Complex and tightly coupled systems are inherently vulnerable to major system accidents, but some difficult structural changes can reduce their vulnerability. They can be decomposed into units that are connected by monitored links, despite the inefficiency of such decentralization. Designs can be inelegant and robust, rather than elegant and sensitive, despite this affront to engineering norms. Redundancies and all other safety measures should be designed in from the start and not added afterwards, since add‐ons are disproportionately the source of accidents. Skepticism should be structured into the organization through explicit roles and generating worst case scenarios, and sensitive channels deliberately opened to daylight and monitoring. A formal system of error feedback should be instituted with contributions rewarded. Most important of all is increasing the role of external stakeholders in accident investigations and organizational changes, thus creating a dense network of independent organizations that keeps the risky system honest. Secret organizations which gather intelligence and perform covert actions are especially vulnerable to complexity but the least likely to adapt such structural changes. Examples are provided for each of the points.
Journal of Contingencies and Crisis Management – Wiley
Published: Sep 1, 1999
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