Drift into Failure

From Hunting Broken Components to Understanding Complex Systems

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. This book explores complexity theory and systems thinking to understand better 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.

What Happened to Goldman Sachs

An Insider's Story of Organizational Drift and Its Unintended Consequences

What Happened to Goldman Sachs

This is the story of the slow evolution of Goldman Sachs—addressing why and how the firm changed from an ethical standard to a legal one as it grew to be a leading global corporation. In What Happened to Goldman Sachs, Steven G. Mandis uncovers the forces behind what he calls Goldman’s “organizational drift.” Drawing from his firsthand experience; sociological research; analysis of SEC, congressional, and other filings; and a wide array of interviews with former clients, detractors, and current and former partners, Mandis uncovers the pressures that forced Goldman to slowly drift away from the very principles on which its reputation was built. Mandis evaluates what made Goldman Sachs so successful in the first place, how it responded to pressures to grow, why it moved away from the values and partnership culture that sustained it for so many years, what forces accelerated this drift, and why insiders can’t—or won’t—recognize this crucial change. Combining insightful analysis with engaging storytelling, Mandis has written an insider’s history that offers invaluable perspectives to business leaders interested in understanding and managing organizational drift in their own firms.

The Field Guide to Understanding 'Human Error'

The Field Guide to Understanding 'Human Error'

This latest edition of The Field Guide to Understanding ‘Human Error' will help you understand how to move beyond 'human error'; how to understand accidents; how to do better investigations; how to understand and improve your safety work. You will be invited to think creatively and differently about the safety issues you and your organization face. In each, you will find possibilities for a new language, for different concepts, and for new leverage points to influence your own thinking and practice, as well as that of your colleagues and organization.

Safety Differently

Human Factors for a New Era, Second Edition

Safety Differently

The second edition of a bestseller, Safety Differently: Human Factors for a New Era is a complete update of Ten Questions About Human Error: A New View of Human Factors and System Safety. Today, the unrelenting pace of technology change and growth of complexity calls for a different kind of safety thinking. Automation and new technologies have resu

Ten Questions About Human Error

A New View of Human Factors and System Safety

Ten Questions About Human Error

Ten Questions About Human Error asks the type of questions frequently posed in incident and accident investigations, people's own practice, managerial and organizational settings, policymaking, classrooms, Crew Resource Management Training, and error research. It is one installment in a larger transformation that has begun to identify both deep-rooted constraints and new leverage points of views of human factors and system safety. The ten questions about human error are not just questions about human error as a phenomenon, but also about human factors and system safety as disciplines, and where they stand today. In asking these questions and sketching the answers to them, this book attempts to show where current thinking is limited--where vocabulary, models, ideas, and notions are constraining progress. This volume looks critically at the answers human factors would typically provide and compares/contrasts them with current research insights. Each chapter provides directions for new ideas and models that could perhaps better cope with the complexity of the problems facing human error today. As such, this book can be used as a supplement for a variety of human factors courses.

Human Factors in Aviation

Human Factors in Aviation

Human Factors in Aviation, written for the widespread aviation community--engineers, scientist, pilots, managers, government personnel, and others--is also be of interest to those in nonaviation fields. The authors/contributors were chosen not only as experts in their fields, but because they could write for a wider audience than they customarily address. The organization of the book takes the reader from the general to the specific, first covering broad issues, then the more specific topics of pilot performance, human factors in aircraft design, and vehicles and systems. The physiological and medical aspects are well documented also.

