Improvement of Process and Outcomes Through a STEEPLED Analysis of System Failures

Failure of systems occur in all domains of human activity. Apart from identifying who will be deemed accountable, a thorough analysis of a failure also provides understanding of the causes. This is the first step towards learning and future improvement. It has become evident that process improvement improves the resulting products and services. Prevention is always desirable, but more often than not, the predictability of future behavior of systems is difficult. Hence, most of the learning takes place in the analysis of failures. This paper focuses on a STEEPLED analysis of system failures, with particular emphasis on failed systems from the fields of Architecture, Engineering, and Healthcare systems. This transdisciplinary and multi-dimensional view of systems provides a holistic thinking instrument for structuring the analysis of failures and for enabling action in order to avoid or at least minimize future failures.