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Drift into Failure: From Hunting Broken Components to Understanding Complex Systems (English Edition) 1. Auflage, Kindle Ausgabe

4,4 von 5 Sternen 158 Sternebewertungen

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.
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Sicherheits- und Produktressourcen

Produktbeschreibungen

Pressestimmen

'"Accidents come from relationships, not broken parts." Sidney Dekker's meticulously researched and engagingly written Drift into Failure: From Hunting Broken Parts to Understanding Complex Systems explains complex system failures and offers practical recommendations for their investigation and prevention from the combined perspectives of unruly technology, complexity theory, and post-Newtonian analysis. A valuable source book for anyone responsible for, or interested in, organizational safety.' Steven P. Bezman, Aviation safety researcher 'Dekker's book challenges the current prevalent notions about accident causation and system safety. He argues that even now, what profess to be systemic approaches to explaining accidents are still caught within a limited framework of 'cause and effect' thinking, with its origins in the work of Descartes and Newton. Instead, Dekker draws his inspiration from the science of complexity and theorises how seemingly reasonable actions at a local level may promulgate and proliferate in unseen (and unknowable) ways until finally some apparent system "failure" occurs. The book is liberally illustrated with detailed case studies to articulate these ideas. As with all Dekker's books, the text walks a fine line between making a persuasive argument and provoking an argument. Love it or hate it, you can't ignore it.' Don Harris, HFI Solutions Ltd 'Dekker's book contributes to the growing debate around the nature of retrospective investigations of safety-critical situations in complex systems. Both provocative and insightful, the author shines a powerful light on the severe limits of traditional linear approaches. His call for a diversity of voices and narratives, to deepen our understanding of accidents, will be welcomed in healthcare. Dekker's proposal that we shift from going "down and in" to "up and out" suggests a paradigm shift in accident investigation.' Rob Robson, Healthcare System Safety and Accountability, Canad

Buchrückseite

Explores complexity theory and systems thinking to better understand how complex systems drift into failure. This book develops a vocabulary that allows us to harness complexity and find different ways of managing drift.

Produktinformation

  • ASIN ‏ : ‎ B01NCHX2DQ
  • Herausgeber ‏ : ‎ CRC Press
  • Barrierefreiheit ‏ : ‎ Erfahre mehr
  • Erscheinungstermin ‏ : ‎ 5. Dezember 2016
  • Auflage ‏ : ‎ 1.
  • Sprache ‏ : ‎ Englisch
  • Dateigröße ‏ : ‎ 2.5 MB
  • Gleichzeitige Verwendung von Geräten ‏ : ‎ Bis zu 4 Geräte gleichzeitig, je nach vom Verlag festgelegter Grenze
  • Screenreader ‏ : ‎ Unterstützt
  • Verbesserter Schriftsatz ‏ : ‎ Aktiviert
  • X-Ray ‏ : ‎ Nicht aktiviert
  • Word Wise ‏ : ‎ Aktiviert
  • Seitenzahl der Print-Ausgabe ‏ : ‎ 234 Seiten
  • ISBN-13 ‏ : ‎ 978-1351942904
  • PageFlip ‏ : ‎ Aktiviert
  • Amazon Bestseller-Rang: Nr. 798.984 in Kindle-Shop (Siehe Top 100 in Kindle-Shop)
  • Kundenrezensionen:
    4,4 von 5 Sternen 158 Sternebewertungen

Informationen zum Autor

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Sidney Dekker
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Kundenrezensionen

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Spitzenrezensionen aus Deutschland

  • Bewertet in Deutschland am 31. Mai 2012
    A must read for anyone interested in system safety. Dekker goes a step beyond Reason, chellenging not only traditional safety and justice thinking, but Reason's cheese model as well. Unfortunately, this books gives more questions than answers, which the author admits - a beggining of the next big chapter in safety science. I can't wait for more!
  • Bewertet in Deutschland am 10. September 2017
    It's extremely rare that I stop reading a book, I can only remember one other instance where this happened. And yet, I stopped reading Drift into Failure and don't expect to finish it.

    I was hoping that it would be a good intro to safety, complex systems and safety management. Instead I found a repetitive, hard to follow book. Sydney Dekker can't write and they had a useless editor.

    The thesis is very interesting: it's not really possible to make a complex system safe and it's very difficult to properly evaluate the real causes of an accident. There are two examples, one from aviation, the other from medicine which aptly illustrate the above and those were the highlight of the entire book.

    Unfortunately that's where the positives stop. The author belabors that thesis beyond any reasonable expectation. Any competent editor would have cut this book in half, instead we are forced to suffer through yet another complaint about "newtonian logic" every few pages. Repetition could be a good method of conveying information, assuming that information is not brain-dead simple, in which case repeating the same thing over and over again is mind-numbingly boring.

