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New case studies spotlight good and bad safety practice for complex systems

The Engineering X Safer Complex Systems (SCS) mission has published 18 new case studies examining the systemic successes and failures of different events around the world and how approaches to the design, construction, operation, management or governance of complex systems have resulted in safe or unsafe outcomes.

From fires and train crashes to flood management and nursing care, the case studies provide a new resource to support the education and professional development necessary to achieve safer complex systems.

The case studies cover a wide variety of events, involving different complex systems, geographies, and stakeholders, such as the 2011 Brisbane floods, the 2019 economic and health crises in Chile, and major fires in Dhaka and the Cape. Also covered are failures of humanitarian supply chains in famine areas, the partial collapse of new school buildings in Edinburgh, the Netherlands Delta flood protection programme, and the structural integrity of offshore wind turbines. Several well-known accidents from the past are revisited, including the capsizing of the Herald of Free Enterprise and Hatfield rail crash.

Many of the lessons learned are specific to a certain location or particular combination of factors but there are some common themes that are transferable and relevant to all sectors:

  • Lack of systemic thinking and action over the lifetime of the systems
  • Little or no attention to structure of governance early in activity
  • Treating complex uncertain issues and risks with tools developed for complicated ones
  • Lack of alignment of purpose between actors
  • Ill-defined boundaries of responsibility, authority, accountability, and legal structures
  • Unverified assumptions
  • Poor information sharing in the face of a blame or project-driven culture
  • Inconsistent and poor data management to support statistical analysis and modelling
  • Safety seen as an engineering or technology issue rather than a cultural or social issue.

The case studies are:

  • Cyber–physical system shortfalls in the 2011 Brisbane flood (Australia)
  • Australian climate extremes and building transport network resilience (Australia)
  • Planned Adaptive Regulation: Learnings from the Delta Programme (The Netherlands)
  • A comparative study of fire risk emergence in informal settlements in Dhaka and Cape Town (South Africa, Bangladesh)
  • Community evacuation from wildfire events (USA, Canada)
  • Towards a simple and safer nuclear sector: The 2005 THORP internal leak (UK)
  • Bexley train crash—a system failure (UK)
  • Revisiting the causes of the Hatfield Rail Crash (UK)
  • A systems approach to reducing train accident risk (UK)
  • Understanding and utilising data for a seasonally agnostic railway (UK)
  • Ro passenger ferry safety: the capsizing of the Herald of Free Enterprise (UK and Belgium)
  • Towards intelligent dynamics of an active transport system for biking (Colombia)
  • Complex systemic failures in the Edinburgh Schools case (UK)
  • Systemic failures in nursing home care (Australia)
  • Humanitarian supply chains: systems failures, recovery and emerging alternatives (International)
  • Social innovators as a human sensing network solving humanitarian challenges of the XXI century (Chile)
  • Improving resilience to major safety events by analysing case studies (USA, Japan, Australia, Hungary and UK)
  • Beyond the boundaries: characterising situational uncertainty in complex systems (International).

Obtain the case studies.



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