Velocity NY 2013: Richard Cook, "Resilience In Complex Adaptive Systems"

Richard Cook's writing and talks on systems have hugely shaped my thinking on systems. For those interested in more, he gave a highly entertaining talk on system resiliency here and introduces a helpful model. [VIDEO] I also wrote a post summarizing how I think about Rasmussen’s model in startups and web applications. [LINK]

> the staff had become “de-sensitized” to the risk of a serious accident. Yet again serious problems happen due to the Normalization Of Deviance. We really need to find a way to create working conditions that encourage correcting problematic situations immediately before the behavior becomes normalized. Regarding the management/other problems... I encourage everyone in ever industry that is ever involved with safety (i.e. most industries) to see Richard Cook's short talk about "Resilience in Complex Adaptive Systems"[1]. [1] [VIDEO]

One of the most important talks I've ever seen is Richard Cook's "Resilience In Complex Adaptive Systems"[1], in which he explains the fundamental abstract mechanism that causes the normalization of deviance. [1] [VIDEO]

> But if you stop, they may continue increasing the dilution. There’s a normalization of deviance. For a very good explanation of the mechanism that causes this kind of normalization of deviance, I recommend Richard Cook's outstanding talk "Resilience In Complex Adaptive Systems"[1]. [1] [VIDEO]

> Indifference that does not cause a business problem remains indifference. More generally, indifference to small "trivial" problems eventually normalizes the deviant behavior[1]. Evil behavior doesn't happen in one step, it's end result of regularly being indifferent to "minor" problems[2]. For a very good explanation of why this happens, I recommend Richard Cook's excellent talk, "Resilience In Complex Adaptive Systems"[3]. [1] [LINK] [2] [LINK] [3] [VIDEO]

> I cannot believe that everyone is ethicality challenged The difficult ethical discussion probably never happens. The decisions being made in those meetings are usually seen as small/inconsequential. The problems caused by those "small" decisions are ignored. Eventually those problems become normalized allowing another "small" decision to be made. Humans seem to be very bad at recognizing how a set of "small" decisions eventually add up to major - sometimes shocking[1] - consequences that nobody would have approved if asked directly. Most of the time, nobody realizes just how deviant their situation had become. For a good explanation of the mechanism underlying the normalization of deviance (as an abstract model), I strongly recommend this[2] short talk by Richard Cook. [1] [LINK] [2] [VIDEO] ("Resilience In Complex Adaptive Systems")

> both individual and group ethics have to fail However, they don't have to fail at the same time or in a single step. This type of problem can creep in slowly over years as the "normalization of deviance"[1]. Richard Cook presented[2] a very useful model for how this type of problem creeps into complex system. The pressure from economic and workload concerns never goes away, so unless there is a proactive, explicit counter force, way to push back against that force, the system will inevitably be pushed toward failure. Therefor it's important to stop problems early when they are small. The magnitude of the counter force increases rapidly as behavior becomes increasingly deviant. [1] [LINK] [2] [VIDEO]

Aka "Normalization of Deviance"[1]. Fix the minor problems now , or they become the new normal, eventually accumulating until a huge deviance from "normal" behavior isn't even noticed. The stories[2] about airline pilots completely ignoring checklists and unusual alarms while trying to take off with the gust lock still engaged are a shocking example of strong this effect can be. For a very good explanation of how this happens, see Richard Cook's short talk "Resilience in Complex Adaptive Systems"[3]. [1] [LINK] [2] [LINK] [3] [VIDEO]