Drift into Failure : From Hunting Broken Components to Understanding Complex Systems
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.
- Paperback | 234 pages
- 159 x 235 x 12.7mm | 431g
- 28 Feb 2011
- Taylor & Francis Ltd
- Ashgate Publishing Limited
- United Kingdom
- New ed
- Includes 3 b&w illustrations
Table of contents
Contents: Preface; Failure is always an option; Features of drift; The legacy of Newton and Descartes; The search for the broken component; Theorizing drift; What is complexity and systems thinking?; Managing the complexity of drift; Bibliography; Index.
'"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, Canada 'Professor Dekker explodes the myth that complex economic, technological and environmental failures can be investigated by approaches fossilized in linear, Newtonian-Cartesian logic. Today nearly 7 billion people unconsciously reshape themselves, their organizations, and societies through the use of rapidly-evolving, proliferating and miniaturizing technologies powered by programs that supersede the intellectual grasp of their developers. Serious proponents of the next high reliability organizations would do well to absorb Drift into Failure.' Jerry Poje, Founding Board Member of the U.S. Chemical Safety and Hazard Investigation Board 'Today, catastrophic accidents resulting from failure of simple components confound industry. In Drift into Failure, Dekker shows how reductionist analysis - breaking the system down until we find the "broken part" - does not explain why accidents in complex systems occur. Dekker introduces the systems approach. Reductionism delivers an inventory of broken parts; Dekker's book offers a genuine possibility of future prevention. The systems approach may allow us to Drift into Success.' John O'Meara, HAZOZ 'Dekker is a specialist in things going wrong. He is the world's leading thinker on airline safety. He is concerned about drift into failure in hospitals, on oil drilling platforms, in financial services, on NASA missions. But my hope that the book would somehow be about the human condition in a more intimate way was not disappointed' Australian Library Review, May 2011 'Dekker wants investigations to go up and out, not down and in, because understanding comes from knowing how the system fits into a larger network of other systems, of tracing the relationships with those, and how those spread out to interact with factors that lie far way in time and space from the moment things went wrong. This thought-provoking book is highly recommended.' Ergonomics Review 2012 'In this beautifully written and absorbing book, Professor Dekker takes as his starting point the notion that most of us have trouble grasping the complexity coupled with the sheer normality that can give rise to catastrophic events...This book explores complexity theory and systems thinking to understand better how complex systems drift into failure...a work which has to read from first to last if the thrust of Professors Dekker's meaning is to be understood.' RoSPA Occupational Safety & Health Journal, July 2012 'Drift Into Failure 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 organization 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. Standing on the shoulders of others, especially Diane Vaughan, Dekker gives us a rich model for what might be called the "banality of normalization of deviance".' SafetyMatters blog
About Professor Sidney Dekker
Sidney Dekker is Professor and Director of the Key Centre for Ethics, Law, Justice and Governance at Griffith University in Brisbane, Australia. Previously Professor at Lund University, Sweden, and Director of the Leonardo Da Vinci Center for Complexity and Systems Thinking there, he gained his Ph.D. in Cognitive Systems Engineering from The Ohio State University, USA. He has worked in New Zealand, the Netherlands and England, been Senior Fellow at Nanyang Technological University in Singapore, Visiting Academic in the Department of Epidemiology and Preventive Medicine, Monash University in Melbourne, and Professor of Community Health Science at the Faculty of Medicine, University of Manitoba in Canada. Sidney is author of several best-selling books on system failure, human error, ethics and governance. He has been flying the Boeing 737NG part-time as airline pilot for the past few years. The OSU Foundation in the United States awards a yearly Sidney Dekker Critical Thinking Award.