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Accident Precursor Analysis and Management Reducing Technological Risk Through Diligence (2004) / Chapter Skim
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Appendix A Letters to the Committee
Pages 175-186

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From page 177...
... I place dnis possible theory in the context of complexity and the statistical mechanics of physical phase change.
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From page 178...
... , earthquakes, pulsar glitches, turbidite layers (fossil undersea avalanches) , solar flares, sounds from the volcano Stromboli, fossil genera life spans, t ffic jams, variations in cotton futures, people killed in deadly conflicts, and research paper citations.
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From page 179...
... This distribution of cluster sizes describes cluster distributions near phase chance m many physical systems, including the Ising model of magnetization, and clusters of water molecules near the phase chance from steam to liquid water. Catastrophic system failures are what they seem to be, phase changes, for example, from org mined shuttle to rubble (a "liquid")
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From page 180...
... For example, usually highly hierarchical Navy crews, when working together as flight deck teams on an aircraft ca rier during flight operations, become a flat, highly communicating group, in which authority comes from knowledge and the perception of problems rather than from organizational position, In summary, the statistical properties of designed machines and organizations are similar to those of natural SOC systems, and we should expect the same theoretical framework that applies to them, and to statishcally similar physical
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From page 181...
... Naval War College Review 40(4)
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From page 182...
... At the 2001 Australirm Aviation Psychologists' Symposium Bob Helmreich quoted the remark "checklists are for the lame and the weak." It is a good representation of this attitude.
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From page 183...
... I believe that these tendencies have profound consequences for dealing with accident precursors. The Reason model provides a good general approach to the problem of latent pathogens, but I believe we c m do better.
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From page 184...
... In a pathological environment, pomtmg out a latent pathogen is personally dangerous and may result m the spotter, rather than the pathogen, getting "fixed." I believe that knowing the specific types of failure and their typical generating conditions cam help organizations eliminate latent pathogens. If pathogemc situations vary with the environment, then maybe our approach to clearing them up ought to va y, too.
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From page 185...
... 1994. Cnhtnes with Requisite imagination.
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Key Terms

  • latent pathogens
  • phase change
  • generative organizations
  • accident precursors
  • theoretical framework

  • phase changes
  • pathological environment
  • requisite imagination
  • information flow
  • latent pathogen

  • conscious decisions
  • natural soc
  • flight operations
  • situations vary
  • previous work

  • eliminate latent
  • percolation model
  • link failures
  • environment encourages
  • accident precursor

  • percolation theory
  • accidents typically
  • power law
  • generative environment
  • statistical properties

  • inverse power
  • organizational cultures
  • complete catastrophe
  • occurrence pyramid
  • symposium bob


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