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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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Glossary of terms

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Active learning: A form of learning where lessons learned from incident, accident and near-miss inspire safety improvements (see Toft (1992) and Toft and Reynolds (1997) for a definition).

Bimodality: A way of describing a component or system (for example, a light-bulb) whose performance-range is either: working (functioning); or non-working (non-functioning). In terms of function, a light-bulb does not have a degraded mode.

Emergence: Due to unanticipated interactions, a situation where a complex system behaves in unexpected ways or produces unexpected results (as when a computer programme produces an unexpected instruction or answer). Behaviour is described as emergent when a system ‘exhibits behaviours that cannot be identified through functional decomposition’ (Johnson 2005: 1). ‘Emergent outcomes are … not predictable from knowledge of their components, and not decomposable into those components’ say Hollnagel, Wears and Braithwaite (2015: 38).

Groupthink: A process whereby the members of a tight-knit, under-pressure work-group see the world, and interpret intelligence, in the same way. Mind-guards keep order. Dissenters are ostracised or excluded and out-groups undermined. Members claim moral superiority and consider themselves invulnerable (Janis 1972; Neck and Moorhead 1995).

High-fidelity investigation: A form of incident or accident investigation that recognises the contribution of systemic factors. A high-fidelity investigation is inclusive/holistic/panoptic.

High-reliability organisation: High-reliability organisations (HROs) demonstrate: a preoccupation with failure (HROs learn from incidents, accidents and near-misses and ensure that remediations work); a reluctance to simplify (every incident, accident and near-miss is investigated); sensitivity to operations...

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