Reframing the Itaewon crowd crush: a systems analysis using Perrow’s framework

Purpose This paper uses Charles Perrow’s normal accident theory (NAT) to analyze the 2022 Itaewon Halloween crowd crush, revealing systemic vulnerabilities and organizational failures involved in the disaster. It examines how cultural factors, such as deference to authority and collectivism, worsened the event, providing insights for managing high-risk systems to avert future tragedies. The study aims to deliver actionable strategies for improving crowd management and disaster preparedness in urban settings. Design/methodology/approach This study uses a qualitative case study approach to analyze public reports, media coverage, and expert analyses of the 2022 Itaewon crowd crush. It employs Charles Perrow’s NAT to identify complex interactions among human, organizational, systemic and cultural factors, including deference to authority, that contributed to the disaster. Findings The analysis reveals that the Itaewon crowd crush stemmed from high system complexity, tight coupling and inadequate organizational responses. Key findings include insufficient crowd control, poor interagency coordination and cultural factors such as high power distance and collectivism, which delayed proactive actions. The study underscores the need to address systemic vulnerabilities and improve disaster response mechanisms. Originality/value This study offers a novel application of Perrow’s NAT to the Itaewon crowd crush, extending its theoretical insights to crowd management. This study focuses on NAT’s systemic inevitability, integrating Korean cultural factors such as power distance to provide a unique perspective. Contextualizing the disaster within socio-cultural and systemic frameworks contributes to disaster management discourse, offering actionable recommendations for policymakers to enhance safety in high-risk urban settings.