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\subsection{Complexity}  Complex systems have multiple parts. Human use the technical parts and interact with other humans, introducing communication. All this is in constant change over time. I stumbled upon this example on the internet. We could consider the magnets as non-human parts of the system, marbles as humans, and sticks and pieces of wood as designed control factors to keep the components in a safe range. We can see there are many ways things can go wrong and how hard it is to modify one part without unexpected results elsewhere. \marginnote{Marbles and Magnets \url{http://www.eetimes.com/author.asp?section_id=216&doc_id=1329692}}  \subsection{Investigating and Defining Complex Systems Failre} This area has been investigated extensively and from many points of view. A summary of important considerations concerning health care  is found at the Cognitve Technologies Lab in  a paper handout  by Richard I. Cook\marginnote{How Complex Systems Fail \url{http://web.mit.edu/2.75/resources/random/How%{20Complex%20Systems%20Fail}.pdf}}} Cook.\marginnote{https://www.researchgate.net/publication/228797158}  \subsection{Extending an Investigation}  While we began with specific incidents we found in order to have an adequate context we needed both a wider and a deeper look. In the literature this is called \emph {thick description} an idea introduced by Gilbert Ryle, a philosopher of Mind \cite{Ryle_2003},and popularized by Clifford Geertz, an anthropologist, who applied the idea in field work in Bali. \cite{Ryle_2003}