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The first 6 of 18 sections to https://how.complexsystems.fail:
1. Complex systems are intrinsically hazardous systems
2. Complex systems are heavily and successfully defended against failure
3. Catastrophe requires multiple failures – single point failures are not enough
4. Complex systems contain changing mixtures of failures latent within them
5. Complex systems run in degraded mode
6. Catastrophe is always just around the corner
…The second 6 of 18 sections in https://how.complexsystems.fail:
7. Post-accident attribution to a ‘root cause’ is fundamentally wrong
8. Hindsight biases post-accident assessments of human performance
9. Human operators have dual roles: as producers and as defenders against failure
10. All practitioner actions are gambles
11. Actions at the sharp end resolve all ambiguity
12. Human practitioners are the adaptable element of complex systems
…The third 6 of 18 sections in https://how.complexsystems.fail:
13. Human expertise in complex systems is constantly changing
14. Change introduces new forms of failure
15. Views of ‘cause’ limit the effectiveness of defenses against future events
16. Safety is a characteristic of systems and not of their components
17. People continuously create safety
18. Failure free operations require experience with failure
— Richard I. Cook
MD Cognitive Technologies Labratory
University of Chicago
…My thanks to @glyph for pointing me at Richard Cook’s ‘Short Treatise on the Nature of Failure’ outlined above, which I’m finding a very helpful layering of https://mastodon.social/@urlyman/114641074939985465
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