Drift into failure – challenging the current prevalent notions about accident causation and system safety

Drift into Failure

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.

Sidney Dekker’s new book Drift into Failure explores complexity theory and systems thinking to better understand 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.

Reviews:

‘”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, Canada

‘Professor Dekker explodes the myth that complex economic, technological and environmental failures can be investigated by approaches fossilized in linear, Newtonian-Cartesian logic. Today nearly 7 billion people unconsciously reshape themselves, their organizations, and societies through the use of rapidly-evolving, proliferating and miniaturizing technologies powered by programs that supersede the intellectual grasp of their developers. Serious proponents of the next high reliability organizations would do well to absorb Drift into Failure.’   Jerry Poje, Founding Board Member of the U.S. Chemical Safety and Hazard Investigation Board

‘Today, catastrophic accidents resulting from failure of simple components confound industry. In Drift into Failure, Dekker shows how reductionist analysis – breaking the system down until we find the “broken part” – does not explain why accidents in complex systems occur. Dekker introduces the systems approach. Reductionism delivers an inventory of broken parts; Dekker’s book offers a genuine possibility of future prevention. The systems approach may allow us to Drift into Success.’   John O’Meara, HAZOZ

About the Author: Sidney Dekker is Professor and Director of the Key Centre for Ethics, Law, Justice and Governance at Griffith University in Brisbane, Australia.

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