Normal Accident Theory Research Articles

Normal Accident Theory and Learning from Major Accidents at the National Aeronautics and Space Administration (NASA).

A review of NASA’s accident history through the lens of Normal Accident Theory (NAT) offers insights into the prospects for safety during the Artemis Program. NAT is applied to NASA’s four major human spaceflight accidents: the Apollo launch pad fire, Apollo 13, Challenger and Columbia. NAT predicts that in the complex and tightly coupled systems used for human spaceflight, an accident type known as the “normal accident”, is inevitable. These accidents are attributable to hidden system interactions that overwhelm the cognitive abilities of human operators and, thereby, escape detection. A review of the four official accident reports and supporting secondary analyses suggests NASA has had one such accident: Apollo 13. It was also the only major accident without injury and a successful recovery effort. NAT would categorize the other three as component failure accidents. Unlike normal accidents, component failure accidents are not inevitable. They stem from an organization’s failure to appropriately monitor, assess and mitigate the risk associated with a faulty component. In such cases, NAT would ask if production pressures, often rooted in scheduling and resource constraints, were a factor.Production pressures are ultimately imposed on organizations through the exercise of power. These pressures impede an organization’s ability to adequately assess risk and increase the likelihood of component failure accidents. The substantial organizational literature on NASA’s human spaceflight accidents has yielded potential remedies to help mitigate the risks associated with production pressure. This paper discusses these remedies and their potential safety benefits. It also proposes a modification to a safety governance mechanism recommended by the Columbia Accident Investigation Board (CAIB). The resulting changes could help NASA, and other organizations administering high risk technologies, further improve safety.

The theory of high hazard (HHT) based on grounded theory method and theories integration

PurposeOrganizations working in high-hazard environments contribute significantly to modern society and the economy, not only for the valuable resources they hold but also for the indispensable products and services they provide, such as power generation, transportation and defense weapons. Therefore, the main purpose of this study is to develop a framework that outlines future research on systems safety and provides a better understanding of how organizations can effectively manage hazard events.Design/methodology/approachIn this research, we developed the high hazard theory (HHT) and a theoretical framework based on the grounded theory method (GTM) and the integration of three established theoretical perspectives: normal accident theory (NAT), high reliability theory (HRT) and resilience engineering (RE) theory.FindingsWe focused on the temporal aspect of accidents to create a timeline showing the progression of hazard events and the factors contributing to safety and hazards in organizations. Given the limitations of the previous theories in providing a coherent explanation of hazard event escalation in high-hazard organizations (HHOs), we argue that the highlighted theories can be more complementary than contradictory regarding their standpoints on disasters and accident prevention.Practical implicationsA proper appreciation of the hazard nature of organizations can help reduce their susceptibility to failure, prevent outages and breakdowns of systems, identify areas for improvement and develop strategies to enhance performance.Originality/valueBy developing HHT, we contribute to systems safety research by developing a new, refined theory and enrich the theoretical debate. We also expand the understanding of scholars and practitioners about the characteristics of organizations working in high-hazard environments.

The Effects of Complexity and Coupling on Supply Chain Disruptions

Business executives have recently indicated that supply chain disruptions represent a major threat to their firm’s profitability and revenue growth (Smyrlis, 2006; Hendricks and Singhal, 2009). In the literature, a number of conceptual studies have suggested that supply chain complexity is a main driver of supply chain disruptions (Choi & Krause, 2006; Christopher & Lee, 2004; Juettner et al., 2003). Other studies have suggested that the degree of coupling in the supply chain is a major determinant of supply chain disruptions (Agrawal and Nahimias, 1997; Ahuja, 2000). Building on the theoretical foundation of Normal Accident Theory (NAT), this paper proposes a nuanced relationship between supply chain complexity and coupling and their collective impact on supply chain disruptions. Through an empirical examination, we seek to validate the theoretical proposition that complex, tightly coupled systems are inherently prone to failures or accidents. This study contributes significantly to the supply chain management discourse, providing a detailed analysis of the mechanisms underlying supply chain vulnerabilities and offering practical guidance for developing more resilient and responsive supply chain systems. Our findings invite future research to further explore the intricacies of supply chain disruptions, complexity, and coupling, aiming to refine and expand upon the mitigation strategies discussed herein.

