Normal Accidents by Charles Perrow - Notes
2026-05-22 β Transcribed notes on Failure Areas, Failure Origins, Operating Experience, and Process Adherence from Charles Perrow's Normal Accidents.
Normal Accidents
π View Original Handwritten Notes (English Source)
Failure areas:
- Design
- Equipment
- Procedures
- Operators
- Supplies and material
- Environment
Failure origins:
- Tightly coupled systems
- Complexly interactive systems
βSeeing is not necessarily believing;
Sometimes, we must believe before we can seeβ
System (2 sides)
independent decisions
Creative
β
decentralized
tight coupling
time control
β
centralized
Reliability Graph
- Event A: Collapse of a medieval Cathedral
High learning (at a time) β applied - Event B: Nuclear plant accident
Low learning (comparative) β hard to apply - AI: perhaps we can use AI for better supervision & control on mission-critical objects leading to breaking plateau?
Operating experience
Cumulative operating capacity = Ξ£ (plant capacity Γ time operated)
Anticipated expansion / scale rate = 2 Γ (higher theoretical border of risk)
(Formula: cumulative operating capacity / ordered capacity)
(Formula: cumulative operating capacity / ordered capacity)
- Actual expansion / scale rate: 3.5%! β actually scaling 60x more aggressively (or) having 60x less experience with new tech
Lower experience
higher operational costs
β
expectations mismatch
continuous engineering changes
β
undervaluing technical complexity
Process adherence issues:
- cover-ups
- intimidations
- falsifications
- neglect
- mistakes
- deception
- mistraining
β¦
Niche demand
β
Enforced design
β
Mass adoption
β
Limited flexibility