Drift into failure, p.35
Drift Into Failure, page 35
accidents:
banality of accidents thesis 48
and emergence 158—60, 188
as failure of risk management 5
overdose accidents 79, 80, 129–30
role of relationships in 63—5, 68, 128
system accidents 128
accounting methods, at Enron 191—2
accuracy 199
adaptive capacity of systems 18
Aeronautical Weather Services 72
Afghanistan 147, 148—9, 162
Africa:
Coltan (Columbite-Tantalite) mining 132—3, 139—40
drug trafficking 145—6
impact of climate change 135, 136
agriculture 56
air traffic control, and psychology 77
airborne collision prediction and avoidance system (TCAS II) 129, 150
aircraft accidents:
hailstorm damage 72—3
see also Alaska 261 air accident; aviation industry, safety record; Trans World Airlines flight 800 accident
aircraft carriers 93, 173, 180
aircraft certification 40—1
aircraft maintenance 47—8, 102
and Alaska 261 air accident 31—3, 39–40, 43, 45, 97–8
DC9/MD80 39—40, 43–4, 45, 46, 47–8, 97–8
regulation of 45—6
aircraft, safety 151—2
Airline Deregulation Act (1978) 37
airlines, and goal conflicts 101, 102
airworthiness 42
al Qaeda 149
Alaska 261 air accident 25—30, 149, 150–1, 159
investigation 31—3, 33—4
and maintenance practices 31—3, 39—40, 43, 45, 97–8
and regulation 32, 38
alternative compliance 17
altimeters, in Boeing 737 aircraft 152—3
amoral calculator 4—5, 104
amplification of effects 141—2
analytic reduction see reductionism
ant colonies 157
asset management 9—10
asynchronous evolution 116—17
ATOS (Air Transportation Oversight System) 38
authentic stories 199, 202
automation, as layer of redundancy 129
aviation industry:
deregulation 36—7
regulation 38
safety record 135
see also aircraft accidents
aviation, and software 150
Bacon, Francis 55, 56
Baghdad see Iraq
Bali 92
banality of accidents thesis 48
banks:
and Enron 194—5
see also global financial crisis
barriers 63, 91—3, 127—8
bartering 185—6
Beaufort Sea, Alaska, BP operations 16, 17, 18, 179
behaviourism 80
bin Laden, Osama 149
biology and systems thinking 137
Black Death 55
Black Hawk helicopters accident, Iraq 103, 110, 188
Blackwater U.S.A. 161—3
Boeing 737, safety 149, 150, 151, 152–3
boundaries 136
in open systems 139–40
Boyle, Robert 57
BP:
Alaska operations 4, 15, 16, 17, 18, 179
Deepwater Horizon accident 1, 3—4, 10, 14—15
maintenance practices 15
and regulation 17—18
safety record 4
Texas City explosion 4
brain, and emergent behavior 158
broken components 71—2, 73–4, 84, 155, 187
aircraft damaged by hailstorm 72—3
in the Alaska 261 accident investigation 31—5
in Space Shuttle accidents 61—3
and Swiss Cheese Model 92
to explain broken system 75—6
in Trans World Airlines flight 800 accident 74—5
see also accident investigations
bubbles 11
Buchanan, George 178
"bullets", in information presentation 112–14
butterfly effect (sensitive dependence on initial conditions) 16, 40—2, 143–4, 154, 178–80
Buy, Rick 194
cause and effect 76
in Newtonian science 79—80, 84
Causey, Richard 197
cell phones 132—3, 139
chaos, optimization at the edge of 138, 164–6
chaos theory 133
Chinese Wall 195
Chlorine 155
CIA, and Blackwater U.S.A. 161—3
Cilliers, P. 138–9,141
Civil Aeronautics Board (CAB) 37
climate change 135—6, 142—3
closed loop communication 129
closed systems, and high reliability organizations 93, 94, 139
co-evolver/ counter-evolver 184
CO2 emissions see climate change
coal mining, Aberfan disaster 87, 89, 99
cocaine see drug trafficking
collateralized debt obligations, and Gaussian copula 8, 9—11
Collins, F.S. 82–3
Coltan (Columbite-Tantalite) mining 132–3, 139—40
common-cause hypothesis 48
complex adaptive systems, theory of 7
complex systems 169—73
and adaptation 144—6
characteristics of 138—49
components in 138, 140–1
constraints in 37
differ from complexity 149–53
and diversity 173—6
and drift into failure 13—18, 153—5, 169–73
exploration in 165
history 138, 148–9
information gathering in 201
non-linear interactions in 139, 141—4
openness of 138, 139–40
operating under conditions far from equilibrium 138, 146
optimization at the edge of chaos 138, 164–6
complex systems theory 138—41
complexity 6—7
characteristics of 7—8
differs from complex systems 149–53
and drift into failure 13—18, 153—5
interactive 128—9
and local rationality principle 12—13
organized 157—8
complexity and systems theory 7, 127–66, 138, 189
