Charles Perrow

warning system

“Unfortunately, most warning systems do not warn us that they can no longer warn us.”

― Charles Perrow (1925 - 2019)

technology fix commercial airline aviation risk performance

“Unfortunately, the technological fixes have frequently only enabled those who run the commercial airlines, the general aviation community, and the military to run greater risks in search of increased performance.”

― Charles Perrow (1925-2019)

enginer control loop human component pilot disoriented

“Engineers speak of a “control loop,” in which the “man in the loop” is the problematical element. This is the human component in a series of sequentially interacting pieces of equipment that control or adjust a function. But when the pilot is suddenly and unexpectedly brought into the control loop (in other words, participates in decision making) as a result of (inevitable) equipment failure, he is disoriented. Long periods of passive monitoring make one unprepared to act in emergencies. The sudden appearance of several alarms, all there for safety reasons, leads to disorientation.”

― Charles Perrow (1925-2019)

pursuit official goals unlikely common

"Unambiguous pursuit of official goals is not likely to be common."

― Charles Perrow (1925-2019

official goals purpose organization vague

"Official goals are the general purposes of the organization as put forth in the charter, annual reports, public statements... Official goals are purposely vague and general and do not indicate two major factors which influence organizational behavior: the host of decisions that must be made among alternative ways of achieving official goals, and the priority of multiple goals and the many unofficial goals pursued by groups within the organization. "

― Charles Perrow (1925-2019)

activity organization rule supervision

"The vast proportion of the activity in organizations goes on without personal directives and supervision – and even without written rules – and sometimes in permitted violation of the rules."

― Charles Perrow (1925-2019)

normal accident incomprehensible

"Most normal accidents have a significant degree of incomprehensibility. "

― Charles Perrow (1925-2019)

combination circumstances catastrophe error accident

"It takes just the right combination of circumstances to produce a catastrophe, just as it takes the right combination of inevitable errors to produce an accident."

― Charles Perrow (1925-2019)

big accident small incident disaster technology organisation

"People make mistakes, Big accidents almost always escalate from small incidents, Many disasters stem not from the technology but from an organisational failure."

― Charles Perrow (1925-2019)