Unfinished Article: Optimization and Fragility
Have you ever found something you started writing but never finished? Here’s something I started in October 2014. I’ve just rediscovered it in July 2020....
Tagged: systems
Followup… System Focused Root Cause Analysis of Complexity
My previous post about root causes in complex systems, in retrospect, looks a little bit like a rant. That doesn’t bother me too much, really…...
Systems Thinking, Complexity, and Root Cause
I’m getting so very tired of safety/accident researchers claiming that root cause analysis is an invalid, blame-focused practice that ignores systems and complexity. Most root...
Root Cause Bookshelf for 2014Q4
I used to read a lot more than I do now… sometimes for pure enjoyment, but also for research about my favourite topics (like Root...
Optimization Is Not The Goal
Problems come in all shapes and sizes. I’ve been involved in all kinds of investigations, from those dealing with something as mundane a chronic lack...
Root Cause Analysis for Complex Systems?
Is root cause analysis possible for complex systems? Some would say no, claiming that such systems are intractable — that in complex systems, there is...
Interfaces and Contradictions
DrPat reads a lot, and frequently writes about books on Paper Frigate. One recent blog entry caught my eye, a review of Beyond Engineering by...
Event Frequency and Severity
In 1931, HW Heinrich published his findings from a review of hundreds of thousands of safety incidents. His data showed that on average, for every 300...