2 WORST FAILURE - FAILURE TO LEARN ABOUT RISKS

In this chapter we investigate both the nature of complexity and how some people dealt with dynamic and systemic (complex) risky situations. Insights derived from that investigation equip us for our quest to develop better ways of dealing with the detail and dynamic aspects of complexity, as they exist in risky situations.

Events understood to have caused, or contributed to, a recent man-made catastrophe are studied. This case and others dealt with in other chapters were chosen because they provide valuable insights into systemic failures, and because they were comprehensively documented. Records of extensive investigations by boards of inquiry and coroner’s inquests and the like are readily available and contain rich descriptions of systemic problems. They also highlight lessons about complexity we might find valuable for later use. Most importantly, except that sequences of events under investigation invariably resulted in tragedy, the situations described in such reports are strikingly similar to many complex problems we are required to manage daily, although the latter can be relatively benign.