2021/08/09 Normal Accidents, High Reliability, Wicked Messes

Submitted by daviding on Tue, 08/10/2021 - 01:55

Discussion Leader

David Ing

Session Description

The original announcement is at https://wiki.st-on.org/2021-08-09.

Have we learned from brushes with disaster, or have we become complacent about complexities in everyday life?

On March 28, 1979, an accident with a nuclear reactor occurred at Three Mile Island, Pennsylvania. Twelve days earlier, an Academy Awards winning film The China Syndrome had opened with a story fictionalized from a 1975 fire at a nuclear plant in Brown's Ferry, Alabama, raising public awareness of an issue. For a Presidential Commission on the Accident at Three Mile Island, sociologist Charles Perrow contributed organizational analysis report. On a sabbatical to the Center for Advanced Study in the Behavioral Sciences in 1981-1982, that report expanded to include other high-risk systems, becoming the Normal Accidents book, published in 1984.

In the 1990s, a group at Berkeley initiated by Todd LaPorte noticed some high-hazard organizations who able to consistently manage risks to be failure-free. The organizations included the (i) Air Traffic Control System (FAA); (ii) Electric Operations and Power Generations Departments (Pacific Gas and Electric); and (ii) peacetime flight operations in the U.S. Navy. These cases were studies as High Reliability Organizations.

Many of the researchers continue to meet in the Center for Catastrophic Risk Management (CCRM). In the study of complexity, Ian Mitroff has labelled some situations as wicked messes.

Suggested pre-reading: 

Articles in reflection:

Original works:


David Ing, "Normal Accidents, High Reliability, Wicked Messes: The Nature(s) in System(s) Changes, Designing for Learning", Systems Thinking Ontario, Toronto, Canada, August 9, 2021