Richard Cook

Research Scientist (Ohio State University) Author 'How Complex Systems Fail'

Dr. Richard Cook is an internationally recognized expert in safety, accidents, and resilience in complex systems. His thirty years of experience includes work in medicine, transportation, manufacturing, and information technology. He holds appointments at The Ohio State University and is, with John Allspaw and David Woods, a principal in Adaptive Capacity Labs. His most often cited publications are How Complex Systems Fail, Gaps in the continuity of patient care and progress in patient safety, and Going Solid: A Model of System Dynamics and Consequences for Patient Safety.

Richard Cook's talk:

Diagnosis and Treatment of Incidents in Complex Systems with Hard Envelopes

Incident responders confront difficult conditions. Only rarely are sources of failure and pathways to remedy obvious. The current operating point relative to a hard envelope edge may be difficult to discern.

Available remedies, often untried and of unknown efficacy, present their own hazards. Escalating losses ramp up pressure for corrective actions. Events evolve, often quickly, making event recently collected data and assessments stale. Clamoring demands for attention increase as consequences multiply.

Opaque automation, strong, silent, and hard to direct, creates new demands for responders who must track both the underlying problem and that automation’s ‘view’ of that problem.

Incident studies in multiple domains suggest that these problems are likely to worsen as dependence and complexity increase.

This presentation summarizes how incident responders work to minimize consequences and hazard exposure and how this should guide the development of future systems.