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Drift into Failure
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Audible Audiobook
Listening Length: 7 hours and 49 minutes
Program Type: Audiobook
Version: Unabridged
Publisher: Sidney Dekker
Audible.com Release Date: December 20, 2018
Language: English, English
ASIN: B07LGG9LHG
Amazon Best Sellers Rank:
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.
I originally read this book and was thoroughly impressed. I had spent many years studying complexity science, and whilst this book was no real surprise, it was fascinating.I have since purchased many copies in the hope educating mindless managers of the futility of their safety systems. I work in the mining industry in Australia and this industry is paranoid about safety. There are many many many initiatives, innumerable systems, endless tick-boxes, boring mindless safety meetings and really to no avail.I presented my immediate managers these books. Very few considered reading them, and most obviously didn't. The safety approach was being driven at a higher level. "Let's get out CSTRT5b figure below 0.9" because executive management dictates it! So I presented books to the executive level. At that level there is no consideration that they and their methods should be questioned.All in all a futile exercise on my part.That aside the book is great, but unfortunately if it doesn't have pictures, isn't a comic, can't be distiller into a safety index, or presented concisely on a PowerPoint presentation, upward looking Managers and self preservation arrogant Executives just do not have the will to read such books, and dare I say it, the IQ to understand it.
Perhaps one of the most important books of the last 100 years.Four stars because it is dry and takes a long time to get to the point. Easy to bog down. WORTH the read.
As advertised. Well written. An introduction to the concept of failure over time from another vantage point
A great book on describing how traditional beliefs clash with complex systems. Great, recent examples reviewed of drift in organizations leading to disasters. An essential read for all senior management as well as safety personnel.
A must read for those working in HRO's
I gave this book as a gift and it has since been passed around and raved about, A little depressing considering current state of the world in general but still a thought provoking read.
This book will change the way you see the world and think about systems in general. Any industry that you work in will benefit from reading this book, it shows our arrogance and simple view of a complex world and how it catches us by surprise.
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