Analyzing systems failures through the use of case histories

Systems failures are highly complex and to be properly understood they have to be examined from the perspectives of the stakeholders involved. These stakeholders' decisions are influenced by their immediate environment and by their own individual motivations. In the course of projects, there are times when warnings of risk are not heeded and it is important to be able to appreciate how such situations arose. This means understanding properly how the stakeholders' decisions affect project outcomes. A way of analyzing these systems failure phenomena through the use of case histories is currently being developed. It provides a simple means of gathering and collating data into a tabular format which may then be extracted according to specific criteria and analyzed. A case study is presented to focus on different views of what happened by stakeholder activities through the decisions that they made and the risks that they took.