Researchers and practitioners continue to study the causes of high consequence failures in complex socio-technical systems. Often linear causal pathways are identified in investigations that blame individual human error, or technical malfunctions. This study represents a significant expansion in the analysis of high profile accidents, crimes, crises, and tragedies to accommodate system complexity. Presented is a model of socio-technical system wholeness that provides an integral framework with which socio-technical system deficiencies are analyzed. The research questions if lack of systemic wholeness is the cause for selected high profile events.
This case study used historical documents pertaining to 13 actual events that included espionage, high consequence accidents, mass killings, and the response to natural disasters. The documentation included government commission reports and previously recorded interviews. A hermeneutic analysis method guided the iterative development of deficiency codes. These codes were assigned to key statements in the documentation that described the varied deficiencies. The qualitative analysis software, Atlas.ti aided in the coding of approximately 5,000 of pages of documentation. Deficiency codes were then organized and the highest frequency codes are listed and are also shown graphically on the integral model, to reveal characteristic patterns.
In all of the cases, significant deficiencies are shown in all dimensions of the integral wholeness model. Deficiencies are described as systemic holes and shadow aspects. Holes and shadow aspects form patterns within and among cases, spanning the various subject areas. Systemic boundaries pertaining to each case are also described using the wholeness model. In several of the cases, multiple systems are shown with systemic links. Deficiencies in the links were also identified from the data and are presented.
The dynamic process of movement towards socio-technical systems wholeness is perpetual. It is also essential when the consequence of socio-technical systems failure threatens individuals, communities or the natural environment. The research shows the need for constant vigilance and attention to holes in protective defenses, and reconciliation with shadow aspects to avert systemic failure. This research has a broad span. Additional research opportunities include using this wholeness model for in-depth analysis of single socio-technical system prior to failure
|Advisor:||Metcalf, Gary S.|
|Commitee:||Piazza, Charles F., Southern, Nancy L.|
|School Location:||United States -- California|
|Source:||DAI-A 78/07(E), Dissertation Abstracts International|
|Subjects:||Organization Theory, Organizational behavior, Systems science|
|Keywords:||Organizational, Security, Shadow, Systems, Wholeness|
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