How Complex Systems Fail
Introduction (Via Zdnet)
Enterprise systems are inherently complex, often involving many business processes, people, and organizations across a company. Given this built-in complexity, it’s no surprise that failures abound; it’s amazing these systems function at all.
We could make these same comments about any complex, mission critical system. For example, look no further than the space program or health care delivery. In both cases, massive complexity is connected to a need to get things right: failure means potential loss of life.
To say that complicated systems are more prone to break down than simpler systems is obvious. But there are also other, more subtle truths regarding failure and complex systems.
A paper copyrighted in 1998, called How Complex Systems Fail and written by an M.D., Dr. Richard Cook, describes 18 truths about the underlying reasons complicated systems break down. On the surface the list appears surprisingly simple, but deeper meaning is also present. Some of the points are obvious while others may surprise you.
The 18 Truths Of Complexity
1. Complex systems are intrinsically hazardous systems.
2.Complex ystems are heavliy & successfully defended against failure
3. Catastropherequiresmultiplefailures- single pointfailures are not enough
4. Complex systems contrain changing mixtures of failures latent within them
5. Complex systems run in degraded mode.
6. Catastrophe is always just around the corner
7. Post-accident attribution accident to a root cause is fundamentally wrong
8. Hindsight biases post accident assessments of human performance
9. Human operators have dual roles: as producers & as defenders
10. All practitioner actions are gambles
11. Actions at the sharp end resolve all ambiguity
12. Human practitioners are the aaptableelement of complex systems
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 views
16 . Safety is a characteristic of systems and not their components
17. People continuously create safety.
18. Failure freeoperations require experience with failure