complexity theory 7, 76–8
compliance, alternative 17
components:
in complex systems 138, 140—1, 153
locality principle 140—1
see also broken components
Congo, Coltan mining 132—3, 139—40
continued safe operations, challenging belief in 95—9
contradictions in complex systems 21
contribution of the protective structure 17—18, 44—6, 154—5, 182–5
control theory, and drift into failure 116–21
cost pressures 14
critical state 165
culture 78—9
and cockpit safely practices 151—2
cybernetics 11—12, 141
DC9/MD80 aircraft:
certification 40—1, 42
maintenance practice 39–40, 43–4, 45, 46, 47–8, 97–8
see also Alaska 261 air accident
decentralization, and high reliability organizations 93, 94
"decentralized anticipation" 173
decision-making:
in complex systems 13
rationality 12—13, 114
see also information environment
decomposition 71, 76, 84, 134
decoy phenomena 89
decrementalism (small steps) 15—16, 39–40, 49, 106, 115, 121, 179–80
deepwater drilling 17—18
Deepwater Horizon accident (BP) 1, 3—4, 10, 14–15
defenses in depth model see Swiss Cheese Model
deregulation of aviation industry 36—7
derivatives 191
Descartes, René 2, 53, 56—7, 79, 134
see also Newtonian-Cartesian vision
deviance, normalization of 103—8, 121
disasters:
exercises 94
see also man-made disasters
disengagement 38
dissipative state 165
distraction 89
diversity 173–6, 187, 201, 202
contribution of the protective structure 182—5
resource scarcity and competition 176–8
sensitive dependency on initial conditions 178–80
small steps 178—80
unruly technology 180—2
DNA 82–3
doctors, training of 73
domino model 91
Dörner, Dietrich 99, 101
doublespeak 101
Douglas, maintenance system 39—40, 43–4, 45
see also McDonnell Douglas
drift into failure 34—6
and complex systems 13—18, 153–5, 169–73
contribution of protective structure 17–18, 44–6, 154—5, 182–5
and control theory 116—21
definition of 18—19
occuring in small steps (decrementalism) 15—16, 39—40, 154, 178–80
practical drift 110
and resource scarcity and competition 14—15, 36—9, 153—4, 176–8
sensitive dependence on initial conditions 16, 40—1, 154, 178—80
and structural secrecy 108—12
and unruly technology 16—17, 42–4, 154, 180–2
drift into success 185—7
drug trafficking 145—6, 164—6
see also organized crime
dualism 57
duplication see redundancy
Durkheim, Emile 80, 83
dynamic equilibrium 116
East Siberian Arctic Shelf 142
economic boundary, in complex systems 37
Eden, Anthony 143—4
Egypt, and the Suez crisis 143—4
Einstein, Albert 133, 134
eisegesis 21
elephants, threat of Coltan mining to 132, 133
emergence 155—8, 187
and accidents 158—60, 188
emerging markets 191
Enron 169, 176, 189–98
epidural anaesthetic accident (Wisconsin) 51—5, 58, 66—7 root cause analysis of 65—6
epistemé 85
epistemological space 2, 22n3
essentialism 83
eureka part 75
and reductionism 77—9
Europe, population growth 56
Excel (airline) 101
exegesis 20—1
expertise, deference to 96, 97, 115
explanations, families of 1—2
exploitation 165
exploration, in complex systems 165
failure:
incubation of 88—90
linear progression of 91
mechanistic thinking about 132
Newtonian ethic of 76—7, 84—6, 187
pre-occupation with 96
psychological sources of 77
surprise of 88—90
systems thinking about 130–3
famine 55
"Faster, Better, Cheaper" philosophy (NASA) 100–1, 177
Federal Aviation Administration (FAA) 37
and Alaska 261 accident 32
feedback imbalance 38—9
feedback loops 142–3
Feynman, Richard 62, 104, 112, 114
financial instruments see collateralized debt obligations; derivatives
Flight 800 Independent Researchers Organization (FIRO) 75
flight crews, and accidents 75—6
folk model, drift as 19—21
foreseeability of harm 80–1, 84, 188–9
Foucault, M. 21, 85
fractals 146
frame problem 139—40
Freud, S. 80
functional decentralization 93
fundamental surprise 89
Galileo Galilei 55, 56
Gas Bank see Enron
Gaussian copula 7—11, 16—17, 181
see also Li, David
General Systems Theory 138
genes see human genome
Gershenson, C. 141
global financial crisis, and the Gaussian copula 8—11
global warming see climate change
goal conflicts, and production pressure 99–103
God, language of 82—3
gorillas, threat of Coltan mining to 132, 133, 139–40
Gould, Stephen Jay 20, 21
Grodzins, Morgan 161
Guinea, drug trafficking 145—6
Guinea-Bissau, drug trafficking 145—6
hail 72–3
Hall, Jim 75
Hayward, Tony 1
