7 September 2010 Causes of catastrophic failure in complex systems
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Root causes of mission critical failures and major cost and schedule overruns in complex systems and programs are studied through the post-mortem analyses compiled for several examples, including the Hubble Space Telescope, the Challenger and Columbia Shuttle accidents, and the Three Mile Island nuclear power plant accident. The roles of organizational complexity, cognitive biases in decision making, the display of quantitative data, and cost and schedule pressure are all considered. Recommendations for mitigating the risk of similar failures in future programs are also provided.
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David A. Thomas, David A. Thomas, "Causes of catastrophic failure in complex systems", Proc. SPIE 7796, An Optical Believe It or Not: Key Lessons Learned II, 77960K (7 September 2010); doi: 10.1117/12.859906; https://doi.org/10.1117/12.859906

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