two or more failures. These failures will occur in multiple and unforeseen ways
since the system has just too many possible action pathways. They are hard to
prevent because they are virtually impossible to predict in foresight. As
explained below, tight coupling creates a network of interdependencies. A
consequence is that it makes it hard to see at a glance how some particular
works. Consequently, the processes involved in the system, and
the events that occur there, are opaque, rather than transparent. Perrow terms
this incomprehensibility, and it can be a major contributing factor. Yet, in sad
contrast, the cause of the accident tends to be easy to understand in hindsight.
Complexity
Complexity in an institution can either be technological or organisational. In
many cases it is a bit of both.
Tight Coupling
Coupling is a term used in computer science and is taken by analogy into the
study of organisational behaviour. Coupling is an interaction between
components or applications. In computer science coupling is used in the
context of interaction between two pieces of software. Coupling is measured
by (and thus describes) the degree of knowledge that a programmer of one of
the pieces of software must have about the other in order to make a successful
interaction between the two pieces of software.
Coupling, of course, is a concept of degrees. At one extreme there can be a
fully decoupled exchange where the two participants need have no knowledge
about each other in order to interact. In a loosely coupled exchange, the two
participants may have specific, but more limited knowledge about each other.
In a tightly coupled exchange, the participants require detailed knowledge.
In social science “coupling” takes on a spread of meanings although there is at
least a whiff of commonalty among many of them. In this context, “coupling”
means control or dependency. There is a network of dependency so that
change in one component in the system requires the other system to change to
accommodate it or to keep working, or causes change in it in a chain reaction.
How the Accident Happens
One theory on how accidents happen is that people who are trained and
experienced such as a professional, operate on feel or instinct as well as logic,
and will also ‘sniff around’ and ‘taste’ before they seek to deal with a
complicated problem. However, this changes at an organisation increases in
size. This occurs because with increased size, an organisation generally
contains more elments and more employees. Along with this comes
specialisation. Additionally, there may be some tendency for larger
organisations to become highly formalised so that operations become
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