Resilient Health Care, Volume 2

The Resilience of Everyday Clinical Work

Resilient Health Care, Volume 2

Health systems everywhere are expected to meet increasing public and political demands for accessible, high-quality care. Policy-makers, managers, and clinicians use their best efforts to improve efficiency, safety, quality, and economic viability. One solution has been to mimic approaches that have been shown to work in other domains, such as quality management, lean production, and high reliability. In the enthusiasm for such solutions, scant attention has been paid to the fact that health care as a multifaceted system differs significantly from most traditional industries. Solutions based on linear thinking in engineered systems do not work well in complicated, multi-stakeholder non-engineered systems, of which health care is a leading example. A prerequisite for improving health care and making it more resilient is that the nature of everyday clinical work be well understood. Yet the focus of the majority of policy or management solutions, as well as that of accreditation and regulation, is work as it ought to be (also known as ‘work-as-imagined’). The aim of policy-makers and managers, whether the priority is safety, quality, or efficiency, is therefore to make everyday clinical work - or work-as-done - comply with work-as-imagined. This fails to recognise that this normative conception of work is often oversimplified, incomplete, and outdated. There is therefore an urgent need to better understand everyday clinical work as it is done. Despite the common focus on deviations and failures, it is undeniable that clinical work goes right far more often than it goes wrong, and that we only can make it better if we understand how this happens. This second volume of Resilient Health Care continues the line of thinking of the first book, but takes it further through a range of chapters from leading international thinkers on resilience and health care. Where the first book provided the rationale and basic concepts of RHC, the Resilience of Everyday Clinical Work breaks new ground by analysing everyday work situations in primary, secondary, and tertiary care to identify and describe the fundamental strategies that clinicians everywhere have developed and use with a fluency that belies the demands to be resolved and the dilemmas to be balanced. Because everyday clinical work is at the heart of resilience, it is essential to appreciate how it functions, and to understand its characteristics.

The Rebecca Notebook

and other memories

The Rebecca Notebook

This book of occasional pieces from Daphne du Maurier's workshop is good to have: it is something of a continuation of her autobiography MYSELF WHEN YOUNG. The title piece is the remarkable Notebook she kept when REBECCA was forming itself in her mind -- the book that made her a worldwide bestseller and conquered both stage and films and ... television. The other pieces are mainly autobiographical but have no less variety than charm. 'Her devoted readers will not be disappointed' SPECTATOR

People-Centric Security: Transforming Your Enterprise Security Culture

People-Centric Security: Transforming Your Enterprise Security Culture

A culture hacking how to complete with strategies, techniques, and resources for securing the most volatile element of information security—humans People-Centric Security: Transforming Your Enterprise Security Culture addresses the urgent need for change at the intersection of people and security. Esentially a complete security culture toolkit, this comprehensive resource provides you with a blueprint for assessing, designing, building, and maintaining human firewalls. Globally recognized information security expert Lance Hayden lays out a course of action for drastically improving organizations’ security cultures through the precise use of mapping, survey, and analysis. You’ll discover applied techniques for embedding strong security practices into the daily routines of IT users and learn how to implement a practical, executable, and measurable program for human security. Features downloadable mapping and surveying templates Case studies throughout showcase the methods explained in the book Valuable appendices detail security tools and cultural threat and risk modeling Written by an experienced author and former CIA human intelligence officer

Morgan and Mikhail's Clinical Anesthesiology, 6th edition

Morgan and Mikhail's Clinical Anesthesiology, 6th edition

The most engagingly written, clinically relevant overview of the practice of anesthesiology IN FULL COLOR! A Doody’s Core Title for 2019! Hailed as the best primer on the topic, Morgan & Mikhail’s Clinical Anesthesiology has remained true to its stated goal: “to provide a concise, consistent presentation of the basic principles essential to the modern practice of anesthesia.” This trusted classic delivers comprehensive coverage of the field’s must-know basic science and clinical topics in a clear, easy-to-understand presentation. At the same time it has retained its value for coursework, review, or as a clinical refresher. This Sixth Edition has been extensively revised to reflect a greater emphasis on critical care medicine, enhanced recovery, and ultrasound in anesthesia practice. Key features that make it easier to understand complex topics: •Rich full-color art work combined with a modern, user-friendly design make information easy to find and remember •Case discussions promote application of concepts in real-world clinical practice •Boxed Key Concepts at the beginning of each chapter identify important issues and facts that underlie the specialty •Numerous tables and figures encapsulate important information and facilitate recall •Up-to-date discussion of all relevant areas of anesthesiology, including equipment and monitors, pharmacology, pathophysiology, regional anesthesia, pain management, and critical care •URLs for societies, guidelines, and practice advisories