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"How complex systems fail" by Dr. Richard Cook makes exactly this point – all complex systems are, by definition, running in a degraded mode, with catastrophe j
by Robin_Message 14y ago
"How complex systems fail" by Dr. Richard Cook makes exactly this point – all complex systems are, by definition, running in a degraded mode, with catastrophe just around the corner. They are keep up through a series of gambles – and you never hear about the good ones.
Interesting it is written by a doctor about medical environments, but works for any complex system.
The essay is reproduced in Web Operations by John Allspaw and Jesse Robbins with a web ops spin on it, and is also available online at http://www.ctlab.org/documents/How%20Complex%20Systems%20Fail.pdf http://www.ctlab.org/documents/How%20Complex%20Systems%20Fai...
- jacques_chester 14y agoYes, I started reading into the literature on failures recently because of that exact essay. It's been a great supplement to my reading on systems thinking.
- scott_s 14y agoPoint 7 is a new idea to me: "Post-accident attribution accident to a ‘root cause’ is fundamentally wrong."
- jacques_chester 14y agoI disagree with that nostrum -- I wrote about it in nauseating detail here: http://chester.id.au/2012/04/09/review-drift-into-failure/ http://chester.id.au/2012/04/09/review-drift-into-failure/