Great paper on failure of complex systems

It is not often you read something that completely changes the way you look at IT. This paper How Complex Systems Fail rocked me. Reading this made me completely rethink ITSM, especially Root Cause Analysis, Major Incident Reviews, and Change Management. It dates from 1998!!. Richard Cook is a doctor, an MD. He seemingly knocked this paper off on his own, it is a whole four pages long, and he wrote it with medical systems in mind. But that doesn't matter: it is deeply profound in its insight into any complex system and it applies head-on to our delivery and support of IT services.

Read the post over at the IT Skeptic here.