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Drift into Failure: From Hunting Broken Components to Understanding Complex Systems 1st Edition, Kindle Edition

4.4 out of 5 stars 162 ratings

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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Review

'"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

From the Back Cover

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.

Product details

  • ASIN ‏ : ‎ B01NCHX2DQ
  • Publisher ‏ : ‎ CRC Press
  • Accessibility ‏ : ‎ Learn more
  • Publication date ‏ : ‎ 5 Dec. 2016
  • Edition ‏ : ‎ 1st
  • Language ‏ : ‎ English
  • File size ‏ : ‎ 2.5 MB
  • Simultaneous device usage ‏ : ‎ Up to 4 simultaneous devices, per publisher limits
  • Screen Reader ‏ : ‎ Supported
  • Enhanced typesetting ‏ : ‎ Enabled
  • X-Ray ‏ : ‎ Not Enabled
  • Word Wise ‏ : ‎ Enabled
  • Print length ‏ : ‎ 234 pages
  • ISBN-13 ‏ : ‎ 978-1351942904
  • Page Flip ‏ : ‎ Enabled
  • Best Sellers Rank: 940,234 in Kindle Store (See Top 100 in Kindle Store)
  • Customer reviews:
    4.4 out of 5 stars 162 ratings

About the author

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Sidney Dekker
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Sidney Dekker is Professor of Human Factors and Flight Safety, and Director of Research at the School of Aviation, Lund University, Sweden. He has previously worked at the Public Transport Cooperation in Melbourne, Australia; the Massey University School of Aviation, New Zealand, British Aerospace, UK, and has been a Senior Fellow at Nanyang Technological University in Singapore. His specialties and research interests are system safety, human error, reactions to failure and criminalization, and organizational resilience. He has some experience as a pilot, type trained on the DC-9and Airbus A340.

Customer reviews

4.4 out of 5 stars
162 global ratings

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Top reviews from United Kingdom

  • Reviewed in the United Kingdom on 18 December 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.
    3 people found this helpful
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  • Reviewed in the United Kingdom on 31 July 2014
    I enjoyed this book. It is a quiet, rather dry, but effectively devastating academic study of how things drift into failure. In fact right now, there's probably something in your life or work that's actively drifting towards failure!

    The book is a very good description of how temporary success and achievement are, and how hard they are to sustain. A bit like Gibbon's narrative of the Decline and Fall of the Roman Empire the question is either how early where the flaws obvious? Or the reciprocal- With all its flaws how this this system manage to stagger on for so long?

    Dekker writes well as an academic. There are detailed examples and references- reflecting his knowledge and experience.

    He's superb in his discussions of our notions of controllability and responsibility. He's not sure these ideas really exist, or can be exercised well in complex adaptive systems. He's less convinced anything is "accidental" or that the word can be well defined- every event has its antecedents.

    He's quite sceptical of linear descriptions of accidents or system failures. Sometimes they are right- and the causal chain can be mapped out across part of its trajectory. But he's very sceptical these explain the whole story.

    He defines the book well in his introduction which is worth quoting,
    "Drifting into failure is a gradual, incremental decline into disaster driven by environmental pressure, unruly technology and social processes that normalise growing risk. No organisation is exempt from drifting into failure.....Failure does not come from the occasional, abnormal dysfunction or breakdown of these structures, processes and tasks, but is an inevitable by product of their normal functioning. The same characteristics that guarantee the fulfilment of that organisations mandate will turn out to be responsible for undermining that mandate...
    Drifting into failure is a slow incremental process. An organisation using all its resources in pursuit of its mandate (e.g. providing safe air travel,delivering electricity reliably, taking care of your savings) gradually borrows more and more from the margins of what once buffered it from the assumed boundaries of failure.The very pursuit of the mandate, over time, and under pressure environmental factors (competition and scarcity most most prominently) dictates that it does this borrowing- does things more efficiently, does more with less, perhaps takes greater risks. Thus it is the very pursuit of the mandate that creates the conditions for its eventual collapse."

    Perhaps all organisations need to be recreated every so often? Perhaps he's describing beautifully why great companies come and go- and maybe why we should allow this to happen, not try to control it.

    What he says about drift into failure could probably be flipped around- and some people and organisations drift into success- without much conscious thought or care- but by managing to be around in right time and right place.

    His concluding comment is not that there is an easy answer to questions about drifting in to failure but there is one concept which is helpful- "Truth, if there is such a concept, lies in diversity, not singularity."
    7 people found this helpful
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  • Reviewed in the United Kingdom on 19 May 2018
    Dr Dekker is probably the leading thinker in the world of safety
    One person found this helpful
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  • Reviewed in the United Kingdom on 14 August 2015
    When a different point of view, comes to transform the way we analyse our systems and surroundings. Clear definitions, a clear story and pragmatic results.
  • Reviewed in the United Kingdom on 20 April 2015
    Interesting read, but he has little advice to offer on managing complexity to avoid failure. From a practitioners perspective there are more useful texts, for example " Six simple rules:how to manage complexity without getting complicated".
    2 people found this helpful
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  • Reviewed in the United Kingdom on 2 November 2017
    Part of a series of HS publications on failure modes and models, but keep an open mind
  • Reviewed in the United Kingdom on 27 December 2013
    Full of insights as to how our own culture influences our perceptions of events past and future. A slow careful read is needed.
    One person found this helpful
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  • Reviewed in the United Kingdom on 16 January 2015
    This book is a description of how complex systems fail.

    If you like me are looking for a rigorous way to avoid this, a method, a process that can tame compex systems then the message from this book is "dream on"

    With many examples this book demolishes various approaches that have been used to address problems in complex systems

    The main idea the book has is that there are five concepts that characterize drift

    * Scarcity and competition
    * Decrementalism or small steps
    * Sensitivity to initial conditions
    * Unruly technology
    * Contribution of the protective structure

    being aware of these factors and what they do is a important way to avoid the "drift into failure". To summarise some of the ideas to help mitigate these things

    * don't optimise 100% or make performance the goal
    * have diverse opinions on the correctness of the system
    * see failure as an opportunity to learn
    * monitor the interconnections within the system rather than parts

    A really interesting, thought provoking book
    2 people found this helpful
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Top reviews from other countries

  • Waking life
    5.0 out of 5 stars Fascinating insight
    Reviewed in Australia on 15 October 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 out of 5 stars Fantastic book, spot-on so far...
    Reviewed in the United States on 11 May 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.
  • Tomislav Gradisar
    5.0 out of 5 stars Another great book from Mr. Dekker
    Reviewed in Germany on 31 May 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!
  • M. Bolan
    5.0 out of 5 stars Insightful guide to complex adaptive systems
    Reviewed in Australia on 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 out of 5 stars Informative and Thought-Provoking
    Reviewed in the United States on 13 December 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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