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Safety

Normal Accident Theory

In some systems, accidents are structural.

The article

If

In systems that are both interactively complex and tightly coupled, small independent failures interact in ways no designer anticipated and propagate faster than operators can intervene — so accidents become a property of the structure, not bad luck.

Then

Reduce coupling — add buffers, timeouts, bulkheads, and circuit breakers — and cut complexity before adding more safety interlocks, which themselves add interactions.

Unless

High-Reliability Organizationsculture, slack, and decoupling measurably beat fatalism

Perrow's two axes: interaction complexity against coupling, with the accident-prone quadrant markedNormal accidents live hereAssembly lineBatch jobDamRail networkUniversityR&DNuclear plantMicroservice meshdecouplecut interactionsTight couplingLoose couplingLinear interactionsComplex interactions
Perrow put systems on two axes. Only the top-right quadrant produces accidents nobody designed and nobody can catch in time. Both axes are yours to move: decouple with buffers, timeouts and bulkheads, or cut the interactions. Adding another safety interlock moves you the wrong way on the horizontal one.

Source

Charles Perrow, Normal Accidents: Living with High-Risk Technologies (Basic Books, 1984).

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See also