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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.

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Chapter1 Systems-thinking


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Promoted by Professors Elwyn Edwards (1972), Barry Turner (1978), Charles Perrow (1983, 1984), James Reason (1990), Diane Vaughan (1996), Erik Hollnagel (2004) and Sidney Dekker (2014b), systems-thinking first registered in the public consciousness in a serious way in the early 1990s (Maurino, Reason, Johnston and Lee 1998), with the publication of the Honourable Mr Justice Virgil P. Moshansky’s (1992) systems-thinking-informed investigation into the 1989 Dryden air disaster – where, in the context of operational pressures and resource issues, a crew’s failure to de-ice their aircraft cost twenty-four lives.

Moshansky’s innovation was that he considered both the immediate and proximate causes of the disaster, including the politics and day-to-day management of Canada’s air transportation sector. Moshansky’s high-fidelity, inclusive investigation led him to conclude that Dryden ‘was the result of a failure in the air transportation system’ (Moshansky 1992: 5–6). Instead of identifying a single ‘probable cause’, Moshansky’s report made 191 recommendations (from which a list of active and latent failures could be deduced), including some pertaining to the evolving structure of Canada’s recently deregulated air transportation industry: ‘The report … criticised deregulation of the aircraft industry, which started in Canada in 1985. … It found that even though safety controls were supposed to have been maintained, deregulation brought an increase in paperwork and fewer officials overseeing safety requirements’ (Farnsworth 1992). Moshansky’s report was system-thinking’s ‘big bang’ event.

With reference to Edwards’s (1972) conceptualisation of the air...

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