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Author: Sidney Dekker
Publisher: CRC Press
ISBN: 1351942913
Category : Technology & Engineering
Languages : en
Pages : 332
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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.
Author: Sidney Dekker
Publisher: CRC Press
ISBN: 1351942913
Category : Technology & Engineering
Languages : en
Pages : 332
Get Book
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.
Author: Sidney Dekker
Publisher: CRC Press
ISBN: 1482242001
Category : Technology & Engineering
Languages : en
Pages : 304
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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
Author: David D. Woods
Publisher: CRC Press
ISBN: 1317175530
Category : Technology & Engineering
Languages : en
Pages : 292
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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.
Author: Sidney Dekker
Publisher: Routledge
ISBN: 1351786032
Category : Social Science
Languages : en
Pages : 137
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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.
Author: Rachel Maddow
Publisher: Crown
ISBN: 0307461009
Category : Political Science
Languages : en
Pages : 285
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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.
Author: Sidney Dekker
Publisher: Ashgate Publishing, Ltd.
ISBN: 1409440605
Category : Technology & Engineering
Languages : en
Pages : 201
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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.
Author: Ernest Dunlop Swinton
Publisher:
ISBN:
Category : Guerrilla warfare
Languages : en
Pages : 74
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Book Description
Author: Sidney Dekker
Publisher: CRC Press
ISBN: 146658341X
Category : Medical
Languages : en
Pages : 131
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Book Description
How do people cope with having "caused" a terrible accident? How do they cope when they survive and have to live with the consequences ever after? We tend to blame and forget professionals who cause incidents and accidents, but they are victims too. They are second victims whose experiences of an incident or adverse event can be as traumatic as that of the first victims’. Yet information on second victimhood and its relationship to safety, about what is known and what organizations might need to do, is difficult to find. Thoroughly exploring an emerging topic with great relevance to safety culture, Second Victim: Error, Guilt, Trauma, and Resilience examines the lived experience of second victims. It goes through what we know about trauma, guilt, forgiveness, and injustice and how these might be felt by the second victim. The author discusses how to conduct investigations of incidents that do not alienate second victims or make them feel even worse. It explores the importance support and resilience and where the responsibilities for creating it may lie. Drawing on his unique background as psychologist, airline pilot, and safety specialist, and his own experiences with helping second victims from a variety of backgrounds, Sidney Dekker has written a powerful, moving account of the experience of the second victim. It forms compelling reading for practitioners, risk managers, human resources managers, safety experts, mental health workers, regulators, the judiciary, and many other professionals. Dekker provides a strong theoretical background to promote understanding of the situation of the second victim and solid practical advice about how to deal with trauma that continues after an event leading to preventable harm or even avoidable death of a patient, consumer, or colleague. Listen to Sidney Dekker speak about his book
Author: Casey Rosenthal
Publisher: "O'Reilly Media, Inc."
ISBN: 1492043818
Category : Computers
Languages : en
Pages : 312
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Book Description
As more companies move toward microservices and other distributed technologies, the complexity of these systems increases. You can't remove the complexity, but through Chaos Engineering you can discover vulnerabilities and prevent outages before they impact your customers. This practical guide shows engineers how to navigate complex systems while optimizing to meet business goals. Two of the field's prominent figures, Casey Rosenthal and Nora Jones, pioneered the discipline while working together at Netflix. In this book, they expound on the what, how, and why of Chaos Engineering while facilitating a conversation from practitioners across industries. Many chapters are written by contributing authors to widen the perspective across verticals within (and beyond) the software industry. Learn how Chaos Engineering enables your organization to navigate complexity Explore a methodology to avoid failures within your application, network, and infrastructure Move from theory to practice through real-world stories from industry experts at Google, Microsoft, Slack, and LinkedIn, among others Establish a framework for thinking about complexity within software systems Design a Chaos Engineering program around game days and move toward highly targeted, automated experiments Learn how to design continuous collaborative chaos experiments
Author: Steven G. Mandis
Publisher: Harvard Business Press
ISBN: 1422194205
Category : Business & Economics
Languages : en
Pages : 256
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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.
