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Drift into Failure

Drift into Failure PDF Author: Sidney Dekker
Publisher: CRC Press
ISBN: 1351942913
Category : Technology & Engineering
Languages : en
Pages : 332

Book Description
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.

Drift into Failure

Drift into Failure PDF Author: Sidney Dekker
Publisher: CRC Press
ISBN: 1351942913
Category : Technology & Engineering
Languages : en
Pages : 332

Book Description
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.

Drift into Failure

Drift into Failure PDF Author: Professor Sidney Dekker
Publisher: Ashgate Publishing, Ltd.
ISBN: 1409486559
Category : Psychology
Languages : en
Pages : 277

Book Description
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.

Safety Differently

Safety Differently PDF Author: Sidney Dekker
Publisher: CRC Press
ISBN: 1482242001
Category : Technology & Engineering
Languages : en
Pages : 304

Book Description
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. Today, the unrelenting pace of technology change and growth of complexity calls for a different kind of safety thinking. Automation and new technologies have resu

Drift

Drift PDF Author: Rachel Maddow
Publisher: Crown
ISBN: 0307461009
Category : Political Science
Languages : en
Pages : 285

Book Description
The #1 New York Times bestseller that charts America’s dangerous drift into a state of perpetual war. Written with bracing wit and intelligence, Rachel Maddow's Drift argues that we've drifted away from America's original ideals and become a nation weirdly at peace with perpetual war. To understand how we've arrived at such a dangerous place, Maddow takes us from the Vietnam War to today's war in Afghanistan, along the way exploring Reagan's radical presidency, the disturbing rise of executive authority, the gradual outsourcing of our war-making capabilities to private companies, the plummeting percentage of American families whose children fight our constant wars for us, and even the changing fortunes of G.I. Joe. Ultimately, she shows us just how much we stand to lose by allowing the scope of American military power to overpower our political discourse. Sensible yet provocative, dead serious yet seri­ously funny, Drift reinvigorates a "loud and jangly" political debate about our vast and confounding national security state.

The Field Guide to Human Error Investigations

The Field Guide to Human Error Investigations PDF Author: Sidney Dekker
Publisher: Routledge
ISBN: 1351786032
Category : Social Science
Languages : en
Pages : 137

Book Description
This title was first published in 2002: This field guide assesses two views of human error - the old view, in which human error becomes the cause of an incident or accident, or the new view, in which human error is merely a symptom of deeper trouble within the system. 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. The second part of this guide focuses on the circumstances which unfold around people, which causes their assessments and actions to change accordingly. It shows how to "reverse engineer" human error, which, like any other componant, needs to be put back together in a mishap investigation.

Behind Human Error

Behind Human Error PDF Author: David D. Woods
Publisher: CRC Press
ISBN: 1317175530
Category : Technology & Engineering
Languages : en
Pages : 292

Book Description
Human error is cited over and over as a cause of incidents and accidents. The result is a widespread perception of a 'human error problem', and solutions are thought to lie in changing the people or their role in the system. For example, we should reduce the human role with more automation, or regiment human behavior by stricter monitoring, rules or procedures. But in practice, things have proved not to be this simple. The label 'human error' is prejudicial and hides much more than it reveals about how a system functions or malfunctions. This book takes you behind the human error label. Divided into five parts, it begins by summarising the most significant research results. Part 2 explores how systems thinking has radically changed our understanding of how accidents occur. Part 3 explains the role of cognitive system factors - bringing knowledge to bear, changing mindset as situations and priorities change, and managing goal conflicts - in operating safely at the sharp end of systems. Part 4 studies how the clumsy use of computer technology can increase the potential for erroneous actions and assessments in many different fields of practice. And Part 5 tells how the hindsight bias always enters into attributions of error, so that what we label human error actually is the result of a social and psychological judgment process by stakeholders in the system in question to focus on only a facet of a set of interacting contributors. If you think you have a human error problem, recognize that the label itself is no explanation and no guide to countermeasures. The potential for constructive change, for progress on safety, lies behind the human error label.

The Defence of Duffer's Drift

The Defence of Duffer's Drift PDF Author: Ernest Dunlop Swinton
Publisher:
ISBN:
Category : Guerrilla warfare
Languages : en
Pages : 74

Book Description


Just Culture

Just Culture PDF Author: Sidney Dekker
Publisher: Ashgate Publishing, Ltd.
ISBN: 1409440605
Category : Technology & Engineering
Languages : en
Pages : 201

Book Description
While many organizations see the value of creating a just culture they struggle when it comes to developing it. In this Second Edition, Dekker expands his views, additionally tackling the key issue of how justice is created inside organizations. Dekker also introduces new material on ethics and on caring for the' second victim' (the professional at the centre of the incident). Consequently, we have a natural evolution of the author's ideas.

What Happened to Goldman Sachs

What Happened to Goldman Sachs PDF Author: Steven G. Mandis
Publisher: Harvard Business Press
ISBN: 1422194205
Category : Business & Economics
Languages : en
Pages : 256

Book Description
This is the story of the slow evolution of Goldman Sachs—addressing why and how the firm changed from an ethical standard to a legal one as it grew to be a leading global corporation. In What Happened to Goldman Sachs, Steven G. Mandis uncovers the forces behind what he calls Goldman’s “organizational drift.” Drawing from his firsthand experience; sociological research; analysis of SEC, congressional, and other filings; and a wide array of interviews with former clients, detractors, and current and former partners, Mandis uncovers the pressures that forced Goldman to slowly drift away from the very principles on which its reputation was built. Mandis evaluates what made Goldman Sachs so successful in the first place, how it responded to pressures to grow, why it moved away from the values and partnership culture that sustained it for so many years, what forces accelerated this drift, and why insiders can’t—or won’t—recognize this crucial change. Combining insightful analysis with engaging storytelling, Mandis has written an insider’s history that offers invaluable perspectives to business leaders interested in understanding and managing organizational drift in their own firms.

Outwitting the Devil

Outwitting the Devil PDF Author: Napoleon Hill
Publisher: Sharon Lechter
ISBN:
Category : Self-Help
Languages : en
Pages : 30

Book Description
Originally written in 1938 but never published due to its controversial nature, an insightful guide reveals the seven principles of good that will allow anyone to triumph over the obstacles that must be faced in reaching personal goals.