Acknowledgements

This is a book of other people’s ideas, and it owes them everything.

It owes the most to the people whose work it was built on: Ross Ashby and Roger Conant, who proved that a regulator must be a model of what it regulates; Stafford Beer, who spent a lifetime showing organisations what they were for; James C. Scott, who taught a generation to ask what a map leaves out; Lisanne Bainbridge, whose five pages from 1983 describe the work of 2026 better than most of what was written in 2026; Richard Cook, Charles Perrow, Jens Rasmussen, Sidney Dekker and Diane Vaughan, who taught us how things actually fail; W. Edwards Deming and Taiichi Ohno, who showed what it means to trust the people doing the work; Donella Meadows, John Gall and Valentin Turchin; and, above all, Nancy Leveson, who carried these ideas into engineering practice long before this book existed, and who made Engineering a Safer World free for anyone to read.

It owes a great deal to people who write in public about their own work — often candidly, often about their own mistakes. The engineers and leaders whose essays, blog posts and talks appear in these pages are too many to list again here, but the book could not have been written without the habit, still unusual in most professions, of publishing an honest account of what went wrong. The same is true of the companies that publish their post-mortems, and of Dan Luu and the volunteers who have kept a list of them for more than a decade. The anonymous practitioners on Hacker News, Lobsters and elsewhere, whose comments are paraphrased throughout, supplied the texture that no report can.

It owes a particular debt to public institutions that investigate failure and publish what they find: the US Government Accountability Office, the Columbia Accident Investigation Board, the US House Committee on Transportation and Infrastructure, the Office of Inspector General of the US Department of Health and Human Services, the Auditor General of Canada, the Royal Commission into the Robodebt Scheme, the UK Parliament’s Public Accounts Committee, and the Post Office Horizon IT Inquiry. Their reports are models of the kind of feedback this book argues for.

And it owes the most serious debt of all to the sub-postmasters and their families who gave evidence to the Horizon inquiry, some of whose accounts are summarised in Chapter 7. They were not writing for a book. They were telling the truth about what had been done to them, after years in which a governing system had been believed instead of them. Any reader who takes one thing from Chapter 7 should take this: read their accounts in their own words, in the inquiry’s report.

Every error that remains is mine.

— Muhammad Hammad Shakeel, 2026