Normal accidents

Perrow, C. (1999). Normal Accidents Living with High-Risk Technologies. Princeton Princeton University Press. 

For all 17 accidents of this study, precursors could be identified. None of the 17 accidents could be classified as unforeseen . A total number of 39 precursors were identified in these 17 accidents which seems extremely low compared to normal accident analysis experience. Detailed accident analysis normally retrieves dozens of near misses and deviations leading to the final accident (e.g. van der Schaaf (Schaaf van der, 1992)), implying the existence of many more precursors. However, the limited amount of detailed information present in the FACTS database is the restricting factor here. The FACTS database reflects the kind of accident information companies and government agencies collect. It demonstrates clearly that detailed information about the period before the accident is not often collected. 

Perrow C., 1984. Normal accidents, Basic Books, New York. 

Secondary prevention and mitigation, by themselves, are unable to eliminate the risk of serious or catastrophic chemical accidents, although improved process safety management can reduce their probability and severity. Most chemical production involves transformation processes, which are inherently complex and tightly coupled. Normal accidents are an unavoidable risk of systems with these characteristics [11]. However, the risk of serious, or catastrophic, consequences need not be. Specific industries use many different processes. In many cases, alternative chemical processes exist which completely or almost completely eliminate the use of highly toxic, volatile, or flammable chemicals [12]. 

Perrow, C. "Normal Accidents Living with High-Risk Technologies" Basic Books, Inc. New York, 1984,... 

Leveson, Nant G., Nicolas Dulac, Karen Marais, and John Carroll. (February/March 2009). Moving beyond normal accidents and high reliability organizations A systems approach to safety in complex systems Organization Studies 30227-249. 

Systemic models, assuming non-linear dependencies, explaining accidents as a result of complexity and tight couplings or performance variability. Examples of a systemic model based on complexity and tight couplings are mentioned in Perrow (1984) Normal Accidents . 

In general there was little focus on systemic accident models. However complexity has been mentioned, but no references to theory. The theory of Normal Accidents could have been explored and discussed, and may have given broader insight in causal factors behind the accidents. 

Perrow, C. 1984. Normal Accidents Living with high risk technologies N.Y. Basic Books. 

In this article we claim that this is not a random train of unfortunate circumstances . Rosness et cd (2002) place the accident according to theories on HRO (Reason 1997) and Normal Accident (Per-row 1985). Our perspective is systemic approach of innovations and how this is creating mismatches in technological systems. 

Perrow, C. (1984). Normal accidents living with high-risk technologies. New York Basic Books. 

Figure 4. Resilience engineering, mitigating normal accidents.

We suggest that resilience engineering has given us a perspective to discuss and mitigate normal accidents. When we move into the Black Swan environment, see Taleb (2007), exploring an highly improbable... 

In the case of a major accident you have all of the normal accident considerations and decisions, such as ... 

Perrow, C. Normal Accidents Doing with High-Risk Technolo es. Princeton, NJ. Princeton University Press, 1999. 

The acceptance criterion for the resolution of GSI II.D.l is that the qualification testing for the RCS block, relief, and safety valves must be performed in accordance with the guidance identified in NUREG-0737 and with ASME B PV code. Section III. The performance testing shall include both normal and off-normal (accident) conditions. Furthermore, the accident conditions... 

Marais K, Dulac N, Leveson N (2004) Beyond normal accidents and high reliability organizations the need for an alternative approach to safety in complex systems, http //sunnyday.mit.edu/ papers/hro.pdf. Accessed 16 April 2014... 

Perrow C (1999) Normal accidents. Living with high-risk technologies. Princeton University Press, Princeton... 

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