Drift Into Failure, page 36
Ontario, water contamination accident 117–20
Operation Provide Comfort 110
operations, sensitivity to 96–7
optimization 177—8
at the edge of chaos 138, 164—6
order 172
organizational learning, and high reliability organizations 93, 94
organizations, as open systems 109
organized complexity 157—8
organized crime 146—7
see also drug trafficking
overdose accidents:
lindocaine poisoning of baby 79, 80
radiation therapy 129—30
overlap see redundancy
Page, Scott 3
paperclip, bartering for a house 185—6
pension funds, investments 10
PETN (Pentaerythritol Tetranitrate) 74
phase shifts 160—1
Pidgeon, N.F. 171
plagues 55
Planck, Max 133
Poincaré, Henri 133
population growth, Europe 56
post-structuralism 21
Powerpoint presentations 114
practical drift 110
Presidential Commission into Space Shuttle Challenger accident 62, 64, 103—4, 105, 108, 112
production pressure, and goal conflicts 99–103
progress 20
protective structure, contribution of 17–18, 44–6, 154–5, 182–5
proximal causes 58
psychology 80
of failure 77
quantum physics 133, 134—5
radiation therapy, software safety 129–30
Rasmussen, Jens 37, 112, 120
rational choice theory 2—6, 12—13, 104
rationality:
decision-making 12—13, 114
local rationality principle 12—13
RCA (root cause analysis), Wisconsin epidural anaesthetic accident 65—6
reconstruction 81, 84, 170–1
recursion 146
reductionism 2, 57, 80, 91, 140, 149
and the eureka part 77—9
redundancy 63, 106, 127—8
automation as layer of 129
and high reliability organizations 93, 94
and software 129
regional climates, impact of climate change 135—6
regress 19, 20
regulation 182—5
and BP 17–18
and Enron 193—4
see also protective structure
relationships, as cause of accidents 63–5, 68, 128
relatively closed systems, and high reliability organizations 93, 94, 139
relativity theory 134
resilience engineering 121—3, 173
resource scarcity and competition 14–15, 36–9, 153–4, 176–8
resultant phenomena 156
accidents as 158
risk:
as energy to be contained 90—3
Newtonian-Cartesian perspective on 2
and organizational practices 93 high reliability organizations (HRO) 93–5
risk management, failure of and accidents 5
road traffic legislation 81
root cause analysis (RCA), Wisconsin epidural anaesthetic accident 65—6
Royal Society, London 85, 133
rules 120
Rwanda 133
safe operations, challenging belief in 95–9
safety boundaries 120
in complex systems 37
safely certification of aircraft 41—2
safety culture 77—8, 109
and high reliability organizations 93, 94
safely inspection 184—5
safety work 84
salt, emergent properties of 155—6
Scientific Management 171—2
Scientific Revolution 54–6, 137
SEC (Securities and Exchange Commission) 192—3
secrecy, structural 108—12
securities 8, 9
securitization 10
and Enron 196
sensitive dependence on initial conditions (butterfly effect) 16, 40–2, 143—4, 154, 178–80
Severe Weather Chart 72
ships:
closed loop communication 129
naval aircraft carriers 93, 173, 180
simplicity, of Newtonian science 79
simulation 94
Skilling, Jeff 190, 192, 193, 194, 195–6, 198, 199, 200
slime mold study, New York City 156–7
small steps (decrementalism) 15—16, 39–40, 49, 106, 115, 121, 179–80
Snook, Scott 110—11, 188
social sciences 80, 83
and systems thinking 137
sociology, and tipping point concept 161
Sodium (Natrium) 155—6
software, and safety 129—30, 150
South America, drug trafficking 145–6
Space Shuttles:
Challenger accident 11, 61, 62, 64—5, 96, 103–5, 182
Presidential Commission 62, 64, 103—4, 105, 108, 112
Columbia accident 58—61, 163—4, 166, 179
Columbia Accident Investigation
Board 62, 112, 113–14, 115
and organizational culture 61—3, 65, 96, 100–1, 108
information environment 112—15
operations 18—19, 102—3, 180
Spain, drug trafficking 145
Spurlock, Morgan 156
Stech, F.J. 89
stock markets, investment in 9—10
structural secrecy 108—12
Subjective Expected Utility Theory 3
subversion 93
success, drift into 185–7
Suez crisis 143—4
surprise, of failure 88–90
Svedung, I. 112
Swiss Cheese Model 54, 58, 77, 91–2
swivel chair accidents 160
system accidents 128
system safety 76, 128, 158, 188
systems approaches 33—4, 89
systems engineering 128
systems thinking 130—8, 155
Taylor, Frederick 171—2
TCAS II (airborne collision prediction and avoidance system) 129, 150
technology, development faster than theory 6—7, 169
temperature, and level of violence 135, 136–7
terrorism 147
Thatcher, Margaret 78
theory, development slower than technology 6—7, 169
Therac-25 radiation therapy machine 129–30
thermodynamic systems 160—1
Thiokol, Morton 176
time-reversibility 81, 84
tipping points 160—4
Trans World Airlines flight 800 air accident 74—5
Transocean 1, 14
see also BP, Deepwater Horizon accident
true story, of accidents 83, 84, 182, 200–1
Turner, Barry 87–8, 89, 90, 92, 95, 99, 103, 123n2
see also man-made disaster theory
Tutfe, Edward 113–14
unruly technology 16—17, 42–4, 154, 180–2
"up and out" thinking 130—3
Vaughan, Diane 103, 104, 105—6, 107–8, 109–10
Von Bertalanffy, L. 138
Wales, Aberfan disaster 87, 89, 99
Walkerton, Ontario, water contamination accident 117—20
war risk, and climate change 135, 136
water contamination accident, Walkerton, Ontario 117—20
Waxman, Henry 3—4
weather, and air accidents 71—2
Weber, Max 147, 148, 177
Western culture 77—8
"white flight" 160
Wildavsky, A.B. 173
Wisconsin, epidural anaesthetic accident 51—5, 58, 65—7
workload boundary, in complex systems 37
WPUC (Walkerton Public Utilities Commission) 117—20
Wynne, Brian 42—3, 46
Yom Kippur war 89
zonally symmetric synchronously coupled biosphere-atmosphere model 136
Sidney Dekker, Drift Into Failure
