Download Drift into failure : from hunting broken components to by Sidney Dekker PDF

By Sidney Dekker

What does the cave in of sub-prime lending have in universal with a damaged jackscrew in an airliner’s tailplane? Or the oil spill catastrophe within the Gulf of Mexico with the burn-up of area go back and forth Columbia? those have been structures that drifted into failure. whereas pursuing good fortune in a dynamic, advanced surroundings with restricted assets and a number of objective conflicts, a succession of small, daily judgements ultimately produced breakdowns on a tremendous scale. now we have difficulty greedy the complexity and normality that offers upward thrust to such huge occasions. We hunt for damaged components, fixable houses, humans we will be able to carry responsible. Our analyses of advanced procedure breakdowns stay depressingly linear, depressingly componential - imprisoned within the house of principles as soon as outlined by way of Newton and Descartes. the expansion of complexity in society has outpaced our figuring out of ways advanced platforms paintings and fail. Our applied sciences have got sooner than our theories. we will construct issues - deep-sea oil rigs, jackscrews, collateralized debt responsibilities - whose homes we comprehend in isolation. yet in aggressive, regulated societies, their connections proliferate, their interactions and interdependencies multiply, their complexities mushroom. This booklet explores complexity idea and platforms considering to appreciate higher how advanced structures float into failure. It reviews delicate dependence on preliminary stipulations, unruly know-how, tipping issues, variety - and unearths that failure emerges opportunistically, non-randomly, from the very webs of relationships that breed good fortune and that should shield enterprises from catastrophe. It develops a vocabulary that permits us to harness complexity and locate new methods of dealing with flow.

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Extra resources for Drift into failure : from hunting broken components to understanding complex systems

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It got worse,” the captain managed to say. ” Airframe vibration was getting louder now. ” A click sounded. ” “Okay,” the first officer responded. “Center, Alaska two sixty one we are, ah, in a dive here,” the captain told the air traffic controller. ” The overspeed warning came on, and continued for the next 33 seconds. ” the controller asked in disbelief. ” For a moment, things seemed to get better. ” 28 drift into failure The first officer didn’t think so. “No we don’t,” he immediately told the controller.

Systems thinking is about non-linearity and dynamics, not about linear cause-effect-cause sequences. Systems thinking is about accidents that are more than the sum of the broken parts. It is about understanding how accidents can happen when no parts are broken, or no parts are seen as broken. Which produces a second question, perhaps even more fascinating. Why did none of these deficiencies strike anybody as deficiencies at the time? Or, if somebody did note them as deficiencies, then why was that voice apparently not sufficiently persuasive?

2004). The smartest guys in the room: The amazing rise and scandalous fall of Enron.  133. As Snook explains in his 2000 book, sudden contractions or stochastic fits in system coupling (indeed the crises where all correlations go to 1) occur in systems that have undergone practical drift, where locally grown logics of action have made individual units slide apart. Once crisis, or a sudden contraction in coupling, puts them back together with demands for quick and safe cooperation, the fissures and gaps that have developed become acutely active and sometimes even visible, leading to misunderstandings, an increase in risk and to failure.

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