Dangerous systems usually required standardized procedures and some form of centralized control to prevent mistakes. That sort of management was likely to work well during routine operations. But during an accident, Perrow argued, “those closest to the system, the operators, have to be able to take independent and sometimes quite creative action.” Few bureaucracies were flexible enough to allow both centralized and decentralized decision making, especially in a crisis that could threaten hundreds or thousands of lives. And the large bureaucracies necessary to run high-risk systems usually resented criticism, feeling threatened by any challenge to their authority. “Time and time again, warnings are ignored, unnecessary risks taken, sloppy work done, deception and downright lying practiced,” Perrow found. The instinct to blame the people at the bottom not only protected those at the top, it also obscured an underlying truth. The fallibility of human beings guarantees that no technological system will ever be infallible.
After serving as a consultant to the Joint Chiefs of Staff on strategic nuclear policy, Scott D. Sagan applied “normal accident” theory to the workings of the American command-and-control system during the Cuban Missile Crisis. According to Sagan, now a professor of political science at Stanford University, the crisis was the most severe test of that system during the Cold War, “the highest state of readiness for nuclear war that U.S. military forces have ever attained and the longest period of time (thirty days) that they have maintained an alert.” Most historians attributed the peaceful resolution of the crisis to decisions made by John F. Kennedy and Nikita Khrushchev — to the rational behavior of leaders controlling their military forces. But that sense of control may have been illusory, Sagan argued in The Limits of Safety, and the Cuban Missile Crisis could have ended with a nuclear war, despite the wishes of Khrushchev and Kennedy.
With hundreds of bombers, missiles, and naval vessels prepared to strike, the risk of accidents and misunderstandings was ever present. At the height of the confrontation, while Kennedy and his advisers were preoccupied with the Soviet missiles in Cuba, an Atlas long-range missile was test-launched at Vandenberg Air Force Base, without the president’s knowledge or approval. Other missiles at Vandenberg had already been placed on alert with nuclear warheads — and the Soviet Union could have viewed the Atlas launch as the beginning of an attack. The Jupiter missiles in Turkey were an issue of great concern to Secretary of Defense Robert McNamara throughout the crisis. McNamara ordered American troops to sabotage the missiles if Turkey seemed ready to launch them. But he was apparently unaware that nuclear weapons had been loaded onto fighter planes in Turkey. The control of those weapons was “so loose, it jars your imagination,” Lieutenant Colonel Robert B. Melgard, the commander of the NATO squadron, told Sagan. “In retrospect,” Melgard said, “there were some guys you wouldn’t trust with a.22 rifle, much less a thermonuclear bomb.”
During one of the most dangerous incidents, Major Charles Maultsby, the pilot of an American U-2 spy plane, got lost and inadvertently strayed into Soviet airspace. His mistake occurred on October 27, 1962—the same day as the Atlas missile launch and the shooting down of a U-2 over Cuba. Maultsby was supposed to collect air samples above the North Pole, seeking radioactive evidence of a Soviet nuclear test. But the flight path was new, the aurora borealis interfered with his attempt at celestial navigation, and Maultsby soon found himself flying over Siberia, pursued by Soviet fighter planes. The U-2 ran out of fuel, and American fighters took off to escort Maultsby back to Alaska. Under the DEFCON 3 rules of engagement, the American fighter pilots had the authority to fire their atomic antiaircraft missiles and shoot down the Soviet planes. A dogfight between the two air forces was somehow avoided, the U-2 landed safely — and McNamara immediately halted the air sampling program. Nobody at the Pentagon had considered the possibility that these routine U-2 flights could lead to the use of nuclear weapons.
