Complexity, swiss cheese and failure

friday2Friday’s Finds:

@TomGram1 “Resources not courses”. A new mantra.

“5% of interactions account for 90% of misery” – Rob Cross on how energy spreads across an organization. – via @ActivateN

@austinkleon – Why I make no distinction between Big Writing (books) and little writing (tweets): Twitter as a machine for book invention

In my experience, stock is best made by collecting, organizing, and expanding upon flow. You gather your bits, combine them, and then turn them into something new. But this process requires being able to get at your flow.

For some of our most-read findings, see 20 facts from Pew Research Center – via @zecool

65% of Americans say news organizations focus on unimportant stories rather than on important ones (28%).
Nearly one-third—31%—of people say they have deserted a particular news outlet because it no longer provides the news and information they had grown accustomed to.

How Complex Systems Fail [PDF] Complexity, swiss cheese and failure. The classic 1998 article by Richard Cook – via @commutiny

Complex systems contain changing mixtures of failures latent within them.
Hindsight biases post-accident assessments of human performance.
Human operators have dual roles: as producers & as defenders against failure.
All practitioner actions are gambles.
Human practitioners are the adaptable element of complex systems.
Human expertise in complex systems is constantly changing.

 

5 Responses to “Complexity, swiss cheese and failure”

  1. Earl Mardle

    Cook’s piece should be nailed to every wall, nay, printed in large type on a wall in every room of every organisation. Especially this bit,
    Human operators have dual roles: as producers & as defenders against failure.
    All practitioner actions are gambles.
    Human practitioners are the adaptable element of complex systems.

    But it also has a corollary that too often goes unsaid, that every time an organisation acts to remove human operator flexibility from the system, or to remove those operators completely, it reduces the only source of flexibility to respond to novel situations.

    Unions always understood that, short of a strike, the surest way to cripple an organisation was to “work to rule”. As organisations become more and more dependent on non-human operations, they move ever closer to a situation where they will be working to rule and hence crippling themselves.

    This, BTW, is quite probably the best outcome we can hope for from organisations run by people who think in that way.

    Reply
    • Harold

      So true, Earl! – “every time an organisation acts to remove human operator flexibility from the system, or to remove those operators completely, it reduces the only source of flexibility to respond to novel situations”

      Reply

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