Stephen Lansing paper Balinese water temples: https://anthrosource.onlinelibrary.wiley.com/doi/abs/10.1525/aa.1987.89.2.02a00030

Elinor Ostrom(?) paper mentioned, not sure which one it is Stuck at 27:13

Stephens, Patterson & Woods paper: people getting stuck in the ER: https://www.researchgate.net/publication/312624891_Patient_boarding_in_the_emergency_department_as_a_symptom_of_complexity-induced_risks

Maladaptive patterns and critical incidents in urban firefighting

• If requset resources when need is definitive, it is alraedy too late
• Regulate additional adaptive capacity (tactical reserves)
  • maintain capacity for maneuver (ability to handle next surprise)
  • "avoid all hands situation" (incident command)
• Bumpy transfers of control

Decompensation

• Actions of one group increase threats to other groups (opposing fire hoses; rendering escape routes or protected areas unaccessible)
• Failure to resynchronize
• Goal priorities/conflicts in response to distressed firefighter
• Tradeoff between information sharing versus data bottlenecks

Working at cross-purposes (both horizontal and vertical)

• Failures to modify plans in progress as situation and kinds of threats change

Getting stuck in outdated behaviors

10 proto-theorems

From The theory of graceful extensibility: basic rules that govern adaptive systems

1. Boundaries are universal
2. Surprise occurs, continuously
3. Risk of saturation is monitored and regulated
4. Synchronization across multiple units of adaptive behavior in a network is necessary
5. Risk of saturation can be shared
6. Pressure changes what is sacrificed when
7. Pressure for optimality undermines graceful extensibility
8. All adaptive units are local
9. Perspective contrast overcomes bounds
10. Reflective systems continually risk mis-calibration