Quotes from Charles Perrow

Unfortunately, most warning systems do not warn us that they can no longer warn us.)

Organizational theorists, at least since Burns and Stalker, 1961 and Joan Woodward, 1965 in what came to be called the contingency school, have recognized that centralization is appropriate for organizations with routine tasks, and decentralization for those with nonroutine tasks.

Unfortunately, the technological fixes have frequently only enabled those who run the commercial airlines, the general aviation community, and the military to run greater risks in search of increased performance.

Shoddy construction and inadvertent errors, intimidation and actual deception—these are part and parcel of industrial life. No industry is without these problems, just as no valve can be made failure-proof. Normally, the consequences are not catastrophic. They may be, however, if you build systems with catastrophic potential.

example of a phenomenon that will concern us in this chapter: production pressures in this high-risk system.

The nuclear power industry, for example, lacks a strong union, has random public victims with delayed effects, has no safety board that is independent of licensing and regulatory functions, and does not see an immediate effect on its profits if safety flags (though a far more severe incentive exists to avoid a catastrophic accident which could shut down the industry).

Edwards continues by arguing that all this automation has not reduced the workload of the pilot a great deal; instead, it has increased the operational effectiveness of the system.

workload has become more "bunched," with long periods of inactivity and short bursts of intense activity. Both of these are error-inducing modes of operation.

no matter how effective conventional safety devices are, there is a form of accident that is inevitable.

If interactive complexity and tight coupling—system characteristics—inevitably will produce an accident, I believe we are justified in calling it a normal accident, or a system accident.