by Andrew Bugera, EIT. When I am designing software with logging functionality, I try to log descriptions of what decisions are being made by the software in addition to the actions occurring. I have found the following tools and techniques to be effective when trying to understand failures in a complex system like RIVA: When investigating a failure in a remote, complex system, it can be difficult to understand what happened unless you have good logging infrastructure in place. Consider your toilet. This fragility comes from all sorts of specific consequences of that inequality, from secrecy to group think to brain drain to two-tiered justice to ignoring incompetence and negligence to protecting incumbents necessary to maintain such an unnatural order. (Example Tarvis and Aronon’s recent book: Mistakes Were Made (But Not by me)). 39 One of the advantages of having systems is that it is possible to build in more defenses against failure. Human practitioners are the adaptable element of complex systems. The Republicans have a majority in Congress, and refuse–for ideological and monetary reasons–to admit that the problem exists. Found inside – Page 13Current evidence tends to indicate that human error may be an increasing contributor to system failures. The degree to which human error appears to be on the increase may be related to the increased degree of system complexity. The paper concludes with a ray of hope to those have been through the wars: 18. In a conservative approximation, one may assume that all … Another thought about world social collapse: if such a thing is likely, (and I’m sure the PTB know if it is, judging from the reports from the Pentagon about how Global Warming being a national security concern) wouldn’t it be a good idea to have a huge ability to overpower the rest of the world? And these have smaller still to bite ’em, Systems thinking, which treats public services as complex adaptive systems, offers an alternative route to developing solutions and increasing system performance. For example, relatively simple organisms grow, persist and reproduce despite drastic pharmaceutical or … However, fault tree analysis can also be used during software development to debug complex systems.
“And what rough beast, its hour come round at last, Population explosion (as TG points out) would be a good example of a failure in a complex social system that is part of a critical path to catastrophic failure. 6) Good rule for any large complex and poorly tested system, like many of the medical systems pushed into the market. The present system in China, although not exactly “socialism”, certainly involves a massively powerful govenment but a glance at the current news shows that massive governmental power does not necessarily prevent accidents. It comes from chemistry, where it’s used to calculate the production from a reaction. Interestingly, Bookstaber (2007) does not reference Cook’s significant work on complex systems. Only jointly are these causes sufficient to create an accident. So while it’s possible that the failure would have occurred no matter what, the failure of the management to implement even the most basic of safety procedures made the failure much worse than it otherwise would have been. Found inside – Page 517System. reliability. analysis. of. fatigue-induced,. cascading. failures. using. critical. failure. sequences ... For efficient reliability analysis of such complex system problems, many research efforts have been made to identify ... Each ant has only simple behavior. There are a number of counter-examples; engineered and natural systems with a high degree of complexity that are inherently stable and fault-tolerant, nonetheless. It is its natural manure.” Those presently benefiting greatly from the present arrangement are fighting with all means to retain their position, whether successfully or not, we will see. Pollution was much worst in the non-capitalist Soviet Union, East Germany and Eastern Europe than it was in the Capitalist West.
It wouldn’t require any real change in the national majority of creepy grabby people. “Forgive them Father, for they know not what they do”, First, I don’t think the use of “practitioner” is an evasion of agency. Human plus culture is not the same as human. That’s what breakdown is going to look like. The need then is to reformulate how these relationships function, in order to direct and locate our economic activities within the planetary resources. So basically, yes, complex systems are finite, but we need to recognize and address the particular issues of the system in question. The contribution of latent human failures to the breakdown of complex systems 3Y J. We can plan based on everything going right because most of us don’t know in our gut that things can always go wrong. If it is intended to continue operation of the process with out-of-service If MDs in hospital management made similar wages as home health aides, then how would they get rich off the labor of others? 15.
For analytic convenience (or laziness), we may prefer to distill narrow causes for failure, but that can lead to incorrect conclusions: 7. Focus your efforts on something useful instead of wasting them on a hopeless, and worthless, cause. The next big fix is to use the US military to wall off our entire country, maybe include Canada (language is important in alliances) during the Interregnum. However, the piece does contain an argument against the importance of agency; it argues that the system is more important than the individual practitioners, that since catastrophic failures have multiple causes, individual agency is unimportant. 16. Why did you do that?
