Systems Failures

When I was at the college used book sale, I picked up a copy of Normal Accidents, by Charles Perrow. I have mentioned that I am delighted by the concept of 'systems', so it would stand to reason that I am also interested by system failure -- failure as a result of the system itself, not as a result of a flaw in a system component. This, from the introduction, makes the key point:

We start with a plant, airplane, ship, biology laboratory, or other setting with a lot of components (parts, procedures, operators). Then we need two or more failures among components that interact in some unexpected way. No one dreamed that when X failed, Y would also be out of order and the two failures would interact so as to both start a fire and silence the fire alarm...Next time they will put in an extra alarm system and a fire suppressor, but who knows, that might just allow three more unexpected interactions ...

Exactly. The joining of two components brings another layer of complexity and opportunity for interaction, once which is not always immediately apparent, and some times not apparent at all. I am always fascinated, in a minor way, when people are found to be injured now by something that for quite some time was considered to be safe, and perhaps even desirable. Take the use of asbestos in schools, or nuclear power plants, which were to have created power so cheap that it would not be worth your time to meter it. While each of those stands alone in the condition of now being seen as a danger, each is also a component of a system which was to have been better than that which came before. We don't think that now. And I suspect that if you turn your mind to how we used to think of these things, and how we think of them now, then some of the comments -- dare I say ravings -- of people on the fringe, people who refuse to accept the utter usefulness of society's interlocked systems, might begin to make just a little more sense.

Of course, in Oath of Fealty, they're the idiots.