Charles Perrow

The organizational context of human factors engineering.

Human factors engineering concerns the design of equipment in accordance with the mental and physical characteristics of operators. Human factors engineers advise design engineers, but the organizational context limits their influence and restricts their perspective. The discussion of organizational context in this paper explains why military and industrial top management personnel are indifferent to good human factors design and shows how the social structure favors the choice of technologies that centralize authority and deskill operators and how it encourages unwarranted attributions of operator error. The role of equipment and system design in shaping cognitive maps and mental models is explored, and the technology-social structure paradigm is questioned.

Organization theory : from Chester Barnard to the present and beyond

This collection of papers is edited by renowned business thinker Oliver Williamson, who is currently Transamerica Professor of Corporate Strategy at the School of Business Administration at Berkeley. The fiftieth anniversary of the publication of Chester I. Barnards remarkable and still influential book, The Functions of the Executive, was celebrated with a seminar series at the University of California, Berkeley in the Spring of 1988. Eight of those lectures are published here. The contributors include organization specialists and sociologists (Barbara Levitt and James March; W. Richard Scott; Glenn Carroll; Jeffrey Pfeffer), an anthropologist, a political scientist, and two economists (Mary Douglas; Terry Moe; Oliver Hart; Oliver Williamson). An important contribution to organization theory, this volume reports on recent progress in this field, and projects a productive research future.

Organizing to Reduce the Vulnerabilities of Complexity

Complex and tightly coupled systems are inherently vulnerable to major system accidents, but some difficult structural changes can reduce their vulnerability. They can be decomposed into units that are connected by monitored links, despite the inefficiency of such decentralization. Designs can be inelegant and robust, rather than elegant and sensitive, despite this affront to engineering norms. Redundancies and all other safety measures should be designed in from the start and not added afterwards, since add-ons are disproportionately the source of accidents. Skepticism should be structured into the organization through explicit roles and generating worst case scenarios, and sensitive channels deliberately opened to daylight and monitoring. A formal system of error feedback should be instituted with contributions rewarded. Most important of all is increasing the role of external stakeholders in accident investigations and organizational changes, thus creating a dense network of independent organizations that keeps the risky system honest. Secret organizations which gather intelligence and perform covert actions are especially vulnerable to complexity but the least likely to adapt such structural changes. Examples are provided for each of the points.

Prosaic Organizational Failure

We use the case of the now-dead Shoreham Nuclear Power Station to pose some questions, and a few answers, about organizational failure. The analysis centers on the symbolism of organizational plans, specifically how organizations use plans to justify increasingly complex systems to themselves and to others. That such plans are based on sparse or nonexistent experience, and that they are often wildly unrealistic, suggests some reasons why high-technology, high-risk systems do not foster organizational learning.

Fukushima and the inevitability of accidents

Governments regulate risky industrial systems such as nuclear power plants in hopes of making them less risky, and a variety of formal and informal warning systems can help society avoid catastrophe. Governments, businesses, and citizens respond when disaster occurs. But recent history is rife with major disasters accompanied by failed regulation, ignored warnings, inept disaster response, and commonplace human error. Furthermore, despite the best attempts to forestall them, “normal” accidents will inevitably occur in the complex, tightly coupled systems of modern society, resulting in the kind of unpredictable, cascading disaster seen at the Fukushima Daiichi Nuclear Power Station. Government and business can always do more to prevent serious accidents through regulation, design, training, and mindfulness. Even so, some complex systems with catastrophic potential are just too dangerous to exist, because they cannot be made safe, regardless of human effort.

The meltdown was not an accident

This volume includes two major explanations of the meltdown that I critically discuss. The first is a “normal accident theory” arguing that the complexity and coupling of the financial system caused the failure. Although these structural characteristics were evident, I argue that the case does not fit the theory because the cause was not the system, but behavior by key agents who were aware of the great risks they were exposing their firms, clients, and society to. The second interpretation is a neoinstitutional one, emphasizing that ideologies, worldviews, cognitive frames, mimicry, and norms were the source of behaviors that turned out to be disastrous for the elites and others. The implication is that elites were victims, not perpetrators. I argue that while ideologies, etc., can have real effects on the behavior of many firm members and society in general, in this case financial elites, to serve personal ends, crafted the ideologies and changed institutions, fully aware that this could harm their firms, clients, and the public. Complexity and coupling only made deception easier and the consequences more extensive. For anecdotal evidence I examine a decade of deregulation, examples of elected representative, regulatory officials, firms, and the plentiful warnings.

The Reluctant Organization and the Aggressive Environment

This is an analysis of the origins and development of a city Youth Commission. The organization had little reason to be formed, no goals to guide it, and was staffed by people who sought to insure a minimal, no-action role in the community. By virtue of its existence and broad province, however, it was seized upon as a valuable weapon by other organizations for the pursuit of their goals. In the course of being used, the Commission became a viable organization in its own right with new goals, even as its members denied that the no-action policy had been compromised. John Maniha is a graduate student in the department of sociology, University of Michigan. Charles Perrow is associate professor in the department of sociology, and research associate in the Administrative Science Center, University of Pittsburgh.

Nuclear Waste: Knowledge Waste?

A stalled nuclear waste program, and possible increase in wastes, beg for social science input into acceptable solutions. Nuclear power is re-emerging as a major part of the energy portfolios of a wide variety of nations. With over 50 reactors being built around the world today and over 100 more planned to come online in the next decade, many observers are proclaiming a “nuclear renaissance” (1). The success of a nuclear revival is dependent upon addressing a well-known set of challenges, for example, plant safety (even in the light of improved reactor designs), costs and liabilities, terrorism at plants and in transport, weapons proliferation, and the successful siting of the plants themselves (2, 3).

Nuclear denial: From Hiroshima to Fukushima

Governments and the nuclear power industry have a strong interest in playing down the harmful effects of radiation from atomic weapons and nuclear power plants. Over the years, some scientists have supported the view that low levels of radiation are not harmful, while other scientists have held that all radiation is harmful. The author examines the radiation effects of nuclear bombs dropped on Japan in 1945; nuclear weapons testing; plutonium plant accidents at Windscale in England and Chelyabinsk in the Soviet Union; nuclear power plant emissions during normal operations; and the power plant accidents at Three Mile Island in the United States, Chernobyl in the Soviet Union, and Fukushima Daiichi in Japan. In each case, he finds a pattern of minimizing the damage to humans and attributing evidence of shortened life spans mostly to stress and social dislocation rather than to radiation. While low-level radiation is now generally accepted as harmful, its effects are deemed to be so small that they cannot be distinguished from the much greater effects of stress and social dislocation. Thus, some scientists declare that there is no point in even studying the populations exposed to the radioactive elements released into the atmosphere during the 2011 accident at Fukushima.

Disasters Ever More? Reducing U.S. Vulnerabilities

Natural disasters, unintended disasters (largely industrial and technological), and deliberate disasters have all increased in number and intensity in the United States in the last quarter century2(see Figure 32.1) In the United States we may prevent some and mitigate some, but we can’t escape them. At present, we focus on protecting the targets and mitigating the consequences, and we should do our best at that. But our organizations are simply not up to the challenge from the increasing number of disasters. What we can more profitably do is reduce the size of the targets, that is, reduce the concentrations of energy found in hazardous materials, the concentration of power in vital organizations, and the concentrations of humans in risky locations. Smaller, dispersed targets of nature’s wrath, industrial accidents, or terrorist’s aim will kill fewer and cause less economic and social disruption.