“Après moi, le déluge.”. I think you’re missing the point by saying look at all our complex systems, they work fine and then you ramble off a list of things with high failure potential and say look they haven’t broken yet, while things that have broken and don’t support your view are left out. The other nice thing about using this type of representation is that you can also see the effects of changes you make. Thanks for posting this very interesting piece! So when ‘the system’ breaks down, it’s hard to tell with any degree of testable objectivity whether the breakdown resulted from “the system” or from something outside the system and the rest was just “an accident that could have happened to anybody'”. Found inside – Page 591The Signature of Complex System Failures Our usual conception is that a system fails when some single ... The scale , complexity , and coupling of these systems create a different pattern for serious failures where incidents develop or ... Failure free operations are the result of activities of people who work to keep the system within the boundaries of tolerable performance. Found inside – Page 51function properly if called on , such as the maintenance failure that resulted in the emergency feedwater system being unavailable during the Three Mile Island incident ( The Kemeny Commission , 1979 ) . Latent failures require a ... ( And here the doctor’s sensitivity to malpractice suits may be guiding his language.) Minimal cut sets have traditionally been used to obtain an estimate of reliability for complex reliability block diagrams (RBDs) or fault trees that can not be simplified by a combination of the simple constructs (parallel, series, k-out-of-n). The state of safety in any system is always dynamic; continuous systemic change insures that hazard and its management are constantly changing. I’ll have to read this guys book article to find out exactly what he’s getting at here. Loose coupling prevents disturbances from swamping major systemic parameters and/or cascading system wide reordering (read disordering or prior systemic order). Since each situation is different, one cannot assume that a universal process will be able to determine the cause of every failure. we either don’t know what they are or underestimate, ignore, or misprice the risks? 17) People do NOT create safety. However, it is worth noting that, for the societies Tainter studied, the process was ineluctable. 2. provided the safety shields are not discarded for bad reasons like expedience or ignorance or avarice. Being the Third Edition of Systemantics, extensively revised and expanded by the addition of several new Chapters including new Axioms, Theorems, and Rules of Thumb, together with many new Case Histories and Horrible Examples. And so, ad infinitum. This total loss is control between nature and our lifestyles will be our waterloo . Splitting wood was hard work that required calories. Found inside – Page 161Failures need to be understood , and it is the argument of this book that understanding is best achieved by exploring the systemic background of the failures . In a complex system , failures are never due to a single cause , so by ... 13) Hugh!!!!!? I think this artificial market construct is an intrinsic driver for firming tight couplings for commodifying everything–and is now morphing because of # 14) “Change introduces new forms of failure.”. If you have a complex system and struggle when investigating failures, consider investing some time into logging improvements so that frequently-used data is easily available. Our customers and their patients depend on RIVA to maintain and enhance the safety of pharmacy compounding operations. Meltdown potential of a globalized ‘too big to fail’ financial system associated with trade imbalances and international capital flows, and boom and bust impact of volatile “hot money”. Although software systems are effective at calculating large and complex data, they have one main weakness: humans create these systems. At maturity, what is left is a highly redundant cohort of B cells that only recognize (and neutralize) foreign antigens. READ IT HARD. atoms, the weather formed out of air flows are all examples of complex systems. There is much simpler way to look at it, in terms of natural cycles, because the alternative is that at the other extreme, a happy medium is also a flatline on the big heart monitor. We might be the only nation that survives as a nation, and we might actually have an Empire of the World, previously unattainable. Eliminate the bottleneck!) system". 1 In this case to get the $$$Rug out of the way. Interesting comment! See chaos theory.
Actually I believe F1 has rules regarding the number of changes that can be made to a car during the season.
And still it moves. A key characteristic of complex systems is that they cannot be closely controlled or predicted. The next group goes beyond the nature of complex systems and discusses the all-important human element in causing failure: 8. We’re going to get city after city imploding. 14. In particular, wear-out char-acteristics are often found where equipment comes into direct contact with the product. Change introduces new forms of failure. More robust system performance is likely to arise in systems where operators can discern the "edge of the envelope". Combining the two results yields a System reliability of 97.85%. Not all failures are as destructive as the CRS-7 launch, though. 3) Like #2 — We HOPE all the single point failure modes for a complex system have been repaired, though that is all too seldom the case in fact.
