[FoRK] How Complex Systems Fail
wgstoddard at gmail.com
Fri Nov 6 14:39:32 PST 2009
Ken Ganshirt @ Yahoo wrote:
> A short paper; 18 significant points in four pages. I found this to be a very interesting analysis. Some of the points are immediately obvious. Some of the points are a bit counterintuitive, or at least argue against common practice but are on the money in spite of that ... or perhaps because of it.
> He's talking about medical systems but it applies equally to any complex system.
> It's a paper that every CIO should be forced to read once a month, forever. It should be considered the stone tablet for post hoc analysis teams. And probably should be required reading for every project manager.
> For 18 short points there is a tremendous amount of meat in this. Seriously good thinking.
Interesting, however there's a nagging doubt eating away at me ... that
this is really directed an deflecting medical malpractice. "Hey, it's a
'complex system' so it's not my fault that I f&*&*k'ed up"
"7) Post-accident attribution accident to a ‘root cause’ is
fundamentally wrong. "
I have a problem with this assertion. It could be that a 'root cause'
analysis is inconclusive, but to simply wave a hand and say 'this is a
complex system so we're not going to bother trying to understand what
happened' is fundamentally wrong. Maybe I misunderstand the meaning of
'root cause' in this assertion?
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