topic: [[]] people: created: 2024-04-09 *I am the note template.* This reminds me of It's kind of like ##### what is it? A system accident (or normal accident) is an "unanticipated interaction of multiple failures" in a complex system. This complexity can either be of technology or of human organizations and is frequently both. A system accident can be easy to see in hindsight, but extremely difficult in foresight because there are simply too many action pathways to seriously consider all of them. Charles Perrow first developed these ideas in the mid-1980s. Safety systems themselves are sometimes the added complexity which leads to this type of accident.Pilot and author William Langewiesche used Perrow's concept in his analysis of the factors at play in a 1996 aviation disaster. He wrote in The Atlantic in 1998: "the control and operation of some of the riskiest technologies require organizations so complex that serious failures are virtually guaranteed to occur." > [Wikipedia](https://en.wikipedia.org/wiki/System%20accident) Charles Perrow used the term ‘‘normal accidents’’ to characterize a type of catastrophic failure that resulted when complex, tightly coupled production systems encountered a certain kind of anomalous event. These were events in which systems failures interacted with one another in a way that could not be anticipated, and could not be easily understood and corrected. Systems of the production of expert knowledge are increasingly becoming tightly coupled. Unlike classical sci- ence, which operated with a long time horizon, many current forms of expert knowledge are directed at immediate solutions to complex problems. These are prone to breakdowns like the kind discussed by Perrow. The example of the Homestake mine experiment shows that even in modern physics complex systems can produce knowledge failures that last for decades. The concept of knowledge risk is introduced, and used to characterize the risk of failure in such systems of knowledge production. ##### why does it matter? ##### What would the opposite argument be? tags: #note/growing ##### Sources: Edmondson, A. C. (2023). _[[Right Kind of Wrong - the science of failing well]]_ (First Atria books hardcover edition). Atria Books.