Complex system failures represent breakdowns in adaptations by practitioners and organizations. In work, practitioners create safety by bridging gaps. See the following 2 papers for the basics:
Coping with Potential for Surprise pdf
Bridging Gaps pdf

A study of how information on intent helps subordinates adapt to disruptions to a plan. Communicating Intent pdf

Organizational accident via production pressure is focus of this board's conclusions.
MCO Board report

Slides from overview of Board's analysis is also available:
MCO board slides