How Complex Systems Fail

https://how.complexsystems.fail/

How Complex (Complexity) 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), Richard I Cook, MD

• 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.
• Post-accident attribution to a ‘root cause’ is fundamentally wrong.
• Hindsight biases post-accident assessments of human performance.
• Human operators have dual roles: as producers & as defenders against failure.
• All practitioner actions are gambles.
• Actions at the sharp end resolve all ambiguity.
• Human practitioners are the adaptable element of complex systems.
• Human expertise in complex systems is constantly changing
• Change introduces new forms of failure.
• Views of ‘cause’ limit the effectiveness of defenses against future events.
• Safety is a characteristic of systems and not of their components
• People continuously create safety.
• Failure free operations require experience with failure.