Enhancing life cycle product design decision-making processes: Insights from normal accident theory and the satisficing framework

Life Cycle Assessment (LCA), a computational tool for enabling sustainable product design decision making, faces challenges in the interpretation phase, where conclusions are drawn for improvement recommendations. This necessitate the need to incorporate into LCA management-relevant theoretical underpinnings to strengthen decision-making processes. Comparative LCA case studies of lead-based piezoelectric material (lead zirconate titanate – PZT) and lead-free alternatives (potassium sodium niobate – KNN, sodium bismuth titanate – NBT), was employed to demonstrate how two theoretical lenses, namely Normal Accident Theory (NAT) and the Satisficing Framework, are used inductively to enhance decision making regarding unintended consequences in the value chain. By operationalising NAT, which has hitherto focused on the consequences of physical accidents, as a life cycle engineering-based methodology, NAT attributes of interactive complexity and tight coupling was revealed in piezoelectric materials, based on environmental systems’ predictability, observability, and applicability. This led to the introduction of Environmental Impact Accident (EIA) as a new concept, facilitating an early assessment of the associated complexities influencing the sustainability credentials of piezoelectric materials whilst informing mitigation strategies. However, when considering multiple objectives that conflict or trade-off between alternative piezoelectric materials with different environmental and health impacts across the value chain, a conundrum is created but resolved using the Satisficing Framework. The paper concludes by proposing theoretical and practical policy options for incorporating LCA into product life cycle decision making.

Enhance or impair: how does downstream complexity influence supply chain resilience with reconciling effects of intelligent manufacturing?

PurposeThe purpose of this paper is to examine the nuanced effects of downstream complexity on supply chain resilience, based on portfolio theory and normal accident theory. Intelligent manufacturing is considered to clarify their boundary conditions.Design/methodology/approachThe ordinary least squares regression was conducted, based on the data collected from 136 high-tech firms in China.FindingsHorizontal downstream complexity has a positive effect on supply chain resilience significantly, while the negative impact of vertical downstream complexity on supply chain resilience is not significant. Contingently, intelligent manufacturing plays a negative moderating role in the relationship between horizontal downstream complexity and supply chain resilience, while it positively moderates the relationship between vertical downstream complexity and supply chain resilience.Originality/valueThis study disentangles the nuanced effects of both horizontal and vertical downstream complexity on supply chain resilience, based on portfolio theory and normal accident theory. It also clarifies their boundary conditions by considering the focal firm's intelligent manufacturing level as the contingent factor.

Internal Audit and Business Resilience in Power Sector. A Case of Geothermal Development Company

Over years, internal auditors’ roles are changing from checking compliance issues to giving a strategic view of the organization processes. Internal auditors play noble role in evaluating the anticipated level of success of a project. This research sought to establish how risk management, business controls, governance and business advisory contribute to business resilience in Geothermal Development Company Limited. The study was anchored on the balanced score card, strategic choice theory, transient advantage theory, the strategic management theory, complexity theory and the normal accident theory. The study focused on 3 GDC operation regions with a target population of 200 staff based in the office and in the field. The research study used primary data collection method employing a semi-structured questionnaire. Post collecting data, descriptive and inferential statistics were employed in the analysis. Correlation and regression analysis was conducted to establish the relationships between the variables. The presentation of results was through tables and figures. The study found that risk management had a positive and significant effect on business resilience of GDC; business advisory had a positive and significant effect on business resilience of GDC; internal controls had a positive and significant effect on business resilience of GDC; and governance had a positive and significant effect on business resilience of GDC. The study concluded that the internal audits positively and significantly influenced business resilience of GDC. From the study, internal audit plays a critical role in enhancing business resilience at GDC through effective risk management, robust governance, and reliable internal business controls. The study recommended organizations to place internal audit functions at strategic hierarchical positions as well as implement its recommendations. To bolster business resilience at GDC, it is recommended the company strengthen risk management practices, enhance governance structures, and improve internal business controls. Investing in internal audit capacity building and expanding business advisory services can further optimize the internal audit function. Additionally, GDC should consider benchmarking and collaborating with peer organizations to identify areas for improvement and share best practices within the power sector. Keywords: Internal Audits, GDC, risk management, business advisory, business controls, governance, business resilience

Normal cyber accidents

ABSTRACT Several of the most serious cyber incidents affecting critical infrastructure to date have been the result of collateral damage, indirect effects, malware that ‘escaped’ their intended target and/or incontrollable malware proliferation. This tendency has so far been under-explored in the International Relations (IR) literature, and its potential implications largely overlooked. By focusing on the role of socio-technical system dynamics, this article aims to contribute to advancing our understanding of collateral (incidental) damage and unexpected consequences connected to offensive cyber operations. More specifically, it introduces an analytical framework based on Normal Accidents (NA) theory. The framework highlights dynamics which make complex systems more difficult to analyse and more prone to cascading failures. Its application is explored using in-depth interviews and empirical case examples of large-scale cyber incidents. The results highlight the difficulty of achieving controlled and precise effects when disrupting components in complex systems. The article concludes with a discussion on the need for renewed attention to escalatory risks connected to destructive offensive cyber.