Post-accident remedies for "human error" are usually predicated on obstructing activities that can "cause" accidents. And little fleas have lesser fleas A corollary to the preceding point is that complex systems run as broken systems.
http://holyjoe.org/poetry/holmes1.htm. Too bad our “higher” functions are not similarly gifted… But that’s what we get to chat about, here and in similar meta-spaces…. This paper presents a methodology for identifying and eliminating problem root causes, and specifically, the root causes of complex systems failures. A Logical Story https://hbr.org/2011/04/strategies-for-learning-from-failure
And so proceed ad infinitum. All organisational and technical risk reduction measures act as a counterweight to the risk potential. They have been made that way by purposeful public policy choices, from allowing enormous compensation packages in healthcare to dismantling our passenger rail system to subsidizing fossil fuel energy over wind and solar to creating tax incentives that distort community development. It’s about HUMAN systems, even though the concept should apply more widely than that. Complex systems are intrinsically hazardous systems. Humans do what they do because their cultural experiences impel them to do so. Found inside – Page 265... the estimated time the system is unavailable for failure; • the estimated number of system failures; ... Through the various possible applications, studies performed in collaboration with EDF on real complex systems have given the ... For example, look no further than the space program or health care delivery. The book on complex systems, sustainability, and innovation explores a broad set of ideas and presents some of the state-of-the-art research in this field concisely in six chapters. Original reply got eaten, so I hope not double post. A systems failure occurs when a system does not meet its requirements. The failure rate, λ, or the mean time between failures (MTBF), can be determined from past history of the performance of a product or system, or through testing systems over specified periods of time during which system failures are expected.These should be considered as characteristic values of systems or products. When hospitals are staffed so that people are normally busy every minute, patients routinely suffer more as often no one has time to treat them like a human being, and when things deviate from the routine, people have injuries and deaths. I avoided physics, being not so very mathematical, so learned the chemistry version – but I do think it’s the one the economists are thinking of. Introduction In any complex system, most errors and failures in the system can be traced to a human source.
Reliability is the probability that a system performs correctly during a specific time duration. have become steadily LESS prone to failure/disaster over the decades. There isn’t anything in the air or ground as complex as a F-1 car power planet. And yes, my professional experience has taught me that when things go really wrong it was never just one mistake, it is a cluster of those. Understanding and Managing Complexity Risk. Because these new, high consequence accidents occur at a low rate, multiple system changes may occur before an accident, making it hard to see the contribution of technology to the failure. The meaning of complex is a group of buildings, apartments, etc., that are located near each other and used for a particular purpose. Descriptions of what happened from a user perspective can also be useful, but they are often more subjective and may not have all of the detail of a log or photo. One way to examine a system is to study the movement of material within it. It’s Ronnie Ray Gun. Bethany McLean and Joe Nocera’s All The Devils Are Here 9400111899562009933676www.amazon.com/All-Devils-Are-Here-Financial/dp/159184438X/ref=sr_1_1?s=books&ie=UTF8&qid=1440167434&sr=1-1&keywords=all+the+devils+are+here describes beautifully how the erosion of the protective mechanisms in the U.S. financial system, no single one of which would have of itself been deadly in its absence ( Cook’s Point 3 ) combined to produce the Perfect Storm. If you make a change to the system to attempt to resolve an issue, you can collect additional data, add it to your graph, and see whether your change had the impact you were expecting. Hence the attitude called “IBY/YBG” (“I’ll Be Gone, You’ll Be Gone”) appears to be becoming more widespread. Safety is an emergent property of systems; it does not reside in a person, device or department of an organization or system. From the Johnstown Flood in 1889 to the Fukushima Daiichi nuclear disaster in 2011, engineering failures have been caused by problems in design, construction and safety protocol. One of the legendary stories in computer science is that RADM Grace Hopper helped to popularize the term “debugging” after her colleagues discovered an actual moth inside a relay in their Harvard Mark II electromechanical computer in the 1940s. " In the new afterword to this edition Perrow reviews the extensive work on the major accidents of the last fifteen years, including Bhopal, Chernobyl, and the Challenger disaster. Of course, subsumption architecture is not a panacea.
Bill Black would probably agree. So — apply any of these principles to design practice and/or evaluation with great care and skepticism. We really need to foster the intelligent teamwork that our society is capable of, or we will fail to survive challenges like climate change and the need to sensibly control the population. And if they see those relationships as short-term or unstable, they don’t have much reason to invest in helping to preserving the soundness of that entity. When you’re dealing with highly complex and dangerous projects like NASA, there’s always tremendous risk that needs to be tracked. Why is no one mentioning the Foundation Trilogy and Hari Seldon here? Incomplete specifications, design defects, and implementation errors such as software bugs and manufacturing defects, are all caused by human beings making mistakes.
The high consequences of failure lead over time to the construction of multiple layers of defense against failure.
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