What does the collapse of sub-prime lending have in common with a broken jackscrew in an airliner’s tailplane? Or the oil spill disaster in the Gulf of Mexico with the burn-up of Space Shuttle Columbia? These were systems that drifted into failure. While pursuing success in a dynamic, complex environment with limited resources and multiple goal conflicts, a succession of small, everyday decisions eventually produced breakdowns on a massive scale. We have trouble grasping the complexity and normality that gives rise to such large events. We hunt for broken parts, fixable properties, people we can hold accountable. Our analyses of complex system breakdowns remain depressingly linear, depressingly componential - imprisoned in the space of ideas once defined by Newton and Descartes. The growth of complexity in society has outpaced our understanding of how complex systems work and fail. Our technologies have gotten ahead of our theories. We are able to build things - deep-sea oil rigs, jackscrews, collateralized debt obligations - whose properties we understand in isolation. But in competitive, regulated societies, their connections proliferate, their interactions and interdependencies multiply, their complexities mushroom. This book explores complexity theory and systems thinking to understand better how complex systems drift into failure. It studies sensitive dependence on initial conditions, unruly technology, tipping points, diversity - and finds that failure emerges opportunistically, non-randomly, from the very webs of relationships that breed success and that are supposed to protect organizations from disaster. It develops a vocabulary that allows us to harness complexity and find new ways of managing drift.
The two parts of this guide concentrate on each view, leading towards an appreciation of the new view, in which human error is the starting point of an investigation, rather than its conclusion.
This lack of awareness of flaws in knowledge broadly the issue of knowledge calibration (e.g., Wagenaar and Keren, 1986). Put most simply, individuals are well calibrated if they are aware of the accuracy, completeness, limits, ...
Explains how the intense focus on national security is actually compromising the stability of the country, tracing the historical events and contributing factors that have promoted a deeply militarized American culture.
Bureaucracy and compliance now seem less about managing the safety of the workers we are responsible for, and more about managing the liability of the people they work for.
This is a down-to-earth practitioner’s guide to managing maintenance error, written in Dr. Reason’s highly readable style.
"IT veteran Dave Zweiback describes an incident that threatens the very existence of a large financial institution, and the counterintuitive steps its leadership took to stop the downward spiral.
Each chapter provides directions for new ideas and models that could perhaps better cope with the complexity of the problems facing human error today. As such, this book can be used as a supplement for a variety of human factors courses.
The second edition of a bestseller, Safety Differently: Human Factors for a New Era is a complete update of Ten Questions About Human Error: A New View of Human Factors and System Safety.
Continental Drift is the story of a young blue-collar worker and family man who abandons his broken dreams in New Hampshire and the story of a young Haitian woman who, with her nephew and baby, flees the brutal injustice and poverty of her ...
Following a deadly car crash, small-town lawyer Lance Cooper risked everything to battle one of the most powerful auto corporations in the world to get justice for a young woman.