Why trying to make accidents rarer can actually make them more common

excerpt from How Complex Systems Fail

15) Views of ‘cause’ limit the effectiveness of defenses against future events.

Post-accident remedies for “human error” are usually predicated on obstructing activities that can “cause” accidents. These end-of-the chain measures do little to reduce the likelihood of further accidents. In fact that likelihood of an identical accident is already extraordinarily low because the pattern of latent failures changes constantly. Instead of increasing safety, post-accident remedies usually increase the coupling and complexity of the system. This increases the potential number of latent failures and also makes the detection and blocking of accident trajectories more difficult.

From How Complex Systems Fail - Richard I. Cook, MD

Comments

żaden.

Add your voice