What is in the DNA of failure? And how can we prevent it?
By introducing such vividly illustrated examples that range from a holiday social media promotion gone-awry to Three Mile Island, András and Chris outline these common factors and how we can improve and build better outcomes in any kind of situation.
Charles Perrow is introduced to us early on in the book. A brilliant sociologist, Perrow went through vast amounts of data to research what causes failure points.
"For years, Perrow and his team of students trudged through the details of hundreds of accidents, from airplane crashes to chemical plant explosions. And the same pattern showed up over and over again. Different parts of a system unexpectedly interacted with one another, small failures combined in unanticipated ways, and people didn't understand what was happening. Perrow's theory was that two factors make systems susceptible to these kinds of failures. If we understand those factors we can figure out which systems are most vulnerable."
What are these two factors?
Complexity and Tight Coupling. Complexity can be understood as the layers and opacity relevant to an organization, entity, ecosystem, environment... you name it. In a complex system, "we can't go in to take a look at what's happening in the belly of the beast. We need to rely on indirect indicators to assess most situations...we can see some things but not everything." As far as what Tight Coupling is referring to, "in tightly coupled systems, it's not enough to get things MOSTLY right. The quantity of inputs must be precise, and they need to be combined in a particular order and time frame. Redoing a task if it's not done correctly the first time isn't usually an option. Substitutes or alternative methods rarely work...everything happens quickly, and we just can't turn off the system while we deal with a problem."
So what does that look like in action?