Here’s a 30 min YT presso from Sid Dekker on complex system failures and drift. Some extracts: · “this fascination with counting and tabulating little negative events, as if they are predictive of a big bad event over the horizon, is an illusion” · “We should be doing something quite different if we want to understand how your complex system… Continue reading The Pursuit of Success & Averting Drift into Failure – YT vid from Sidney Dekker
Failure modes analysis of organizational artefacts that protect systems
Really interesting 2004 paper discussing how to study the failures associated with organisational artefacts. Artefacts are “rules, procedures, instructions, authority structures and so on that are designed, like physical devices, but have organizational rather than physical functions”. It’s argued that studying failures of artefacts, like in FMEA, isn’t the same as physical failure modes, and… Continue reading Failure modes analysis of organizational artefacts that protect systems
Complex systems and drifting into failure – further extracts from Dekker 2013
More extracts from Dekker’s 2013 paper ‘Drifting into failure’. These parts focus on some properties of complex systems (image 1), and how systems drift to failure (image 2). Extracts:· “Open systems mean that it can be quite difficult to define the border of a system. What belongs to the system, and what doesn’t? This is known… Continue reading Complex systems and drifting into failure – further extracts from Dekker 2013
Drifting into failure: Complexity theory and the management of risk
2013 paper from Dekker discussing drift into failure. Nothing new if you’ve read his 2011 book. Extracts: · “organizations do not just fail because of component breakage or linear propagations of breakdowns. Instead, failure breeds opportunistically, non-randomly, among the very structures designed to protect an organization from disaster” · “A common pattern seems to be a drift… Continue reading Drifting into failure: Complexity theory and the management of risk
Culture and the role of major disasters – James Reason, 1998
Interesting comment from James Reason from a 1998 paper (summary in the next week or two) on the role of culture/s in major system failures. “Because of their diversity and redundancy, the elements of a multilayered defensive system will be widely distributed throughout the organization. As such, they are only collectively vulnerable to something that… Continue reading Culture and the role of major disasters – James Reason, 1998
The contribution of latent human failures to the breakdown of complex systems
What is the role of frontline people within complex system failures? For James Reason, it was often just providing the local triggers to “manifest systemic weaknesses created by fallible decisions made earlier”. This 1990 paper goes through his thinking of human performance in complex failure. It was meant to be a small post, but couldn’t… Continue reading The contribution of latent human failures to the breakdown of complex systems
“By their nature, accidents are not directly controllable” – James Reason, 1993
“By their nature, accidents are not directly controllable”, so says James Reason in this 1993 article. Just a single extract from the article’s conclusion: · “Safety has two faces: a positive one relating to an organization’s intrinsic resistance to chance conjunctions of unsafe acts and hazards, and a negative one, revealed by accident and incident data,… Continue reading “By their nature, accidents are not directly controllable” – James Reason, 1993
Bad apples, counterfactuals, and a focus on imagined systems – extracts from DOE accident analysis manual
REALLY cool read from the Department of Energy’s Accident Analysis Manual. Progressive and integrative of different concepts (eg. barriers, human factors, S-II, bad apples, counterfactuals). Nothing new for most, but some extracts: · They cover barrier analysis, highlighting how these questions should be upacked: o Barriers that were in place and how they performed o Barriers in place… Continue reading Bad apples, counterfactuals, and a focus on imagined systems – extracts from DOE accident analysis manual
Counteracting the Cultural Causes of Disaster
This 1999 article from Andrew Hopkins talks about the cultural factors that helped to incubate the 1994 Moura mine disaster in Australia. He starts by saying that Turner’s work demonstrated that “all socio-technical disasters involve an information or communication failure of some kind, in that they are preceded by a series of `discrepant events’ which… Continue reading Counteracting the Cultural Causes of Disaster
Issues with defining critical controls & relying on injury measures, like TRIFR – Grosvenor Board of Inquiry
More extracts from the Anglo American Grosvenor board of inquiry. This focused on issues with defining critical controls / high potential incidents (HPI), and issues relying on injury measures, like TRIFR. Extracts: · The company standard didn’t require the business unit CEO to be notified of HPIs, and “whilst it prescribes a process of escalation in… Continue reading Issues with defining critical controls & relying on injury measures, like TRIFR – Grosvenor Board of Inquiry
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