I’m reading Charles Perrow’s book Normal Accidents (Living with High-Risk Technologies). It’s about nuclear accidents, among other things, and the ways in which systemic complexity inevitably leads to expected or normal failure modes. I think John Allspaw may have recommended it to me with the words “failure porn”.
I’m only partway through. For a book on engineering and safety it’s completely fascinating, notably for the way it shows how unintuitively-linked circumstances and safety features can interact to introduce new risk. The descriptions of accidents are riveting, not least because many come from Nuclear Safety magazine and are written in a breezy tone belying subsurface potential for total calamity. I’m not sure why this is interesting to me at this point in time, but as we think about data flows in cities and governments I sense a similar species of flighty optimism underlying arguments for Smart Cities.
Loc. 94-97, a definition of what “normal” means in the context of this book:
If interactive complexity and tight coupling—system characteristics—inevitably will produce an accident, I believe we are justified in calling it a normal accident, or a system accident. The odd term normal accident is meant to signal that, given the system characteristics, multiple and unexpected interactions of failures are inevitable. This is an expression of an integral characteristic of the system, not a statement of frequency. It is normal for us to die, but we only do it once.
Loc. 956-60, defining the term “accident” and its relation to four levels of affect (operators, employees, bystanders, the general public):
With this scheme we reserve the term accident for serious matters, that is, those affecting the third or fourth levels; we use the term incident for disruptions at the first or second level. The transition between incidents and accidents is the nexus where most of the engineered safety features come into play—the redundant components that may be activated; the emergency shut-offs; the emergency suppressors, such as core spray; or emergency supplies, such as emergency feedwater pumps. The scheme has its ambiguities, since one could argue interminably over the dividing line between part, unit, and subsystem, but it is flexible and adequate for our purposes.
Loc. 184-88, on the ways in which safety measures themselves increase complexity or juice the risks of dangerous actions:
It is particularly important to evaluate technological fixes in the systems that we cannot or will not do without. Fixes, including safety devices, sometimes create new accidents, and quite often merely allow those in charge to run the system faster, or in worse weather, or with bigger explosives. Some technological fixes are error-reducing—the jet engine is simpler and safer than the piston engine; fathometers are better than lead lines; three engines are better than two on an airplane; computers are more reliable than pneumatic controls. But other technological fixes are excuses for poor organization or an attempt to compensate for poor system design. The attention of authorities in some of these systems, unfortunately, is hard to get when safety is involved.
Loc. 776-90, a harrowing description of cleanup efforts after the October 1966 Fermi meltdown:
Almost a year from the accident, they were able to lower a periscope 40 feet down to the bottom of the core, where there was a conical flow guide—a safety device similar to a huge inverted icecream cone that was meant to widely distribute any uranium that might inconceivably melt and drop to the bottom of the vessel. Here they spied a crumpled bit of metal, for all the world looking like a crushed beer can, which could have blocked the flow of sodium coolant.
It wasn’t a beer can, but the operators could not see clearly enough to identify it. The periscope had fifteen optical relay lenses, would cloud up and take a day to clean, was very hard to maneuver, and had to be operated from specially-built, locked-air chambers to avoid radiation. To turn the metal over to examine it required the use of another complex, snake-like tool operated 35 feet from the base of the reactor. The operators managed to get a grip on the metal, and after an hour and a half it was removed.
The crumpled bit of metal turned out to be one of five triangular pieces of zirconium that had been installed as a safety device at the insistence of the Advisory Reactor Safety Committee, a prestigious group of nuclear experts who advise the NRC. It wasn’t even on the blueprints. The flow of sodium coolant had ripped it loose. Moving about, it soon took a position that blocked the flow of coolant, causing the melting of the fuel bundles.
During this time, and for many months afterwards, the reactor had to be constantly bathed in argon gas or nitrogen to make sure that the extremely volatile sodium coolant did not come into contact with any air or water; if it did, it would explode and could rupture the core. It was constantly monitored with Geiger counters by health physicists. Even loud noises had to be avoided. Though the reactor was subcritical, there was still a chance of a reactivity accident. Slowly the fuel assemblies were removed and cut into three pieces so they could be shipped out of the plant for burial. But first they had to be cooled off for months in spent-fuel pools—huge swimming pools of water, where the rods of uranium could not be placed too close to each other. Then they were placed in cylinders 9 feet in diameter weighing 18 tons each. These were designed to withstand a 30-foot fall and a 30-minute fire, so dangerous is the spent fuel. Leakage from the casks could kill children a half a mile away.
That’s completely insane.
Hi Michal - I haven't read Perrow, but I wonder if he attempted to illustrate Lisanne Bainbridge's observation, "By taking away the easy parts of his task. automation can make the difficult parts of the human operator's task more difficult." Ironies of Automation. Automatica, Vol. 19, No. 6. pp. 775-779, at 777 (1983); http://www.ise.ncsu.edu/nsf_itr/794B/papers/Bainbridge_1983_Automatica.pdf. (I've seen Bainbridge cited as if she had said something more banal and definitive -- something like, taking away the easy parts of a task makes it more difficult.) Anyway ... I'm happy you'll be offering an elevation layer for OSM. Thanks! David
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