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Normal Accidents: Living with High-Risk Technologies: Difference between revisions
Normal Accidents: Living with High-Risk Technologies (view source)
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If, on the other hand, the operator’s role is to manage ''[[complexity]]'' — then technology, checklists and pre-packaged risk taxonomies can only take you so far and, at the limit, can get in the way. Perrow’s account of the control deck at Three Mile Island, as reactant coolant pumps began cavitating, thumping and shaking, is instructive: | If, on the other hand, the operator’s role is to manage ''[[complexity]]'' — then technology, checklists and pre-packaged risk taxonomies can only take you so far and, at the limit, can get in the way. Perrow’s account of the control deck at Three Mile Island, as reactant coolant pumps began cavitating, thumping and shaking, is instructive: | ||
{{quote|“In the control room there were three audible alarms sounding, and many of the 1,600 lights (on-off lights and rectangular displays with some code numbers and letters on them) were on or blinking. The operators did not turn off the main audible alarm because it would cancel some of the annunciator lights. The computer was beginning to run far behind schedule; in fact it took some hours before its message that something might be wrong with the PORV finally got its chance to be printed. Radiation alarms were coming on. The control room was filling with experts; later in the day there were about forty people there. The phones were ringing constantly, demanding information the operators did not have. Two hours and twenty minutes after the start of the accident, a new shift came on.” <ref>{{br|Normal Accidents}} p. 28.</ref> | {{quote|“In the control room there were three audible alarms sounding, and many of the 1,600 lights (on-off lights and rectangular displays with some code numbers and letters on them) were on or blinking. The operators did not turn off the main audible alarm because it would cancel some of the annunciator lights. The computer was beginning to run far behind schedule; in fact it took some hours before its message that something might be wrong with the PORV finally got its chance to be printed. Radiation alarms were coming on. The control room was filling with experts; later in the day there were about forty people there. The phones were ringing constantly, demanding information the operators did not have. Two hours and twenty minutes after the start of the accident, a new shift came on.” <ref>{{br|Normal Accidents}} p. 28.</ref> }} | ||
This is, as Perrow sees it, the central dilemma of the [[complex system]]. The nature of [[normal accidents]] is such that they need experienced, wise operators on the ground ready to think quickly and laterally to solve unfolding problems, but the enormity of the risks involved mean that central management are not prepared to delegate so much responsibility to the mortal, inconstant, narratising [[meatware]]. | This is, as Perrow sees it, the central dilemma of the [[complex system]]. The nature of [[normal accidents]] is such that they need experienced, wise operators on the ground ready to think quickly and laterally to solve unfolding problems, but the enormity of the risks involved mean that central management are not prepared to delegate so much responsibility to the mortal, inconstant, narratising [[meatware]]. | ||