Catastrophe requires multiple failures – single-point failures are not enough
The array of defenses works. System operations are generally successful. Overt catastrophic failure occurs when small, apparently innocuous failures join to create opportunity for a systemic accident. Each of these small failures is necessary to cause catastrophe but only the combination is sufficient to permit failure. Put another way, there are many more failure opportunities than overt system accidents. Most initial failure trajectories are blocked by designed system safety components. Trajectories that reach the operational level are mostly blocked, usually by practitioners.
Source: How Complex Systems Fail, Richard I. Cook, MD, Cognitive Technologies Laboratory, University of Chicago, 1998
Safety Thought of the Week (from Richard I. Cook, MD)
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