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Zusammenfassung von Meltdown

Name: Meltdown
Rating: 4.4 (76 reviews)
Author: Chris Clearfield & András Tilcsik

Chris Clearfield & András Tilcsik

Why Our Systems Fail and What We Can Do About It

4.4 (76 Bewertungen)

22 Min.

Kurz zusammengefasst

Meltdown by Chris Clearfield & András Tilcsik is a non-fiction book detailing major failures across industries due to complex systems and lack of communication. It offers insights and practical solutions to improve decision-making in high-stakes situations.

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What’s in it for me? Facts, failure-proofing and maybe even preventing the next apocalypse.

When you hear the word meltdown, what comes to mind – an accident in a nuclear reactor, maybe? Once you’ve been through these blinks, you’ll also be able to call on dozens of examples of specifically modern kinds of meltdown, their causes and how to prevent the same happening to you or your organization.

We’re living in an age of unprecedented technical capability: transport, commerce, medicine, power… you name it, the systems around us are more advanced and yet also more complex than ever before. That’s why authors Chris Clearfield and András Tilcsik wrote Meltdown, to unpack the ways complexity leads to failure. And they’re making the antidotes available to us all.

In these blinks, we’ll cover the core components that lead to modern system failure and how to tackle them. Then we’ll break down the tools needed to failure-proof systems and organizations – like structured decision-making, diversity, dissent, reflection, iteration and a list of warning signs.

In these blinks, you’ll learn

how the Fukushima nuclear disaster could have been avoided;
why diversity makes organizations stronger; and
how parents can learn from ER teams and harness the power of iteration.

Modern systems often fail for similar reasons in very different contexts.

What do BP’s oil spill in the Gulf of Mexico, the Fukushima nuclear disaster and the global financial crisis all have in common? Yes, they’re all crises, but they also share the same underlying causes.

Modern systems are more capable than ever, yet increased capability has also driven up complexity and made systems less forgiving. Take the finance industry, for instance: the switch from face-to-face to computerized stock-market trading has helped reduce operational costs, increased trading speed and given more control over transactions. But the digital shift has also made the system harder to understand and increased the chance of complex, unexpected interactions. Finance has become a perfect example of what sociology professor Charles Perrow would call a complex, tightly coupled system.

Perrow was an expert on organizations hired in the late 1970s to investigate the causes of a nuclear accident in Pennsylvania. What he discovered revolutionized the science of catastrophic failure.

Perrow identified a combination of small failures behind the disaster that interacted in a domino effect. Instead of blaming the nuclear plant’s operators or calling it a freak occurrence, Perrow saw that the accident had been caused by features inherent in the plant as a system – complexity and tight coupling.

Tight coupling is an engineering term for when a system is unforgiving or has little buffer between its parts. The system for cooking a Thanksgiving dinner, for instance, is tightly coupled: the meal involves many elements that depend on each other, like stuffing that cooks inside the turkey and gravy that comes from the roasted bird’s juices. And with only one oven in most houses, one dish could set back all the rest.

Complexity in a system means that it’s non-linear and hard to see inside. If we stick with the Thanksgiving dinner analogy, cooking a turkey is a complex system, because it’s hard to see inside the bird to tell if it’s cooked. Complexity in a system makes it tough to identify problems and their knock-on effects.

A combination of complexity and tight coupling takes us into what Perrow calls the Danger Zone. This is where meltdown – the collapse or breakdown of a system – becomes highly likely. So that tightly coupled, complex Thanksgiving dinner could well be doomed unless precautions are taken.

Perrow’s complexity/coupling formula reveals the shared DNA behind all kinds of modern meltdowns, so failure in one industry can now provide lessons in other fields. We’ll find out how in the following blinks.

Failure can be avoided by reducing complexity and increasing the buffer between the parts of any system.

When you go for a drive you put on a seatbelt even though you don’t know the exact nature of any accident that could happen. You simply know the danger is there and that the seatbelt could potentially save your life. In the same way, Perrow’s complexity/coupling formula helps prevent failure without showing the exact form it could take.

This means that you can plan ahead to reduce complexity, for instance by increasing the transparency of a system. Failure to do so can even lead to fatal accidents. Take 27-year-old Star Trek actor Anton Yelchin, who, in 2016, died getting out of his Jeep Grand Cherokee when the vehicle rolled and pinned him against a brick pillar.

