Great paper on failure of complex systems
It is not often you read something that completely changes the way you look at IT. This paper How Complex Systems Fail rocked me. Reading this made me completely rethink ITSM, especially Root Cause Analysis, Major Incident Reviews, and Change Management.
It dates from 1998!!. Richard Cook is a doctor, an MD. He seemingly knocked this paper off on his own, it is a whole four pages long, and he wrote it with medical systems in mind. But that doesn't matter: it is deeply profound in its insight into any complex system and it applies head-on to our delivery and support of IT services.
"complex systems run as broken systems"
"Change introduces new forms of failure"
"Views of ‘cause’ limit the effectiveness of defenses against future events... likelihood of an identical accident is already extraordinarily low because the pattern of latent failures changes constantly."
"Failure free operations require experience with failure."
Read this paper. And READ it: none of this 21st Century 10-second-attention-span scanning. READ IT HARD. Blow your service management mind.
Does this change any of your ideas of ITSM? Should any of these ideas be in ITIL?
(My apologies to whoever sent the link to me. This old brain has forgotten and LinkedIn makes it almost impossible to find your message again! Thanks. Remind me and I'll credit you)
[For more on this see this later blog post