The War In Ukraine

Russia started its nuclear war threats with the commencement of its war in Ukraine. In the current case of the war in Ukraine, the most critical question is whether the Russian Federation, the aggressor in this war, would use nuclear weapons. The purpose of this brief paper is to examine the scenarios that are available to Russia to carry out its threat. The theoretical framework employed here is that of Normal Accident Theory (NAT), one of the most prominent theories of catastrophe. Normal Accident Theory explains how Moscow's use of nuclear weapons can trigger a global catastrophe that could bring the international system down. There are scenarios according to which the decisions that may result in the destruction of the international system may cascade fast, and there are scenarios in which such cascading events may be avoided or delayed.

How have lean supply chains coped with the COVID-19 pandemic? A normal accidents theory perspective

This research aims to empirically examine how Lean Supply Chains (LSC) have coped with the disruptive effects of the COVID-19 pandemic from the normal accidents theory (NAT) perspective. Initially, a literature review was conducted to identify the main dimensions of LSC. Then, four experts were interviewed, offering insight into how each of the LSC dimensions copes with disruptions in general. Finally, three case studies of manufacturing shed light on the LSC implications for the pandemic context in particular. From the NAT viewpoint, the effects of the pandemic are analyzed according to two dimensions of the interactions that make up an LSC: linear to non-linear, and loosely to tightly-coupled. The more non-linear and tightly-coupled the interactions the more vulnerable the LSC is to disruptions. Results indicated that LSC might effectively and quickly adapt to keep interactions as linear as possible through transparent information flows and collaborative work while at the same time temporarily reducing tight-couplings through inventory increases. Some of the countermeasures to cope with the disruptions caused by the COVID-19 pandemic conflict with LSC principles, such as inventory reduction, developing a solid customer-supplier relationship, and long-term orientation. This points out the contingent nature of some lean principles as well as the meta principle that guided companies’ behaviours in the case studies, namely adding value to internal and external customers.

Selecting resilient suppliers: Supplier complexity and buyer disruption

The selection of suppliers has a long-term impact on the performance of the buying firm. This is true in stable situations as well as in times of uncertainty, such as during the COVID-19 pandemic. Building on the literature on supplier selection criteria that would help identify suppliers that support the success of the buying firm, we identify a previously unnoticed criterion: a supplier's complexity. In this study, we examine the relationship between supplier complexity and buyer disruptions. Normal accident theory suggests that complex firms are more prone to disruption, while social systems theory views firm-level complexity as essential in avoiding disruption. Given these two opposing theoretical viewpoints, this study examines whether and how supplier complexity affects numbers of disruptions experienced by the buyers. Our data collection entails 59 buyer-supplier dyads, extended to a triadic context (i.e., buyer-supplier-supplier), through a survey taken from 118 German manufacturing firms. The results show that both the internal complexity of a supplier and the complexity of the collaboration with other suppliers increases the number of disruptions experienced by the buyer. A high degree of supplier dependence can dampen this effect. These results introduce a supplier's complexity as a relevant criterion for supplier selection and shed light on the moderating influence of supplier dependency.

How police officers are shot and killed during active shooter events: Implications for response and training

Active shooter events have driven police to change how they respond to events where an attacker is actively engaged in killing civilians. This paper examines these changes through the lenses of Normal Accident Theory (NAT) and Resilience Engineering (RE). Our results show a police officer is shot in one out of every six active shooter events in the United States. We then apply RE to better understand how these shootings occur so that police can improve their ability to anticipate, monitor, and respond during these attacks. Implications for police training are discussed.

