Engineering: A Very Short Introduction (Very Short Introductions)

Looking inwards, your structural subsystem of bones and muscles is also a holon with its own emergent properties such as your body size or muscular dexterity. Looking outwards, your family is a holon with its own emergent properties such as happiness or closeness. The highly connected neural connections in the brain create emergent consciousness. W

How do we deal with risk in this complexity of multiple layers of emergent characteristics?

attempt to get synergy where a combined effect is greater than the sum of the separate effects. It

They have discovered that human factors in failure are not just a matter of individuals making slips, lapses, or mistakes, but are also the result of organizational and cultural situations which are not easy to identify in advance or at the time. Indeed, they may only become apparent in hindsight.

The over-stretched balloon represents an accident waiting to happen.

‘Swiss cheese’ model. He represents the various barriers that keep a system from failing, such as good, safe technical design, alarms, automatic shutdowns, checking and monitoring systems, as separate pieces of cheese with various holes that are the hazards. The holes are dynamic in the sense that they move around as they are created and destroyed

However, if they go unnoticed or are not acted on, then the pressure of events builds up until the balloon is very stretched indeed. At this point, only a small trigger event, such as a pin or lighted match, is needed to release the energy pent up in the system. The trigger is often identified as the cause of the accident but it isn’t.

The answer is that we cannot eliminate risk, but we can learn lessons and we can do better to make sure the risks are acceptable.

We attempt to detect these hazards by looking for changes in important measurements of performance.