How systems fail - a reflection on Fukushima

Fukushima, a name that has along with Chernobyl became synonymous with catastrophic  failure.  At Chernobyl it was the misunderstanding of the reactor indicators and disregard of the reactor's design limits.  At Fukushima, it was the inability of an organization to take timely action.   In both instances, the root cause of failure was hubris.

We can engineer any complex system with multiple layers of safeguards, yet these systems will fail as long as the management structure is insular and immune to critical feedback.  How do we fix this?

As the technology that underpins our lives grow ever more complex, the risk of systemic failure looms.  What to do?  

The key I believe is to have an awareness of how fragile our systems are. Using this awareness, we can focus our efforts to respect the measured data, and to build management structures that embrace critical feedback. 

Management structures are tools that we build to organize complex and chaotic events.  Often in times of tranquility they have a tendency to become moribund ladders of authority - the very antithesis of the original intent.  We engineers have a responsibility to see that the technology that we create are utilized such that they do not fall prey to unintended consequences!