Читать книгу Root Cause Failure Analysis - Trinath Sahoo - Страница 16

In complex organizations such as aircraft carriers, nuclear power plants, and petrochemical plants, system failure is a perpetual risk. A large number of failures are due to the inherent uncertainty of working of such systems.

The lesson from this type of failure is to create systems to try to spot small failures resulting from complex factors, and take corrective action before it snowballs and destroys the whole system. These type of failure may not be considered bad but reviewed how complex systems work. Most accidents in these systems result from a series of small failures that went unnoticed and unfortunately lined up in just the wrong way.

The complex systems are heavily and successfully defended against failure by construction of multiple layers of defense against failure. These defenses include obvious technical components (e.g. backup systems, “safety” features of equipment) and human components (e.g. training, knowledge) but also a variety of organizational, institutional, and regulatory defenses (e.g. policies and procedures, certification, work rules, team training). The effect of these measures is to provide a series of shields that normally divert operations away from accidents.