Show Less
Restricted access

Systems-thinking for Safety

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


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.

Show Summary Details
Restricted access

Glossary of terms


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...

You are not authenticated to view the full text of this chapter or article.

This site requires a subscription or purchase to access the full text of books or journals.

Do you have any questions? Contact us.

Or login to access all content.