Extracts from How Complex Systems Fail by Richard I. Cook:
[it is] impossible for [complex systems] to run without multiple flaws being present. Because these are individually insufficient to cause failure they are regarded as minor factors during operations ... complex systems run as broken systems.
Organizations are ambiguous ... [and that] ambiguity is resolved by actions of practitioners at the sharp end of the system.
Safety is an emergent property of systems ... continuous systemic change insures that hazard and its management are constantly changing.
... all practitioner actions are actually gambles, that is, acts that take place in theImage: https://flic.kr/p/7TxmXk
face of uncertain outcomes ... after accidents ... post hoc analysis regards these gambles as poor ones. But ... successful outcomes are also the result of gambles ...