I'm a retired neurosurgical anesthesiologist (38 years in practice). I read Perrow's book several years after it was published. I was struck by how relevant his points of failure were to the practice of anesthesiology, the concept of the danger of tight coupling. I referred to this book over subsequent decades in my presentations on Grand Rounds, but to my knowledge none of the residents or other attendings ever read it.

Read a sample here: https://www.amazon.com/Normal-Accidents-Living-High-Risk-Tec...

Another case study to add to the maritime chapter of this timeless classic: https://www.amazon.com/Normal-Accidents-Living-High-Risk-Tec...

Like you said (and illustrated well in the book) it's never just 1 thing, these incidents happen when multiple systems interact and often reflect a the disinvestment in comprehensive safety schemes.

You should read Charles Perrow's "Normal Accidents" and all will be revealed. This is hardly a new problem.

http://www.amazon.com/Normal-Accidents-Living-High-Risk-Tech...

If you liked "How Complex Systems Fail", you may be interested in "Normal Accidents" [1]. It's basically the long-form complete version of the paper you mentioned and packed with interesting examples.

[1] http://www.amazon.com/Normal-Accidents-Living-High-Risk-Tech...