How Complex Systems Fail
7) Post-accident attribution accident to a ‘root cause’ is fundamentally wrong. Because overt failure requires multiple faults, there is no isolated ‘cause’ of an accident. There are multiple contributors to accidents. Each of these is necessary insufficient in itself to create an accident. Only jointly are these causes sufficient to create an accident. Indeed, it is the linking of these causes together that creates the circumstances required for the accident. Thus, no isolation of the ‘root cause’ of an accident is possible. The evaluations based on such reasoning as ‘root cause’ do not reflect a technical understanding of the nature of failure but rather the social, cultural need to blame specific, localized forces or events for outcomes.
Someone needs to read http://web.mit.edu/2.75/resources/random/How%20Complex%20Sys... and also probably just stop talking
This may be a good time to review "How Complex Systems Fail"
Related is William Gibson's idea of "the Jackpot", or a "multicausal appocalypse", where a large catastrophe is caused not by a single major factor but by several smaller ones accumulating and interacting over time. Gibson talks about it in https://vimeo.com/116132074.
If this is the kind of thing you find interesting, you should also read How Complex Systems Fail (http://web.mit.edu/2.75/resources/random/How%20Complex%20Sys...).
Richards Cooks How complex systems fail from velocity a couple of years ago https://www.youtube.com/watch?v=2S0k12uZR14
and the paper that's the basis for it is also nice to have handy http://web.mit.edu/2.75/resources/random/How%20Complex%20Sys...