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Systems-thinking for Safety

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

Series:

Simon A Bennett

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.

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Bibliography

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Agerholm, H. (2017). ‘Grenfell Tower memorial: Survivors and victims’ families still struggle to come to terms with fatal tragedy’. accessed 9 January 2018.

Ambrose, S. E. (1985). Rise to Globalism. American foreign policy since 1938. Harmondsworth: Penguin Books.

American Bureau of Shipping (2005). Guidance Notes on the Investigation of Marine Incidents. Houston, TX: American Bureau of Shipping.

Anderson, S. (2013). ‘Chaos and Control’. accessed 22 November 2018.

Associated Press (2016). ‘7 killed in China’s latest coal mine blast, bringing week’s total mining deaths to 60. Blast in Hubei province follows death of 53 miners in two similar accidents last week’. accessed 10 October 2018.

Australian Transport Safety Bureau (2007). Regional Airline Line Operations Safety Audit. Report B2004/0237. Canberra: Australian Transport Safety Bureau.

Baker, J. (2007). The Report of the BP U.S. Refineries Independent Safety Review Panel. Washington, DC: BP U.S. Refineries Independent Safety Review Panel.

Beck, M., and Drennan, L. (2000). Offshore Risk Management: Myths, Worker Experiences and Reality. Paper presented at the Qualitative Evidence-based Practice Conference, Coventry University, 15–17 May 2000.

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