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Welcome! (start here)
The Triple Revolution
Nuclear Power
Nuclear Power Plants
Nuclear Plant Disasters
Fermi 1 Reactor Meltdown (1966)
Three Mile Island Accident (1979)
Normal Accidents: Living with High-Risk Technologies (1984)
In Highly Complex Systems with Many Tightly Linked Elements, Accidents Are Inevitable

How Complex Systems Fail (1998 pdf)

Attachments

Articles About Complexity
Articles About Failure
Cascading Failures
Failures from Technological Complexity
In Highly Complex Systems with Many Tightly Linked Elements, Accidents Are Inevitable
Many Failures Result from the Coincidence of Many Mistakes
Non-Enumerated Wisdom
Resilience Engineering
Richard Cook (resilience)
Systemic Fragility

1. Complex systems are intrinsically hazardous systems.
10. All practitioner actions are gambles.
11. Actions at the sharp end resolve all ambiguity.
12. Human practitioners are the adaptable element of complex systems.
13. Human expertise in complex systems is constantly changing
14. Change introduces new forms of failure.
15. Views of ‘cause’ limit the effectiveness of defenses against future events.
16. Safety is a characteristic of systems and not of their components.
17. People continuously create safety.
18. Failure free operations require experience with failure.
2. Complex systems are heavily and successfully defended against failure.
3. Catastrophe requires multiple failures – single point failures are not enough.
4. Complex systems contain changing mixtures of failures latent within them.
5. Complex systems run in degraded mode.
6. Catastrophe is always just around the corner.
7. Post-accident attribution accident to a ‘root cause’ is fundamentally wrong.
8. Hindsight biases post-accident assessments of human performance.
9. Human operators have dual roles: as producers & as defenders against failure.
How Complex Systems Fail (on its own site)
Velocity 2012: Richard Cook, "How Complex Systems (Don't) Fail"