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 …
Flood plains and land use
An increasingly pressing consequence of climate change is the rising threat of flood in coastal and riverine communities. And yet a combination of Federal and local policies have created land use incentives that have led to increasing development in flood plains since the major floods of the 1990s and 2000s (Mississippi River 1993, Hurricane Katrina …
Testing the NRC
Serious nuclear accidents are rare but potentially devastating to people, land, and agriculture. (It appears that minor to moderate nuclear accidents are not nearly so rare, as James Mahaffey shows in Atomic Accidents: A History of Nuclear Meltdowns and Disasters: From the Ozark Mountains to Fukushima.) Three Mile Island, Chernobyl, and Fukushima are disasters that …
Soviet nuclear disasters: Kyshtym
The 1986 meltdown of reactor number 4 at the Chernobyl Nuclear Power Plant was the greatest nuclear disaster the world has yet seen. Less well known is the Kyshtym disaster in 1957, which resulted in a massive release of radioactive material in the Eastern Ural region of the Soviet Union. This was a catastrophic underground …
Safety and accident analysis: Longford
Andrew Hopkins has written a number of fascinating case studies of industrial accidents, usually in the field of petrochemicals. These books are crucial reading for anyone interested in arriving at a better understanding of technological safety in the context of complex systems involving high-energy and tightly-coupled processes. Especially interesting is his Lessons from Longford: The …
Auditing FEMA
Crucial to improving an organization's performance is being able to obtain honest and detailed assessments of its functioning, in normal times and in emergencies. FEMA has had a troubled reputation for faulty performance since the Katrina disaster in 2005, and its performance in response to Hurricane Maria in Louisiana and Puerto Rico was also criticized …
The 737 MAX disaster as an organizational failure
The topic of the organizational causes of technology failure comes up frequently in Understanding Society. The tragic crashes of two Boeing 737 MAX aircraft in the past year present an important case to study. Is this an instance of pilot error (as has occasionally been suggested)? Is it a case of engineering and design failures? …
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