A short introduction to the theory and practice of systems-thinking.
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.
Systems-thinking explains the origins of incident, accident and near-miss. By revealing the back-story it offers a counterpoint to the false certainties of reductionism and injustices of blamism. It is inherently moral.
The concepts that support systems-thinking, such as coupling, emergence, practical drift, satisficing and reactive patching, promote understanding and create opportunities for active learning. However, as demonstrated by the loss of Nimrod XV230 and the Grenfell Tower disaster, such opportunities are not always taken. Regarding the loss of Nimrod XV230, early warnings included the loss of a Tornado ‘where fuel had been drawn into the lagging round a hot pipe, and had ignited’ (Maffett 2008) and the rupture of a Supplementary Cooling Pack (SCP) duct in Nimrod XV227. Regarding the Grenfell fire, early warnings included several high-profile fires in the Middle East and a fire in a London high-rise.
Incidents, accidents and near-misses often exhibit near-identical failure modes. For example, the Piper Alpha disaster, Nimrod loss and Grenfell Tower fire were triggered by reactive patching. In the case of the Piper Alpha disaster, by Occidental’s decision to add a gas-processing unit. In the case of the Nimrod loss, by the MoD’s decision to add an in-flight refuelling capability, supplementary cooling packs and other items. According to Coroner Andrew Walker, upgrades so increased the ageing airframe’s interactive complexity that it became unsafe. Walker observed: ‘I am satisfied that the design modifications to the [Nimrod] made the aircraft unsafe to fly’ (Walker cited in Maffett 2008)...
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