ABSTRACT It has been 40 years since Charles Perrow published the landmark work Normal Accidents (19841999), built largely on an analysis of the Three Mile Island (TMI) nuclear power plant accident. While still a highly influential framework in the study of complex systems, the status of the argument remains in flux. The central argument was that certain technological systems are so complex and tightly coupled that accidents will occur no matter how hard we try to prevent them. While many analyses proceed on the acceptance of the main argument, various other literatures proceed according to the idea that we can keep such systems operating safely through various safety principles. At this point, a common idea is that, regardless of the technology, errors of management (whether by mistake or misconduct) are the problem. This paper argues that abandoning the concerns about technical complexity is a mistake—that we can and continue to build systems that outstrip our abilities of prediction and control. I illustrate by providing three different ways of characterising the space shuttle Challenger accident—as mistake, as misconduct, and as normal accident. In the end, the space shuttle program was so technically and organisationally complex that occasional failure of missions was probably inevitable regardless of all else.
Joseph H. Spear (Sat,) studied this question.