Why Root Cause Thinking Fails in Complex Systems

The writeup on the AWS outage from AWS themselves, if you haven’t seen it: https://aws.amazon.com/message/101925/

Dave’s department at OSU, Cognitive Systems Engineering: https://ise.osu.edu/human-systems-integration/cognitive-systems-engineering is a part of the larger Integrated Systems Engineering school: https://ise.osu.edu/human-systems-integration 

Dave was talking early on about the discussion on the war on expertise, it was this webinar through the NDM association: https://vimeo.com/1129606494?fl=pl&fe=sh&mc_cid=c807a504fb

Dave was a part of the 

Paul Feltovich got a shout out - he wrote a lot, but one of the best is with Gary Klein on Common Ground and Coordination in Joint Activity: https://www.academia.edu/download/31764257/Common_Ground_Single.pdf

And Studies of Expertise from Psychological Perspectives: https://www.researchgate.net/profile/Paul-J-Feltovich/publication/200772882_Studies_of_expertise_from_psychological_perspectives/links/58bd18b2aca27261e528de07/Studies-of-Expertise-from-Psychological-Perspectives.pdf

Dave mentions his “Command-Adapt Paradox chapter” - you can find that here: https://library.oapen.org/bitstream/handle/20.500.12657/88327/1/978-3-031-45055-6.pdf#page=77

Shout out to Norbert Weiner, the godfather of cybernetics: https://www.jstor.org/stable/24945913

For just two studies on how private equity in hospitals causes worse outcomes for patients you can see: https://hsph.harvard.edu/news/private-equitys-appetite-for-hospitals-may-put-patients-at-risk/

And

https://www.sciencedirect.com/science/article/pii/S0304405X25001151

Dave talks a bit about saturation and crossing boundaries towards failure - it’s worth familiarizing yourself with Rasmussen’s boundary model - Lorin Hochstein writes a good summary over at his blog: https://surfingcomplexity.blog/2021/05/31/transgressing-the-boundaries-rasmussen-and-woods/

Dave also mentions graceful extensibility - this is a concept he’s written quite a bit about, you can start here: https://link.springer.com/article/10.1007/s10669-018-9708-3

Shout out to Slight Reliability: https://slightreliability.com/

One of the great Woods/Cook write ups on anticipation in anesthesiology: https://www.sciencedirect.com/science/article/pii/S0952818096900094

In case you’re unfamiliar with the Chicago Seven: https://en.wikipedia.org/wiki/Chicago_Seven

The Messy 9 are:

congestion

cascade

conflict

lag

saturation

friction

tempo

surprise

tangles

Keep an eye on the merch store over at https://www.bonfire.com/store/risf/ if you want the t-shirt.