standardised according to rules and procedures. This is evidenced by such
things as specialisation, backup systems, double-checking,
rule books and
detailed manuals of procedure. Consequently, the opportunity for instinct or
feel is curtailed and things now have to be done in the “right” way which is
also regarded as “logical,” in a style reminescent of Weber.
Now one effect of these developments into rules and logic is to improve safety
and efficiency. However, another effect is to set the stage and write the script
for system accidents which now become somewhat more likely.
Once the system is set on a logical course it will do what it will do. Of course
those who run the system can foresee that any component of the system can
fail. Consequently, they can take steps to reduce this likelihood and devise a
plan of relief and repair in the event of a failure.
But what they cannot so easily foresee in a complex, opaque system with
many interacting components is a combination of two happenings. There is
not just one failure but two or even more failures, that occur simultaneously.
Once the multiple failures occur, there is a reaction between them. This can be
the disaster, and given the way it has occurred, it is near impossible in the
ordinary course of events for an organisation to foresee.
Because the system is tightly coupled, any adverse effect runs through the
system. It may well do so swiftly and without obstruction from the system. By
this means, small problems or malfunctions in a few components can escalate
into a disaster. System accidents
become more likely (and probably more
serious) when certain conditions are present. For example, components have
multiple functions and can fail in more than one direction or components are
very close to each other.
468
Some examples of system accidents proposed by those who propound the
theory are as follows:
#
The Three Mile Island nuclear power plant meltdown, 28 March
1979. Eventually the reactor was brought under control without loss of life.
#
The crash of ValuJet 592 in the Everglades, 11 May 1996.
#
The crash of the space shuttle Columbia, 1 February 2003.
Columbia
over Texas, on its 28th mission. All
seven crew members aboard perished.
___________________
468
Rijpma, Jos A (1997) “Complexity, Tight-Coupling and Reliability:
Connecting Normal Accidents
Theory and High Reliability Theory” Journal of
Contingencies and Crisis Management 5, No 1, March, pp 15-23, p16
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