Using structured decision-making tools can help you avoid disasters big and small.

We often go through life making snap judgments or using our instincts. There’s no harm in that until we find ourselves operating in a complex system.

Engineers of the Fukushima Daiichi nuclear plant in Japan used their instincts when they falsely estimated the height of their tsunami defense wall. On March 11, 2011, an earthquake caused a wave several meters higher than they had planned for, which flooded the generators responsible for cooling and triggered the world’s worst nuclear accident in 25 years.

Complex systems give off warning signals that we can use to save lives, money and reputations.

We often choose to ignore warning signs – if your toilet blocks, for instance, would you simply consider it a minor inconvenience, or see it as a warning sign of an impending flood?

Ignoring warning signs can sometimes have catastrophic consequences. In Washington DC in 2005, three metro trains came within a few feet of crashing deep under the Potomac River. Only luck and quick action by the train drivers saved the day. Engineers suspected that the underlying cause was a problem with the track sensors, but before they got around to fixing it, the problem went away. So they invented a testing procedure, hoping to ensure the same glitch couldn’t happen again elsewhere. The trouble was, their bosses soon forgot about this near-miss and stopped running the tests. Four years later, the same error showed up in a different spot, causing a horrific crash and the deaths of nine people.

Encouraging dissent makes teams more effective and systems stronger.

Speaking up isn’t easy. In fact, neuroscience shows us that a desire to conform is hard-wired into our brains. But that doesn’t make dissent any less valuable. Here’s why:

In a strange-but-true study of airline crew errors, the US National Transportation Safety Board (NTSB) found that between 1978 and 1990 nearly three-quarters of major accidents happened when it was the captain’s turn to fly. That is, not the less-experienced first officer. That was alarming because the captains were flying 50 percent of the time, so their errors should have been equal to or less than their deputies’.

Building diverse teams helps reduce risk and improve results for organizations.

Most people agree that diversity is a fair and positive thing, right? But did you know that it’s also been shown to reduce risk for organizations?

In a landmark 2014 study, scientists proved the benefits of ethnic diversity when it comes to decision-making. In a simplified stock-market simulation, they observed dozens of diverse and homogenous groups as far afield as Singapore and Texas and assessed the accuracy of their trading. And guess what? The diverse groups performed markedly better than homogenous ones, pricing stocks more accurately and making fewer mistakes. Fascinatingly, the study found that crashes were more severe and price bubbles more frequent in homogenous markets because homogenous groups put too much faith in each others’ decisions, which caused errors to multiply. In diverse markets, participants were more critical of each others’ decisions and copied less often, which led to more rational decision-making.

Reflection and iteration are essential coping strategies for high-pressure scenarios.

We’ve all been there – with the end of a project in sight there’s a strong urge to rush to the finish, even if the conditions have changed.

Pilots call it get-there-itis, but the technical term is plan continuation bias, and it’s an alarmingly common factor in airline accidents. If you’re only 15 minutes away from your destination, and the weather changes, it’s much harder to divert to a nearby airport than when you’ve just started out. Perhaps you’ve experienced the same effect when working toward a deadline?

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Worum geht es in Meltdown?

Meltdown (2018) unpacks the weaknesses shared by local and global systems. With diverse and astonishing examples, it provides empowering solutions to avoid failure. The Financial Times named it one of their best books of 2018, and the book’s message is ultimately hopeful – that the answers are easily within reach if we look for them.

Wer Meltdown lesen sollte

Curious individuals seeking a new perspective on how the world works
Leaders and staff who want to build stronger teams and better handle or prevent crises
Whistleblowers, dissenters and diversity champions

Über den Autor

Co-authors Chris Clearfield and András Tilcsik are world leaders in crisis prevention and bring an unusual combination of specialist skills, prestige and academic credentials to their work. Clearfield is a licensed commercial pilot who once dealt in financial forecasting as a derivatives trader, while Tilcsik has been recognized as one of the world’s top 40 business professors under 40 in his role at the University of Toronto. Between them, they’ve had articles published in respected publications like the Guardian, Forbes and Harvard Kennedy School Review and have even been approved by the United Nations for leading the best course on disaster risk management at any business school.

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Psychologie Wissenschaft Unternehmenskultur

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