Disentangling the multifaceted effects of supply base complexity on supply chain agility and resilience

PurposeThe study investigates how supply base structural complexity influences both supply chain agility and resilience. It employs Normal Accident Theory and Portfolio Theory to disentangle the effects of three structural facets of complexity – numerousness; technical and functional diversity; geographical distribution of suppliers – on the two capabilities simultaneously.Design/methodology/approachThe study is grounded in the Italian footwear industry. 31 manufacturing firms with their global supply base have provided a cross-sectional time series database over a 10-year period (310 observations).FindingsThe results show that supply base numerousness has nonlinear effects on both supply chain agility and resilience. The directions of these effects are opposites. They also show that supply base diversity has an inverted U-shaped effect on supply chain agility while it is insignificant for resilience. Finally, the results show that suppliers' geographical dispersion is detrimental to both capabilities.Originality/valueThis is the first study that considers the multifaceted effects of supply base complexity on both supply chain agility and resilience. In doing so, it also sheds light on some of the most common trade-offs that firms address when they seek a balance between different strategies, such as increasing agility without damaging supply base resilience and vice versa. Considering the resource constraints firms normally face, by disentangling the dual effects of each complexity facet, this study helps decision-makers to develop scalability and leverage the supply base characteristics in order to survive and prosper in uncertain markets.

Diagnosing the service quality of perishable-food logistics: temperature-sensitive milk delivery

PurposeHigh-quality cold-chain logistics are key to effectively managing the quality of temperature-sensitive foods. Hence, this study investigates the service quality of such logistics, using a real-life case of temperature-sensitive milk delivery.Design/methodology/approachThis study focuses on developing business analytics for quality control in cold-chain perishable-food logistics, grounded in normal accident theory and stakeholder theory, and tests them using real-world data.FindingsThe empirical business-analytics results indicate that cargo locations, logistics status and delivery times are the essential factors that influence the quality of temperature-sensitive milk.Research limitations/implicationsThis study confirms that a combination of normal accident theory and stakeholder theory can be usefully applied to the development of strategies for managing perishable-food logistics. As such, its proposed business analytics provide a fresh foundation for research on logistics quality management.Practical implicationsThe balance between efficiency and service quality in a logistics system should be assessed carefully, and logistics companies should collaborate with their stakeholders and can help to mitigate potential cold-chain risks.Originality/valueThis pioneering analytical study explores the essential quality issues that confront cold chains and demonstrates how to extract vital insights from temperature-sensitive food logistics monitoring data. As such, it represents a noteworthy contribution to the field of logistics quality management.

Curse or Blessing? Exploring risk factors of digital technologies in industrial operations

Both practitioners and scholars emphasise the benefits of Industry 4.0 (I4.0) technology implementation, such as increased transparency and the availability of real-time data in operations processes. Current literature on I4.0 technologies tends to overemphasise the positive impact and transformational capabilities of digital technologies while there is little focus on evaluating potential risks associated with their adoption in industrial operations. An understanding of how supply chain risks are perceived in digitalisation projects within industrial operations and an understanding of decision-makers' responses to different types of risks has important managerial implications. Current literature, however, lacks systematic empirical evidence on the implementation of I4.0 applications and related risk factors. This study aims to address this research gap by exploring the relationship between I4.0 technologies and supply chain risks based on empirical evidence from 300 case studies of industrial practice in Germany and fifty-three interviews with relevant managers from selected use cases and with general experts in this field. Our findings show that digital technologies are frequently adopted to address certain existing supply chain risks but that their implementation introduces new sources of risks (e.g. cyber risks). Based on qualitative data analysis and drawing on Normal Accident Theory, we propose a framework to explicate the drivers and contingency factors of new sources of supply chain risks in the context of Industry 4.0 technologies. Practical recommendations are provided for supply chain managers to guide the process of managing supply chain risks based on the technological life cycle.

Systemic failures and organizational risk management in algorithmic trading: Normal accidents and high reliability in financial markets.

This article examines algorithmic trading and some key failures and risks associated with it, including so-called algorithmic ‘flash crashes’. Drawing on documentary sources, 189 interviews with market participants, and fieldwork conducted at an algorithmic trading firm, we argue that automated markets are characterized by tight coupling and complex interactions, which render them prone to large-scale technological accidents, according to Perrow’s normal accident theory. We suggest that the implementation of ideas from research into high-reliability organizations offers a way for trading firms to curb some of the technological risk associated with algorithmic trading. Paradoxically, however, certain systemic conditions in markets can allow individual firms’ high-reliability practices to exacerbate market instability, rather than reduce it. We therefore conclude that in order to make automated markets more stable (and curb the impact of failures), it is important to both widely implement reliability-enhancing practices in trading firms and address the systemic risks that follow from the tight coupling and complex interactions of markets.

