| Popis: |
A complex sociotechnical system has a large number of components, where complex interactions may lead to collective emergent behaviors that cannot, even qualitatively, be derived as a plain resultant from the individual components' behavior. To cope with such complexity, one needs to study all disasters from a common systemic perspective, so that one can thoroughly understand the commonalities as well as the differences, in order to better design and control such systems in the future. The motivation for this paper was the hindsight bias of the accident investigative reports associated with the Deepwater Horizon and the Piper Alpha disasters. The accident analyses were based on simple and linear approaches which tend to blame operators instead of systemic identification of origins. This paper offers an alternative view using systemic thinking concepts to identify some of the human, technical and organizational factors which were believed to be the underlying causes for the Deepwater Horizon, Piper Alpha and many other major recent disasters. |