see also BP
hazardous processes, and control theory 117
health and safety 158–60
Herfindahl index 174—5
Heylighen, F. 141
high reliability organizations (HRO) 93–5, 109, 115, 139, 180
challenging belief in continued safe operations 95—9
resilience engineering 121—3, 173
hindsight 97—8
history:
and complex systems 138, 148—9
of people involved in accidents 71
Holden, Richard 75
holes, in defenses 91—2
home ownership 10
"honest services" law 200
house prices 11
human error 75—6, 77, 155
human factors 76
human genome 82—3
Human Rights Watch 145
humanities, and systems thinking 137
Hutchins, E. 78
IEDs (improvised explosive devices) 147, 148
incident reporting 47, 49, 131
incubation of disasters 88–90, 95, 103
individualism 77–8
induction 56
Industrial Revolution 20
information environment, management of 112—15
information gathering in complex systems 201
initial conditions, sensitive dependence on (butterfly effect) 16, 40—2, 143—4, 154, 178–80
Institute for Safe Medication Practices 52–3
interactive complexity 128—9
International Human Genome Sequencing Consortium 82—3
International Space Station 18—19
interpellation 84, 85
intervention decisions 174—5
investigations see accident
investigations
Iraq:
Black Hawk helicopters accident 103, 110
IEDs 148
privatization of warfare in 161–3
Islamic fundamentalism 149
Israel:
intelligence forces 89
and the Suez crisis 144
James VI of Scotland (King) 178
jester, role of 178
Kahuzi-Biega National Park, Congo 132–3, 139—40
Kelvin, Lord 85, 133
Kinder, Rich 195
Kipling, Saskatoon 186
kitchen salt, emergent properties of 155–6
knowledge 141, 181
completeness of 81—3
and cybernetics 12
Kurds 110
Lanir, Zvi 89
latent causes 58
latent failure model 90, 91—2
see also Swiss Cheese Model
laws, Newtonian 56
Lay, Ken 190, 191, 193, 194, 198
leadership safety objectives 93, 94
Leonardo (Leonardo di Ser Piero, Vinci, Florence) 137–8
Leveson, Nancy 117–20, 129
Lewes, George Henry 156
Li, David 8–9, 11, 16–17, 181
See also Gaussian copula
Liberty project (BP's Beaufort Sea operations) 16, 17, 18, 179
life expectancy 55
linear progression of failure 91, 92
local rationality principle 12—13
locality:
and components 140—1
local decisions 14, 114
local modifications 111
Lockheed 102—3
Lorenz, Edward 143
see also butterfly effect
MacDonald, Kyle 185—6
McDonnell Douglas:
Alaska 261 accident 25—30
see also Douglas
macro-micro Connection 99—100
Maintenance Guidance Steering Group (MSG) 45
maintenance practices:
Alaska 261 air accident 31—3, 39–40, 43, 45, 97–8
BP 15
Maintenance Review Boards (MRB) 45–6
man-made disaster theory 87—8
incubation of disaster 88—90, 95, 103
and prevention of drift 93
and risk as energy to be contained 90–3
see also Turner, Barry
March, J.G. 109
Mark, Rebecca 193
mark-to-market accounting (Enron) 191–2, 198
matter 79, 134
nature of 57
MD-80 see DC9/MD80
mechanics, laws of 76—7
mechanistic worldview 54—5, 57, 172
medical accidents:
epidural anaesthetic accident (Wisconsin) 51—5, 58, 65—7
lindocaine poisoning of baby 79, 80
radiation therapy 129—30
medieval world 54, 55
methane 142
Middle East, culture 148
Minerals Management Service (MMS) 1, 18, 179, 183
mining:
Aberfan disaster 87, 89, 99
Coltan (Columbite-Tantalite) milling 132—3, 139—40
Mujahideen 148–9
multiplication of effects 141—2
NASA:
"Faster, Better, Cheaper"
philosophy 100—1, 177
see also Space Shuttle
Nasser, Colonel 143, 144
National Institutes of Health 82
National Transportation Safety Board (NTSB) 74—5
Natrium 155–6
natural gas see Enron
nature, desire of science to dominate 55
naval aircraft carriers 93, 173, 180
negligence 80—1
New York City, slime mold study 156–7
Newton, Isaac 2, 6, 53—4, 56, 85, 133
Newtonian-Cartesian worldview 2, 23n4
and accidents 53, 58–65, 73—4, 83
and management 172
and cause and effect 79–80
and decomposition 71, 76, 84, 134
limitations of 33, 58–65
and Newtonian ethic of failure 76–7, 84—6, 187
Nietzsche, F 21
non-linear interactions in complex systems 139, 141—4
Nordic Severe Weather Chart 72
normal, definition of 99
normalization of deviance 103—8, 121
NTSB (National Transportation Safety Board) 74—5
nuclear apocalypse 88
nursing profession 68
see also medical accidents
Nyce, Jim 147
observation 82, 140
obstetrics, intervention decisions 174—5
one true story, of accidents 83, 84, 182, 200–1
