Normal Accidents of Expertise

Abstract

The organizational theorist Charles Perrow invented the term "normal accidents" ([1984] 1999) to apply to the kinds of failures that are inevitable in complex systems, such as chemical plants or nuclear plants, which are "coupled" in a tight way, meaning that when something went wrong in one part of the system it would have consequences for other parts of the system (Perrow [1984] 1999, 72, 89-100). Some of the consequences in such systems are predictable linear consequences of failures of components in the system. Others, which will be my main concern here, will involve multiple failures of components with unpredictable consequences. These consequences can include catastrophic outcomes. Loosely coupled systems, such as an assembly process that is made up of several component assembly processes that operate independently but need to converge at the final assembly of a product, also fail, but they allow for more time to correct for failures and to invent responses. Tightly coupled systems are more sensitive: responses need to be immediate and routinized, which means that failures must be anticipated in advance. The failures that can be anticipated in advance are those for which redundant systems can be created or standard operating procedures for correction can be applied in the face of failure. Many failures in a coupled system, however, result from unanticipated interactions between elements of the system in the face of the failure of multiple elements of the system, which produces problems that cannot be solved by standard procedures. When tightly coupled

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