CASE STUDY
There Go the Lights, Here Come the Babies
by
Charles Lamson
In 1984, Yale University organizational sociologist Charles Perrow published a vary influential book entitled Normal Accidents. Perrow's interest in accidents started in 1979, when he testified before a presidential commission established to examine an accident in the three-mile island nuclear power plant, near Harrisburg, Pennsylvania. The committee concluded, as most of these investigations do, that the accident had resulted from operator error. Perrow disagreed with the findings of the committee, because the available evidence indicated that the power plant operators acted in completely sensible ways, given their training and information that was available to them.
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Perrow contended that accidents in complex organizations occur as a result of unique combinations of events, pressures and incentives. The more complex a system is, the larger number of possible unique accident-producing combinations there are. In retrospect, it is easy to see how all of the elements came together to create a particular situation, and to determine what the operators should have done. However, it is virtually impossible to anticipate all of these unique combinations ahead of time, or even to recognize that they are taking place, when one is in the middle of a crisis. When the systems are already tightly coupled (which means that when something goes wrong in one part of the system other parts are affected almost instantly), operators have no chance to obtain the information they need to correctly diagnose the problem, much less to intervene and stop the process.
In some cases systems actually encourage the errors that lead to accidents. For example, in the maritime industry, getting a ship to ts destination on time can mean thousands of dollars to the company. Most shipping companies share the windfall with the captains of the ships that arrive on time. As a result, on the one hand, shipping companies and ships' captains have a financial incentive to take risks. On the other hand, they have few disincentives to do so. Unlike automobile insurance rates, which go up significantly if a driver has an accident, shipping insurance rates are not based on accident records. Although some countries use safety records in decisions about licensing of ships, other ships or companies, other countries do not. So shipping companies can simply obtain licenses in the least demanding countries. Traditionally, these have been Panama and Liberia.
In addition, the costs of accidents usually are shared with many people outside of the company. Also, the companies can limit their liability through a variety of legal tactics. Consequently, the occurrence of accidents like the 1989 wreck of the Exxon Valdez in Prince William Sound, Alaska, is virtually guaranteed. Preventing them would require a complete redesign of the "accident-inducing" system, to use Perrow's phrase.
The 2003 electrical blackout in the northeastern United States and and southern Canada is an example of a systems error. It was not the first blackout - similar events took place in 1965 and 1977 - and a systems level analysis suggests that it almost certainly will not be the last. And the initial investigation, concluded that no one could have anticipated a massive power outage on a calm warm day - an event that could only happen if multiple safeguards broke down simultaneously.
5:06 PM: August 14, 2003
Ohio, USA
A power line owned by FirstEnergy of Ohio came into contact with untrimmed trees and shorted out. Power was automatically redirected to another line, which could not handle the load, overheated, and failed...
...(long story short) In January 2004, FERC chairman Pat Wood announced that his agency would act to force the utility companies to comply with standards that currently are voluntary. As predicted, industry spokespersons opposed the plan.
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