the Scillies in the later eighteenth century:

We pray thee, O Lord, not that wrecks should happen, but if wrecks do happen Thou wilt guide them into the Scilly Isles for the benefit of the poor inhabitants.

[haveialreadyreadthat]

...the events that constitute our lives are subject to many interpretations, not just by outsiders, but by ourselves. When an unexpected event occurs, we need to explain it not only to others, but to ourselves. So we imbue it with meaning in order to make sense of it. We correct history, reconstructing the past so that it will be consistent with the present, reaffirming our sense of self and place in the world. We reconstruct history every day, not to fool others, but to fool ourselves, because it is integral to the process of going on.

The Challenger Launch Decision, Diane Vaughn, 2016 edition

[jellobiafrasays]

Normal Accidents (1984 ed., cover design by Janet Halverson)

[zinjanthropusboisei]

Love to read popular writing about maritime disasters and hit the inevitable part of the book/article where they start quoting Charles Perrow and reaming out the owners/regulators for causing the catastrophe. I’ve just hit that point in Until the Sea Shall Free Them about the Marine Electric sinking - my (former sailor) brother and I have been talking sea shanties lately for obvious reasons and he recommended it. 

[haveialreadyreadthat]

Ironically, efforts to communicate more can result in knowing less. Rules that guarantee wide distribution of information can increase the amount to the point that a lot is not read... The ability to produce, accumulate, store and exchange information using sophisticated transaction systems has become a symbol of legitimacy for many organisations. Obfuscation parades as clarity: they produce too much, obscuring rather than enlightening.  Systematic censorship is a natural response to this abundance.

The Challenger Launch Decision, Diane Vaughn, 2016 edition

[sheathandshear]

...Given the byzantine nature of U.S. health-care logistics and the constant implementation of new technologies, errors may just be part of the game. The theory of "normal accidents" - introduced by Charles Perrow in 1984 and applied to disasters like the meltdown at Three Mile Island and later the Challenger crash - describes serious accidents that occur in complex, high-risk systems as being a result of "multiple failures that are not in a direct operational sequence." Basically, the idea is that as small errors occur independently in different areas of the system, they'll ultimately interact with each other in ways that are more or less impossible to prevent or respond to appropriately.

Cecil Adams, The Straight Dope

[jellobiafrasays]

we almost lost detroit (1976 ed.)

[wordswilling]

Centralization is appropriate for organizations with routine tasks, and decentralization for those with nonroutine tasks.

Charles Perrow, Normal Accidents: Living with High-Risk Technologies