As a student of disasters in the policy process, I am interested in what Charles Perrow has called "normal accidents." Normal accidents are events--also known as system accidents--that occur when complex systems interact in unusual ways. In the New York Times today we learn that
a number of pre-flight errors contributed to the crash of
Continental Connection (that is, Colgan Air) flight 3407 on approach to Buffalo last February.
Perhaps a better example of a system accident was the
2000 crash of a Concorde flight. At least one of the plane's engines failed catastrophically on takeoff from Paris Charles de Gaulle airport, whereupon the plane failed to gain altitude and crashed into a hotel, killing all aboard and several on the ground.
Continental Airlines and five individuals are on trial in France on manslaughter charges; the French authorities determined that the proximate cause of the crash was a strip of metal that had fallen off a Continental Airlines DC-10 that had departed just before the Concorde took off. The claim is that the metal strip shed by the DC-10 damaged the tires on the landing gear of the Concorde, causing a large chunk of rubber to strike the wing, thereby rupturing the fuel tank. But, as the BBC noted this morning, there were other factors involved, including the apparent fact that the fuel tanks were filled higher than recommended, thereby allowing the rubber to create a shock wave in the full tank, compounding damage and leading to the rupture and fire.
What is interesting about these cases is the fundamental question of blame attribution? Whose fault are these accidents? In the Colgan case, arguments have been made that the pilot showed poor skills, the co-pilot had a cold and was inattentive due to lack of sleep, and that, in the end, the pilot failed to fully increase power before lifting the nose of the plane, thereby precipitating a stall that led to loss of control and the crash. But the Times story suggests other causes, including conflicting data being entered into the plane's computers. In the Concorde case, should a piece of debris have been able to so badly damage the plane's tires? Should a piece of rubber be able to damage the wing? Should the fuel tank have been designed to be so vulnerable to shock?
These seem like highly technical arguments, but they really come down to different models of blame attribution that Deborah Stone has written about. And such blame attribution can matter in regulation, and in the investigation and prosecution of those considered responsible.