Dear Thomas,
Thank you for this fine video.
Your video captured the nature of systemic problems, contrasting the systemic problem with the assignment of individual blame and the declaration of individual responsibility. These kinds of problems occur in all complex systems. Some become highly visible and public as a result of high death tolls, financial meltdowns, or other disasters that the general press considers newsworthy.
There is one issue that a video such as this might explore, at least as a contributing factor. This is the question of how human beings create the systems in which individuals work.
The problem of systems is that they function as forms of organisational, social, and cultural accretion in which a great many people design individual parts while no single individual or single group designs the system. It is not clear that a single designer would do better, but some successful systems show that design teams with responsibility, authority, and political support within the context can sometimes succeed.
The problems in your video remind me of the Challenger disaster. Richard Feynman’s description of the Challenger disaster — and the problems of examining and reporting on the disaster — appear in his book, What Do You Care What Other People Think? Further Adventures of a Curious Character.
http://www.amazon.co.uk/What-Care-Other-People-Think/dp/0141030887/ref=sr_1_4?s=books&ie=UTF8&qid=1436691103&sr=1-4&keywords=Feynman
Some of the same problems — and similar incentives for moving past safety limits — are visible in the massive industrial behemoths of Gilded Age America, where a range of social, financial, and cultural systems intersected with poor governance and weak regulation to create the great trusts and companies owned by the financiers Theodore Roosevelt described as “malefactors of great wealth.” Journalists and writers such as Ida Tarbell, Lincoln Steffens, and Upton Sinclair described these kinds of systems in books and articles over a century ago, with equally malign systemic consequences for workers, for public health, for national finance. Their books and articles are filled with accounts of equally major disasters, both in single large incidents and in serial systemic failures with equally high cumulative death tolls.
Mitch Feierstein’s book Planet Ponzi outlines the way that systemic flaws and perverse incentives pose risks to the financial markets today. Feierstein is the manager of a successful hedge fund: his book explains the flawed nature of many global financial systems and the incentives that accrue to those who manipulate those flaws. The challenge is that there seems to be no way to correct the system.
http://planetponzi.com
The history of the world is filled with such incidents. The centennial commemoration of World War I has occasioned a wave of new historical studies demonstrating the ways in which the great powers stumbled into a devastating global conflict without intending to do so. The nuclear power plant disasters at Chernobyl and Fukushima and the near-disaster at Three Mile Island are cases in point.
Many years ago, I studied anthropology with John Collier, Jr., one of the pioneers of visual anthropology and applied anthropology. John used to say that the problem of cultural change is that it is impossible to change any one embedded detail of a system without changing the system itself, while it is impossible to change a system without changing all the details.
It is one thing to identify the cause of a problem, another to reach agreement on the true cause, and yet another to change the systems that cause problems. Consider the reaction of medical professionals to with the development of germ theory by Semmelweiss and Pasteur, and the development of antiseptic hygiene by Lister, Semmelweiss, and Pasteur. Today, the overuse of antibiotics in human and animal populations creates living laboratories for drug-resistant bacteria, while the neglect of simple and effective hand washing procedures and ordinary household cleanliness is often to blame for the outbreak of germs in hospitals and health care facilities. While there have been more dramatic medical advances, fewer have been more far-reaching and few depend as much on culture for continual reinforcement. More than a century and a half after Semmelweiss and long after we reached near-universal agreement on the importance of ordinary cleanliness and rigorous hand washing routines, physicians, nurses, and other health workers often remain careless about simple yet effective cultural practices.
Imagine what medical practice would be like if people were effectively being paid to do the wrong thing. It’s hard enough to ensure effective practices in the face of inertia and laziness. It is far more difficult when people are paid cash bonuses for problematic practices. This is often the case people in shipping, transport, finance, food service, hotels, gambling, and other industries.
It is also the case where people are paid to purposely create doubt about reasonable scientific findings. Naomi Oreskes, a distinguished historian of science, shows how tobacco companies used this kind of effort to delay regulation long after medical science had demonstrated the role of tobacco in disease, and she demonstrates the same principles at work in other major campaigns.
http://www.amazon.co.uk/Merchants-Doubt-Handful-Scientists-Obscured/dp/1408824833/ref=sr_1_1?s=books&ie=UTF8&qid=1436713314&sr=1-1&keywords=Merchants+of+Doubt
Interestingly, major tobacco companies and the United States Chamber of Commerce are engaged in a global campaign to fight legislation and policies designed to reduce, limit, or end tobacco use:
http://www.nytimes.com/2015/07/01/business/international/us-chamber-works-globally-to-fight-antismoking-measures.html
This kind of campaign is not directly relevant to your video, but it is relevant to those complex systems that require legislative and governmental oversight in the face of profits and other benefits from reduced oversight.
What is relevant to the ferry disaster is the fact that systemic oversight failures at all levels helped to shape the context within which the disaster took place.
Thanks for this fine study. It deserves consideration on two levels. One is the systemic problem you address with respect to the ferry disaster and similar disasters. The other is the way in which complex societies generate the cultural, societal, and organisational situations within which these kinds of calamities are commonplace.
Yours,
Ken
Ken Friedman, PhD, DSc (hc), FDRS | Editor-in-Chief | 设计 She Ji. The Journal of Design, Economics, and Innovation | Published by Elsevier in Cooperation with Tongji University | URL: http://www.journals.elsevier.com/she-ji-the-journal-of-design-economics-and-innovation/
Chair Professor of Design Innovation Studies | College of Design and Innovation | Tongji University | Shanghai, China ||| University Distinguished Professor | Centre for Design Innovation | Swinburne University of Technology | Melbourne, Australia
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Gyuchen Thomas Jun wrote:
—snip—
I want to share a 10 min animation on system safety I produced to change prevalent blame culture after accidents. Please click the link below (hopefully engaging enough to watch to the end and share it with others).
https://vimeo.com/122851457
—snip—
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