Thread by @alshalloway

For disasters to happen you need coupling, chaotic events and lack of visibility

These happen in complex systems

it's not the complexity that is the problem. It's that the complexity hides what's occurring that's the problem.
1/

if a person is involved you'll never have predictability. That's because ppl are unpredictable, even in simple situations

RCA may end up showing you that it resides with a person's behavior. But Deming has shown most of the time it's the system.

Culture is part of the system 2/

even simple things can break and cause problems. It's how they are connected to everything else. Systems are about the relationships between components. In complex systems we can't see or know them all. They key is to see what happens and respond.
Why feedback is so important 3/

Agile suggests building small things for 3 reasons:
1) quick feedback
2) small is easier to manage (Goldratt)
3) lower cost of delay
4/

whether something is unpredictable because the system is complex & we can't see what will happen or because we have an unpredictable element (eg., a person) that will cause unpredictable behavior is not important. What's important is that we handle the unpredictability. 5/5

@threadreaderapp unroll

there is a tremendous amount of predictability in the large which is consistent with Isaac Newton's idea of nature being in harmony. We've seen this in software design for the last 2 decades. Now i'm understanding it in process as well.