My friends Chris Clearfield and AndrĂĄs Tilcsik literally wrote the book on complex failure and why itâs on the rise. Meltdown, their engaging, and at times terrifying, book explains the âshared DNA of nuclear accidents, Twitter disasters, oil spills, Wall Street failures, and even wrongdoing.â Like me, Chris and AndrĂĄs were influenced by sociologist Charles Perrow, who identified risk factors that make certain kinds of systems vulnerable to breakdowns.
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As pernicious as basic failures can be, complex failures, described in chapter 4, are the real monsters that loom large in our work, lives, organizations, and societies. Complex failures have not one but multiple causes and often include a pinch of bad luck, too. These unfortunate breakdowns will always be with us due to the inherent uncertainty and interdependence we face in our day-to-day lives. This is why catching small problems before they spiral out of control to cause a more substantial complex failure becomes a crucial capability in the modern world.
Idiosyncratic failures in complex technology. But as before, look more closely and you will see some of the usual culprits defining complex failure: multiple causes in a reasonably familiar setting, with its false sense of security; missed signals; and interactive complexity in a shifting business environment. At times I simply cannot bear the frequency of this recurring story. My research has shed light on why it happensâon the cognitive, interpersonal, and organizational causes that make complex failures so thorny. This multiplicity of factors also means you have many levers with which to interrupt the otherwise inexorable flow toward failure. It means that any one of us can become a complex-failure preventer.
My engineering background had made me a fan of Perrowâs groundbreaking book Normal Accidents, first published in 1984, which had a lasting influence on expertsâ thinking about safety and risk. Perrow focused on how systems, rather than individuals, produce consequential failures. The importance of that distinction cannot be underestimated. Understanding how systems produce failuresâand especially which kinds of systems are especially failure-proneâhelps take blame out of the equation. It also helps us to focus on reducing failure by changing the system rather than by changing or replacing an individual who works in a faulty system.
You canât say how much information a human being is taking in and reacting to at any given time, but you can easily observe the difference between a human being that is coping and one that is overloaded. Thatâs my diagnosis of what led to the series of connected political eruptions between the financial crisis and the pandemic. The hypothesis set out as early as 1970 by Alvin Toffler in his book Future Shock turned out to be correct: the number of people who were no longer able to cope with the modern world reached a critical mass.
Flying Blind: The 737 MAX Tragedy and the Fall of Boeing by Peter Robinson (Penguin Business, 2021) is also an enthralling history of a massive accountability sink. I learned a huge amount from Gill Kernickâs Catastrophe and Systematic Change: Learning from Grenfell (London Publishing Partnership, 2021) about another case study in which interlocking systems combined to create a tragedy that couldnât systematically be pinned on any single organisation, let alone an individual.