Richard Cook: How Complex Systems Fail

I reread Richard Cook's paper on How Complex Systems Fail this morning for maybe the third time. My only complaint is that the paper is a summary of a ton of safety research over the past several decades without a lot of references being cited. But it's a terrific executive summary, and it mentions the constant tension between safety and production pressure that is discussed at length in the work by safety researchers Jens Rasmussen and Sidney Dekker that I've cited.

http://www.ctlab.org/documents/How%20Complex%20Systems%20Fail.pdf

Cook's paper is just a few pages long and is worth your time. Cook is a medical doctor whose interest is specifically in patient safety, a topic that Mrs. Overclock (a.k.a. Dr. Overclock, Medicine Woman) and I frequently discuss.

Here's a video of Dr. Cook giving a talk on this topic. (If your device doesn't support Flash you can find the video on YouTube.)