Audi R8 or Chicken Bus?

Dr Laura Maguire was still a graduate researcher with the Cognitive Systems Engineering Laboratory at the Ohio State University at the time of this talk, REdeploy 2018. Here she offers the myth of the perfectly functioning system. redeploy youtube@7m25s

I wanted to add to that sort of Mythology of the fully functioning system. Most of the engineers that I talked to that we work with through the [SNAFUcatchers] consortium with OSU seem to think that other companies are running these sleek, powerful, shiny systems that don't break in weird ways. There's not a [large] backlog of corrective actions piling up in the corner.

They think that [those other] engineering teams are super disciplined about getting things done and that their system is like a finely calibrated Audi R8.

The actual fact what we see from the research and from spending time in organizations like yours, and in nuclear power, healthcare, aviation, all of these other high-risk, high-consequence domains is that it's actually more like the chicken bus.

If you've never really seen a chicken bus they're very popular and common in the Global South. It gives you an idea of what it's about.

Some features have been strapped on the top. It's kind of bumping along. The windshield a little cracked. The exhaust is really noisy.

It doesn't matter how good of a driver you are of the system, it's not going to handle like an Audi handles.

A lot of times the operators within these systems tend to look back and say well I must be doing something wrong because I'm supposed to be driving the Audi and it's handling like the chicken bus.

The ever quotable Dr. Cook gives us this lovely saying here: "It's not surprising that your system sometimes fails. What's surprising is that it ever works at all."

You are operating in very dynamic conditions. You are doing things that are very complicated, that are complex, that are interacting in ways that are difficult to anticipate. They're difficult to detect when they do change. Sometimes the failures will happen in ways that are unpredictable and sometimes uncontrollable. 

Everything within these systems is sometimes broken. Something is always broken. If nothing seems broken, wait a minute or so.

You are operating fully formed fully functional systems. Recovery, repair, and revision are ongoing. This is a salient feature of your world and of your environment.

This has profound implications for how we design and develop the systems to support the operator or to support the engineer. We need to design knowing systems are operating in degraded modes, and that [operators] are influenced by pressures and constraints within this world, not operating in a vacuum and not operating where you have all the people and all the time and all the resources in the world.

Richard Cook shared insights about complexity in systems emphasizing that failure is the normal state and the study of incidents is the revealing thing about how systems actually work. See Working in the Cyclone.

See also Work as Imagined and as Done.