How Complex Systems Fail (Being a Short Treatise on the Nature of Failure; How Failure is Evaluated; How Failure is Attributed to Proximate Cause; and the Resulting New Understanding of Patient Safety)🔒 SSL Verified

Table of Contents

• ↓ Complex systems are intrinsically hazardous systems.
• ↓ Complex systems are heavily and successfully defended against failure
• ↓ Catastrophe requires multiple failures – single point failures are not enough.
• ↓ Complex systems contain changing mixtures of failures latent within them.
• ↓ Complex systems run in degraded mode.
• ↓ Catastrophe is always just around the corner.
• ↓ Top Alternatives to complexsystems.fail

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"(Being a Short Treatise on the Nature of Failure; How Failure is Evaluated; How Failure is Attributed to Proximate Cause; and the Resulting New Understanding of Patient Safety)"

"All of the interesting systems (e.g. transportation, healthcare, power generation) are inherently and unavoidably hazardous by the own nature. The frequency of hazard exposure can sometimes be changed but the processes involved in the system are themselves intrinsically and irreducibly hazardous. It is the presence of these hazards that drives the creation of defenses against hazard that characterize these systems."

"The high consequences of failure lead over time to the construction of multiple layers of defense against failure. These defenses include obvious technical components (e.g. backup systems, ‘safety’ features of equipment) and human components (e.g. training, knowledge) but also a variety of organizational, institutional, and regulatory defenses (e.g. policies and procedures, certification, work rules, team training). The effect of these measures is to provide a series of shields that normally divert operations away from accidents."

"The array of defenses works. System operations are generally successful. Overt catastrophic failure occurs when small, apparently innocuous failures join to create opportunity for a systemic accident. Each of these small failures is necessary to cause catastrophe but only the combination is sufficient to permit failure. Put another way, there are many more failure opportunities than overt system accidents. Most initial failure trajectories are blocked by designed system safety components. Trajectories that reach the operational level are mostly blocked, usually by practitioners."

Key Topics & Focus Areas for complexsystems.fail:

Complex systems are intrinsically hazardous systems.

Complex systems are heavily and successfully defended against failure

Catastrophe requires multiple failures – single point failures are not enough.

Complex systems contain changing mixtures of failures latent within them.

Complex systems run in degraded mode.

Catastrophe is always just around the corner.