The formal system paradogm for studying failures
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TL;DR
The model that is described forms part of a systemic methodology which has been used successfully in the understanding of failures and could be developed further to become a predictive and preventative tool.
Abstract
One way in which general lessons may be learnt from sets of failures and disasters is by using a common conceptual framework for analysis. Many authors have found the use of individual systems concepts useful in their studies of failure. This paper presents a unified model that draws together those concepts and other related concepts. The model that is described forms part of a systemic methodology which has been used successfully in the understanding of failures. It is suggested that the model could be developed further so as to become a predictive and preventative tool.