October 2016
Intermediate to advanced
480 pages
11h 53m
English
When we work within a complex system, it is impossible for us to predict all the outcomes for the actions we take. This contributes to unexpected and sometimes catastrophic accidents, even when we use static precautionary tools, such as checklists and runbooks, which codify our current understanding of the system.
To enable us to safely work within complex systems, our organizations must become ever better at self-diagnostics and self-improvement and must be skilled at detecting problems, solving them, and multiplying the effects by making the solutions available throughout the organization. This creates a dynamic system of learning that allows us to understand our mistakes and translate that understanding ...
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