Systems-thinking for Safety

A short introduction to the theory and practice of systems-thinking.

by Simon Bennett (Author)
©2019 Monographs XVI, 154 Pages
Series: Systems Thinking for Safety, Volume 1


A manifesto for the systems-thinking-informed approach to incident and accident investigation, this accessible text is aimed at experts and generalists. A Glossary of Terms explains key concepts.

The premise is both unoriginal and original. Unoriginal, because it stands on the shoulders of systems-thinking pioneers – Barry Turner, Bruno Latour, Charles Perrow, Erik Hollnagel, Diane Vaughan and other luminaries. Original, because it is populist: The Systems-thinking for Safety series shows how theoretical insights can help make the world a safer place. Potentially, the series as a whole, and this manifesto text, have agency.

True to its mission to affect change, the book uses case studies to demonstrate how systems-thinking can help stakeholders learn from incidents, accidents and near-misses. The case studies of, for example, the Piper Alpha and Deepwater Horizon offshore disasters, the Lac-Mégantic rail disaster, the Fukushima Daiichi nuclear disaster, the United States Navy collisions and the Grenfell Tower fire, demonstrate the universal applicability of systems-thinking. The manifesto argues that the systems-thinking informed approach to incident, accident and near-miss investigation, while resource intensive and effortful, produces tangible safety benefits and, by ensuring that «right is done», delivers justice and closure.

Table Of Contents

  • Cover
  • Title
  • Copyright
  • About the author(s)/editor(s)
  • About the book
  • This eBook can be cited
  • Contents
  • List of figures
  • List of tables
  • Preface
  • Acknowledgements
  • Introduction
  • Chapter1 Systems-thinking
  • Chapter2 Systems-thinking in practice
  • Chapter3 A case study in systems-thinking
  • Conclusions
  • Glossary of terms
  • Bibliography
  • Index

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Figure 1. The network space: how systems theory conceptualises socio-technical systems

Figure 2. Actor-network theory (ANT) conceptualises a socio-technical system as a hybrid-collectif of stories and things

Figure 3. Almost 80 per cent of China’s coal mines are unregulated. Entrance to a small mine

Figure 4. Dryden: the causal soup (not an exhaustive list of actants)

Figure 5. In happier times: Nimrod XV230 at the 2005 Waddington Air Show, England

Figure 6. RAF Nimrod XV230 loss: the causal soup (not an exhaustive list of actants)

Figure 7. Possible depths of analyses in a systems-thinking-informed investigation

Figure 8. The USS John S. McCain

Figure 9. A severely damaged USS John S. McCain limping towards Changi Naval Base in the Republic of Singapore

Figure 10. Helicopter mission over the inundation caused by the tsunami

Figure 11. Windscale – site of Britain’s most serious nuclear accident

Figure 12. Mindlessness in respect of design and operation increases system vulnerability

Figure 13. Mindfulness is positively linked to safety

Figure 14. International Atomic Energy Agency experts walk the Fukushima Daiichi site post-disaster

Figure 15. Rigs in the Cromarty gas field photographed in untypical weather. Turbulence in the Middle East in ← ix | x → the 1960s and 1970s incentivised the rapid exploitation of local oil and gas reserves, even in the unforgiving North Sea

Figure 16. In the same way that gas-guzzlers were a product of the era of cheap oil, the Piper Alpha disaster was in part a product of the oil-shocks of the 1970s, Reaganomics and Thatcherism

Figure 17. Statistics pertaining to death and injury should be considered against a range of factors, including the scale, complexity and adverse operating conditions of the North Sea oil and gas industry. Rigs and pipelines require constant maintenance

Figure 18. The rig sank thirty-six hours after the initial explosion

Figure 19. The Line Operations Safety Audit virtuous circle, from resourcing the audit to organisational change

Figure 20. Adverse events have complex origins

Figure 21. An obscenity in the world’s fifth largest economy?

Figure 22. The charred hulk of Grenfell Tower photographed nearly eleven months after the fire

Figure 23. Edwards’s innovative SHEL(L) model of aviation as a socio-technical system

Figure 24. In the Cold War motion-picture classic Fail-Safe, a malfunction in a tightly coupled, high-speed command-and-control computer sees a fleet of Convair B-58s tasked to destroy Moscow

| xi →


Table 1. Elements of a positive safety culture

Table 2. How a LOSA is performed

Table 3. LOSA’s TOCs

| xiii →


In a paper titled Advancing socio-technical systems thinking: A call for bravery, Davis, Challenger, Jayewardene and Clegg (2014: 171) observed: ‘Whilst [socio-technical systems thinking] has made an impact, we argue that we need to be braver, encouraging the approach to evolve and extend its reach. In particular, we need to: extend our conceptualization of what constitutes a system [and] apply our thinking to a much wider range of complex problems’. This is my contribution to Davis, Challenger, Jayewardene and Clegg’s call-to-arms.

| xv →


The author would like to thank everyone from the world of aviation who has helped him over the last twenty years. Aviation has changed the world for the better. Long may it thrive.

| 1 →


XVI, 154
ISBN (Softcover)
Publication date
2019 (June)
Systems-thinking Complexity Safety
Oxford, Bern, Berlin, Bruxelles, New York, Wien, 2019. XVI, 154 pp., 24 fig. b/w, 3 tables

Biographical notes

Simon Bennett (Author)

The author reads sociology with psychology and directs the Civil Safety and Security Unit at the University of Leicester, England. His publications include How Pilots Live (Peter Lang), Aviation Safety and Security: The importance of Teamwork, Leadership, Creative Thinking and Active Learning and Innovative Thinking in Risk, Crisis and Disaster Management. An aviation human factors specialist, he has spent circa 1,500 hours on the jump-seat and 200 hours on the ramp. Simon Bennett has observed: 232 A319-operated sectors; sixty-six A320-operated sectors; sixty-two A321-operated sectors; 138 B737-operated sectors; 181 B757-operated sectors; and seven A300-operated sectors. He has observed eighteen EC135 police helicopter sorties (flying time: 792 minutes). The author has completed a gliding course; landed a 737-300 simulator; undergone Safety and Emergency Procedures (SEP) training on several types, including the A319, B737 and B747-800; trained flight-crew in fatigue-risk management and supported a B757 Line Operations Safety Audit.


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172 pages