Command and Control by Eric Schlosser

Author:Eric Schlosser [Schlosser, Eric]
Language: eng
Format: epub, mobi
Google: RIKOnQEACAAJ
Amazon: 1594202273
Barnesnoble: 1594202273
Publisher: THORNDIKE Press
Published: 2013-09-17T04:00:00+00:00

Epilogue

The sociologist Charles B. Perrow began his research on dangerous technologies in August 1979, after the partial meltdown of the core at the Three Mile Island nuclear power plant. In the early minutes of the accident, workers didn’t realize that the valves on the emergency coolant pipes had mistakenly been shut—one of the indicator lights on the control panel was hidden by a repair tag. Perrow soon learned that similar mistakes had occurred during the operation of other nuclear power plants. At a reactor in Virginia, a worker cleaning the floor got his shirt caught on the handle of a circuit breaker on the wall. He pulled the shirt off it, tripped the circuit breaker, and shut down the reactor for four days. A lightbulb slipped out of the hand of a worker at a reactor in California. The bulb hit the control panel, caused a short circuit, turned off sensors, and made the temperature of the core change so rapidly that a meltdown could have occurred. After studying a wide range of “trivial events in nontrivial systems,” Perrow concluded that human error wasn’t responsible for these accidents. The real problem lay deeply embedded within the technological systems, and it was impossible to solve: “Our ability to organize does not match the inherent hazards of some of our organized activities.” What appeared to be the rare exception, an anomaly, a one-in-a-million accident, was actually to be expected. It was normal.

Perrow explored the workings of high-risk systems in his book Normal Accidents, focusing on the nuclear power industry, the chemical industry, shipping, air transportation, and other industrial activities that could harm a large number of people if something went wrong. Certain patterns and faults seemed common to all of them. The most dangerous systems had elements that were “tightly coupled” and interactive. They didn’t function in a simple, linear way, like an assembly line. When a problem arose on an assembly line, you could stop the line until a solution was found. But in a tightly coupled system, many things occurred simultaneously—and they could prove difficult to stop. If those things also interacted with each other, it might be hard to know exactly what was happening when a problem arose, let alone know what to do about it. The complexity of such a system was bound to bring surprises. “No one dreamed that when X failed, Y would also be out of order,” Perrow gave as an example, “and the two failures would interact so as to both start a fire and silence the fire alarm.”

Dangerous systems usually required standardized procedures and some form of centralized control to prevent mistakes. That sort of management was likely to work well during routine operations. But during an accident, Perrow argued, “those closest to the system, the operators, have to be able to take independent and sometimes quite creative action.” Few bureaucracies were flexible enough to allow both centralized and decentralized decision making, especially in a crisis that could threaten hundreds or thousands of lives.

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