A recurring theme in Understanding Society is the topic of technology failure -- air disasters, chemical plant explosions, deep drilling accidents. This diagram is intended to capture several dimensions of failure causes that have been discussed. The categories identified here include organizational dysfunctions, behavioral shortcomings, system failures, and regulatory dysfunctions. Each of these broad categories has contributed …
Organizational factors and nuclear power plant safety
image: Peach Bottom Nuclear Plant The Nuclear Regulatory Commission has responsibility for ensuring the safe operations of the nuclear power reactors in the United States, of which there are approximately 100. There are significant reasons to doubt whether its regulatory regime is up to the task. Part of the challenge is the technical issue of …
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Dysfunctions of Soviet economic ministries
In my book A New Social Ontology of Government (2020) I tried to provide an analytical inventory of the sources of "dysfunctions" in large organizations and government agencies. Why do agencies like FEMA or the NRC so often do such a poor job in carrying out their missions? The book proposed that we can better understand the …
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Strange defeat
One of the consequential puzzles of the Second World War was the sudden, catastrophic collapse of the French army following German invasion in 1940. This is the subject of Marc Bloch's Strange Defeat, written in 1940, and it is an event of major historical importance and mystery. The mystery is this: France was a powerful military …
China’s food-safety governance system
Food safety is a very high-level concern for ordinary consumers. This is true because the food we eat can poison us or ruin our health, and yet consumers have little ability to evaluate the safety of the foods available in the marketplace. Therefore government regulation of food safety appears to be mandatory in any complex …
The power of case studies in system safety
Images: Andrew Hopkins titles Images: Other safety sources One of the genuinely interesting aspects of the work of Andrew Hopkins is the extensive case studies he has conducted of the causation of serious industrial accidents. A good example is his analysis of the explosion of an Esso natural gas processing plant in Longford, Australia in …
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High reliability organizations
Charles Perrow takes a particularly negative view of the possibility of safe management of high-risk technologies in Normal Accidents: Living with High-Risk Technologies. His summary of the Three Mile Island accident is illustrative: “The system caused the accident, not the operators” (12). Perrow’s account of TMI is chiefly an account of complex and tightly-coupled system processes, …
Why do regulatory organizations fail?
Why is Charles Perrow a pessimist about government regulation? Perrow is a leading researcher in the sociology of organizations, and he is a singular expert on accidents and failures. Several of his books are classics in their field -- Normal Accidents: Living with High-Risk Technologies, The Next Catastrophe: Reducing Our Vulnerabilities to Natural, Industrial, and …
Electronic Health Records and medical mistakes
Electronic Health Record systems (EHRs) have been broadly implemented by hospitals and health systems around the country as a way of increasing the accuracy, availability, and timeliness of patient health status and treatment information. (These systems are also sometimes called "Digital Medical Records" (DMRs).) They are generally regarded as an important forward step in improving …
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Regulatory delegation at the FAA
Earlier posts have focused on the role of inadequate regulatory oversight as part of the tragedy of the Boeing 737 MAX (link, link). (Also of interest is an earlier discussion of the "quiet power" through which business achieves its goals in legislation and agency rules (link).) Reporting in the New York Times this week by …
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