To err is human: Exploratory multilevel analysis of supply chain delivery delays

ABSTRACTWe examine the impact of human errors by front‐line supply chain employees on delivery delays. We build on normal accident theory (NAT), a multilevel theory describing the relationship between a firm's latent conditions (systemic managerial, technology, and social factors) and human errors. Latent conditions can have the unintended consequence of intensifying the impact of a human error, thus, we hypothesize a moderating effect of latent conditions on the relationship between errors and delivery delays. Hypotheses are tested using archival shipment data provided by a Fortune 500 company and archival carrier violations data. A multilevel design, with 299,399 shipments (level 1) nested within 97 carriers (level 2), was tested using mixed effects regression modeling. The results indicated that both dispatcher and driver errors were related to the probability of a late delivery, and that dispatcher errors were associated with longer delays. The moderating effects of several carrier latent conditions were significant and positive, indicating that both types of errors were more strongly associated with the likelihood of late delivery and that dispatcher errors were associated with longer delays when moderated by carrier latent conditions. The results are discussed from the perspective of NAT and technology management, developing prescriptions, and suggesting opportunities for future research.

Understanding and Avoiding AI Failures: A Practical Guide

As AI technologies increase in capability and ubiquity, AI accidents are becoming more common. Based on normal accident theory, high reliability theory, and open systems theory, we create a framework for understanding the risks associated with AI applications. This framework is designed to direct attention to pertinent system properties without requiring unwieldy amounts of accuracy. In addition, we also use AI safety principles to quantify the unique risks of increased intelligence and human-like qualities in AI. Together, these two fields give a more complete picture of the risks of contemporary AI. By focusing on system properties near accidents instead of seeking a root cause of accidents, we identify where attention should be paid to safety for current generation AI systems.

Debates and politics in safety science

This article explores what complementary perspectives Science and Technology Studies and in particular Actor Network Theory may bring to safety science beyond what comes out of traditional comparisons between highly profiled theories/perspectives of Normal Accident Theory (NAT), High Reliability Organisations (HRO), Resilience Engineering (RE) and Safety II.In the article, core ideas of NAT, HRO and RE/Safety II are reviewed, and debates over NAT/HRO, HRO/RE and Safety I/Safety II are discussed. Thereafter, controversies over complexity, non-events and uncertainty respectively are identified and elaborated, drawing on a richer repertoire from the social sciences, in particular Actor Network Theory. The article concludes by inviting to more serious engagement in scientific controversies and politics of safety, and operationalises this into three propositions: Take complexity seriously; broaden the perspectives and methodologies for understanding sociotechnical work; and make safety science research politically oriented (again).

General safety concepts used in transport

The article presents selected concepts, models and theories of safety known from research and applications in various areas of technology and suitable for use in the field of transport. In particular, attention was paid to cognitively promising in the field of transport safety, and relatively little used research concepts here: Normal Accident Theory (NAT) Ch.Perrow, "Swiss cheese model" /SCh-M/ by J. Reason, concepts of "safe space of action" by J. Rasmussen and R. Amalberti, the concept of High Reliability Organizations /HRO/, or even interpretations of the transport system as a complex system (CS). The main aim of the article was to present some important general safety concepts and show that they can be used to model safety in the field of transport. The article shows that the so-called Geysen's thesis allows for the development of justified safety analogies between transport systems and such systems of technology that have greater scientific and engineering achievements in the field of safety.

Are Public Bureaucracies Supposed to Be High Reliability Organizations?

This article addresses the question of to what extent conventional theories of high reliability organizations and normal accidents theory are applicable to public bureaucracy. Empirical evidence suggests precisely this. Relevant cases are, for instance, collapsing buildings and bridges due to insufficient supervision of engineering by the relevant authorities, infants dying at the hands of their own parents due to misperceptions and neglect on the part of child protection agencies, uninterrupted serial killings due to a lack of coordination among police services, or improper planning and risk assessment in the preparation of mass events such as soccer games or street parades. The basic argument is that conceptualizing distinct and differentiated causal mechanisms is useful for developing more fine-grained variants of both normal accident theory and high reliability organization theory that take into account standard pathologies of public bureaucracies and inevitable trade-offs connected to their political embeddedness in democratic and rule-of-law-based systems to which belong the tensions between responsiveness and responsibility and between goal attainment and system maintenance. This, the article argues, makes it possible to identify distinct points of intervention at which permissive conditions with the potential to trigger risk-generating human action can be neutralized while the threshold that separates risk-generating human action from actual disaster can be raised to a level that makes disastrous outcomes less probable.