Charles Perrow - Normal Accidents (1984)
7 Sourced Quotes
The nuclear power industry, for example, lacks a strong union, has random public victims with delayed effects, has no safety board that is independent of licensing and regulatory functions, and does not see an immediate effect on its profits if safety flags (though a far more severe incentive exists to avoid a catastrophic accident which could shut down the industry)
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.
Organizational theorists, at least since the pioneering work of Burns and Stalker, 1961 and Joan Woodward, 1965 and others in what came to be called the contingency school, have recognized that centralization is appropriate for organizations with routine tasks, and decentralization for those with nonroutine tasks. For an early statement see Perrow 1967, and Lawrence and Lorch, 1967.