Normal Accidents LO12130
Wed, 22 Jan 1997 15:03:26 -0500 (EST)

Replying to LO12109 --

Hi Kent,

In a message dated 97-01-21 23:08:59 EST, you write:

" Ways have been found to organize the control of dams, and dams rarely fail for
either human or technological reasons. Ship navigation is generally the
same type of technology, but organizations fail in this area. Perrow tells
some fascinating stories about headstrong captains who know for hours that
they are on a collision course, yet collide anyway. He argues that ship
navigation is correctable with better organization.

" Other kinds of technology are "tightly coupled". "

Floodplain dwellers in California might not agree with Perrow! Loose
coupled systems can become "tightly coupled". For example the inhabitants
of the Saguenay region of Quebec experienced catastrophic flooding in July
last year because the flood control system seems to have become "tightly
coupled", destroying the resilience of the system. Contributory factors
seem to have been water levels being kept high to satisfy boaters and
fishers, industry reluctance to lower levels of company dams and "waste"
water and decision makers going on holiday. As a result when a downpour
hit the region the dams had little safety margin and when some overflowed
the entire system collapsed.

Best wishes,
David Hurst
Speaker, Writer and Consultant on Management
Author of "Crisis & Renewal: Meeting the Challenge of Organizational Change"
(HBS Press, 1995) <A HREF="
tml">McGraw-Hill Ryerson - Crisis & Renewal</A>


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