Drift into Failure

235 Pages·2011·3.66 MB·English

Drift into Failure
From Hunting Broken Components to
Understanding Complex Systems
Sidney Dekker
Drift into failure
v

Drift into failure
From Hunting Broken
Components to
Understanding Complex
Systems
v
Sidney Dekker
© Sidney Dekker 2011
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system
or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise without the prior permission of the publisher.
Sidney Dekker has asserted his right under the Copyright, Designs and Patents Act, 1988, to be
identified as the author of this work.
Published by
Ashgate Publishing Limited Ashgate Publishing Company
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England USA
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British Library Cataloguing in Publication Data
Dekker, Sidney.
Drift into failure : from hunting broken components to
understanding complex systems.
1. Complexity (Philosophy) 2. Causation. 3. System theory.
4. Technological complexity. 5. System failures
(Engineering) 6. Cognitive psychology.
I. Title
003-dc22
ISBN: 978-1-4094-2222-8 (hbk)
978-1-4094-2221-1 (pbk)
978-1-4094-2223-5 (ebk)
Library of Congress Cataloging-in-Publication Data
Dekker, Sidney.
Drift into failure : from hunting broken components to understanding complex systems / by
Sidney Dekker.
p. cm.
Includes index.
ISBN 978-1-4094-2222-8 (hbk.) -- ISBN 978-1-4094-2221-1 (pbk.) -- ISBN 978-1-4094-2223-5
(ebook) 1. Social systems. 2. Complex organizations. 3. System theory--Social aspects.
4. System failures (Engineering) 5. Failure (Psychology) 6. Complexity (Philosophy) I. Title.
HM701.D45 2010
302.3'5--dc22
2010034296
contents
v
List of Figures vii
Acknowledgments ix
Reviews for Drift into Failure x
Preface xi
1 Failure is Always an Option 1
Who messed up here? 1
Technology has developed more quickly than theory 6
Complexity, locality and rationality 11
Complexity and drift into failure 13
A great title, a lousy metaphor 18
References 22
2 Features of Drift 25
The broken part 31
The outlines of drift 35
A story of drift 46
References 49
3 The Legacy of Newton and Descartes 51
Why did Newton and Descartes have such an impact? 54
So why should we care? 58
We have Newton on a retainer 65
References 69
4 The Search for the Broken Component 71
Broken components after a hailstorm 72
Broken components to explain a broken system 75
Newton and the simplicity of failure 76
References 86
vi
driFt into FailUre
5 Theorizing Drift 87
Man-made disasters 87
High reliability organizations 93
Goal interactions and production pressure 99
Normalizing deviance, structural secrecy and practical drift 103
Control theory and drift 116
Resilience engineering 121
References 123
6 What is Complexity and Systems Thinking? 127
More redundancy and barriers, more complexity 127
Up and out, not down and in 130
Systems thinking 133
Complex systems theory 138
Complexity and drift 153
References 166
7 Managing the Complexity of Drift 169
Complexity, control and influence 169
Diversity as a safety value 173
Turning the five features of drift into levers of influence 176
Drifting into success 185
Complexity, drift, and accountability 187
A post-Newtonian ethic for failure in complex systems 198
References 202
Bibliography 205
Index 211
list of figures
v
Figure 5.1 Control structure as originally envisioned to guarantee water
quality in Walkerton 118
Figure 5.2 Safety control structure at the time of the water contamination
incident at Walkerton 119
Figure 7.1 The Herfindahl Index 175
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acknowleDgments
v
I want to thank Paul Cilliers and Jannie Hofmeyr at the Centre for Studies in
Complexity at the University of Stellenbosch, South Africa, for our fascinating
discussions on complexity, ethics and system failure. I also want to thank Eric
Wahren and Darrell Horn for their studious reading of earlier drafts and their
helpful comments for improvement.