    To add insult to injurry, the kindle version is full of typos. The scanning process made a complete mess of the book, I think I discovered four different ways of misspelling "the".
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  • Bewertet in Deutschland am 16. Juni 2018
    While the content of the book is interesting, the are regretfully many typing errors in the Kindle version of the book.

Spitzenrezensionen aus anderen Ländern

Alle Rezensionen ins Deutsche übersetzen
  • A Wise Man Listens
    5,0 von 5 Sternen The Real World of Risk and Uncertainty
    Bewertet in Großbritannien am 18. Dezember 2011
    This is a "must read" for not only academics, managers and safety professionals but also the general public. Dekker presents persuasive evidence and arguments that existing 'working to a formula everything is predictable' approaches to managing life and the complex organisations within it simply do not work. He makes complex systems thinking easy to understand. Far from being doom and gloom Dekker describes credible ways in which complexity may be managed.
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  • Waking life
    5,0 von 5 Sternen Fascinating insight
    Bewertet in Australien am 15. Oktober 2017
    This is a text book for one of my courses in OHS. It teases out the components of a system to make a point that there is not one reason for when things go wrong in complex situations. Well worth a read
  • Silicon Valley Engineer
    5,0 von 5 Sternen Fantastic book, spot-on so far...
    Bewertet in den USA am11. Mai 2020
    Just got started, so far it's been a page turner (that's a good thing): well written and compelling. The case is well established for pervasive rot largely (though not entirely) from outside the system the engineer's were asked to design and deliver. Will come back later when I get to the "what to do about it" parts with an update to this review.
  • M. Bolan
    5,0 von 5 Sternen Insightful guide to complex adaptive systems
    Bewertet in Australien am 23. August 2014
    Brilliant and insightful delivering many practical approaches to organisational drift of goals and standards. Highly recommended for anyone interested in systems insights.
  • White Wolf
    4,0 von 5 Sternen Informative and Thought-Provoking
    Bewertet in den USA am13. Dezember 2012
    This book is a noteworthy effort to provide new insights into how accidents and other bad outcomes occur in large organizations. Dekker begins by describing two competing world views, the essentially mechanical view of the world spawned by Newton and Descartes (among others), and a view based on complexity in socio-technical organizations and a systems approach. He shows how each world view biases the search for the "truth" behind how accidents and incidents occur.

    The Newtonian-Cartesian world is ruled by invariant cause-and-effect; it is, in fact, a machine. If something bad happens, then there was a unique cause or set of causes. Investigators search for these broken components, which could be physical or human. It is assumed that a clear line exists between the broken part(s) and the overall behavior of the system. The explicit assumption of determinism leads to an implicit assumption of time reversibility--because system performance can be predicted from time A if we know the starting conditions and the functional relationships of all components, then we can start from a later time B (the bad outcome) and work back to the true causes. Root cause analysis and criminal investigations are steeped in this world view.

    In contrast, a complex system is open (it interacts with its environment), has components that act locally and don't know the full effects of their actions, is constantly making decisions to maintain performance and adapt to changing circumstances, and has non-linear interactions (small events can cause large results) because of multipliers and feedback loops. Complexity is a result of the ever-changing relationships between components.

    The most important feature of a complex system is that it adapts to its environment over time in order to survive. And its environment is characterized by resource scarcity and competition. There is continuous pressure to maintain production and increase efficiency (and their visible artifacts: output, costs, profits, market share, etc) and less visible outputs, e.g., safety, will receive less attention. The cumulative effect of multiple adaptive decisions can be an erosion of safety margins and a changed response of the entire system--a drift into failure.

    Drift by a complex system exhibits several characteristics. First, as mentioned above, it is driven by environmental factors. Second, drift occurs in small steps so changes can be hardly noticed, and even applauded if they result in local performance improvement. Third, complex systems contain unruly technology (think deepwater drilling) where uncertainties exist about how the technology may be ultimately deployed and how it may fail. Fourth, there is significant interaction with a key environmental player, the regulator, and regulatory capture can occur, resulting in toothless oversight.

    "Drifting into failure is not so much about breakdowns or malfunctioning of components, as it is about an organization not adapting effectively to cope with the complexity of its own structure and environment." (p. 121) Drift and occasionally accidents occur because of ordinary system functioning, normal people going about their regular activities making ordinary decisions "against a background of uncertain technology and imperfect information." Accidents can be viewed as an emergent system property, i.e., they are the result of system relationships but cannot be predicted by examining any particular system component.

    This book is not a quick read. Dekker spends a lot of time developing his theory, then circling back to further explain it or emphasize individual pieces. He reviews incidents (airplane crashes, a medical error resulting in patient death, software problems, public water supply contamination) and descriptions of organizational evolution (NASA, international drug smuggling, "conflict minerals" in Africa, drilling for oil, terrorist tactics, Enron) to illustrate how his approach results in broader and arguably more meaningful insights than the reports of official investigations. One star off for repetitiveness, occasional Carl Sagan-like pedantry and poor proof-reading of the final couple of chapters.

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