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Velocity 2012: Richard Cook, "How Complex Systems Fail"

O'Reilly

202K subscribers • 23 videos on Hallway

YouTube
  • Recommended by 4 people: 3 on Hacker News and 1 on Lobsters.
  • A classic. People kept recommending it from 2013 to 2020.
  • Presented by Richard Cook, Professor of Healthcare Systems Safety
  • May be out of date. Uploaded 14 years ago, in an area where tools change fast.

Intermediate. Assumes working knowledge.

60K views14 years ago4 recommendations

Distributed systemsCloud and DevOpsSRE and incidentsFault tolerance and failureSoftware architecture

Richard Cook explains how complex systems fail, arguing that safety is a dynamic activity and systems must be designed for resilience.

Richard Cook Royal Institute of Technology, Stockholm Dr. Richard Cook is the Professor of Healthcare Systems Safety and Chairman of the Department of Patient Safety at the Kungliga Techniska Hogskolan (the Royal Institute of Technology) in Stockholm, Sweden. He is a practicing physician, researcher and educator. Dr. Cook graduated with honors from Lawrence University in Appleton, Wisconsin where he was a Scholar of the University. He worked in the computer industry in supercomputer system design and engineering applications. He received the MD degree from the University of Cincinnati in 1986 where he was a General Surgery intern. Between 1987 and 1991 he was researcher on expert human performance in Anesthesiology and Industrial and Systems Engineering at The Ohio State University. He completed an Anesthesiology residency at Ohio State in 1994. From November 1994 until April 2012 he was faculty in the Department of Anesthesia and Intensive Care of the University of Chicago. Dr. Cook was a member of the Board of the National Patient Safety Foundation from its inception until 2007. He is internationally recognized as a leading expert on medical accidents, complex system failures, and human performance at the sharp end of these systems. He has investigated a variety of problems in such diverse areas as urban mass transportation, semiconductor manufacturing, and military software systems. He is often a consultant for not-for-profit organizations, government agencies, and academic groups. He does not do any expert witness testimony for litigation. Dr. Cook's most often cited publications are "Gaps in the continuity of patient care and progress in patient safety", "Operating at the Sharp End: The complexity of human error", "Adapting to New Technology in the Operating Room", and the report "A Tale of Two Stories: Contrasting Views of Patient Safety"

Why it's here

4 people recommend this

What people say. Recommended as a foundational talk on system safety, reliability, and operations.

wencon Hacker News • Recommends

On “How Complex Systems Fail (1998)”

The accompanying talk by Richard I Cook at the O'Reilly Velocity conference is here: link to this video When I worked in operations, I would watch this talk every couple of months to remind myself of the principles. The principles are summarized in the list, but the talk adds a bit more context. I find that this context matters for seeing how the principles might be applied.

inactive-useron Lobsters • Recommends

Richard Cook, "How Complex Systems Fail" (2012)

rjzzleepon Hacker News • Recommends

On “Stop Fetishizing Failure”

…dea that "when you're dealing with critical things, like healthcare where someone's life may depend on it, you cannot afford failure". except that's not true. those systems actually embrace failure more than anything else. google reliability engineering.or look at this: link there is a nice talk on failure from richard cook at the velocity conf: link to this video…

hedwallon Hacker News • Recommends

On “Ask HN: What are some 'must watch' talks?”

Richards Cooks How complex systems fail from velocity a couple of years ago link to this video and the paper that's the basis for it is also nice to have handy link

wencon Hacker News • Recommends

On “DIB Guide: Detecting Agile BS (2018) [pdf]”

…sign from some idealized notion of inputs and/or worst case scenarios. Ops people know what can go wrong will go wrong, which is why ops is there to handle the deviations from the norm. Real world design exposes lift points, reveals controls and supports continuous maintenance. Highly reliable systems are evolved, not just designed. 1 link 2 link to this video…

wencon Hacker News • Recommends

On “A Lifetime of Systems Thinking”

To build on this discussion, what are some highlights in that book that you found useful? I ask because I've read some systems thinking books (e.g. Systemantics) that were difficult to apply in real life. I come from the perspective of someone with a systems/theory builder personality. The only systems thinking book that I found remotely practical was The Fifth Discipline by Peter Senge. The most useful piece of short writing on systems thinking that I've come across is "How Complex Systems Fail" 1, 2, which talks about designing systems for resiliency, and not for rigid notions of reliability. 1 "How Complex Systems Fail" link 2 Its accompanying O'Reilly conference talk link to this video

aristuson Hacker News • Mentions

On “Rush to Put Death Records Online Lets Anyone be 'Killed'”

The field is called "Operations Research". I had the pleasure of meeting Dr Cook in the speaker lounge right before he gave this keynote at Velocity 2012: link to this video

rramadasson Hacker News • Mentions

On “Root cause of failure, root cause of success”

Huh? See link and watch link to this video The "chain analogy" is just that i.e. a Metaphor. You need to map it to your studies in Systems Science and Complexity Science . Start with the works of Henry Petroski. Then look at the works of Nassim Taleb , in particular Antifragile . Finally, do a search for "Failure in Complex Systems" and you get tons of journal articles one of which i have listed above.