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.
Chapter2 Systems-thinking in practice
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Systems-thinking in practice
Air accident investigation
Aviation’s free-thinking culture has given us many things – a means of defeating the Axis powers, affordable mass-transportation, practical, supersonic air service (for a while) and the systems-thinking-informed approach to incident and accident investigation. Looking back, it is hard to believe that there was a time when air accident investigators either ignored or discounted proximate factors. And it is hard to believe that other high-risk industries (for example, rail transportation, sea transportation, nuclear power generation and offshore oil-and-gas extraction) either ignored or dismissed the systems-thinking-informed approach to investigation. Our disbelief is testament to how far the accident investigation paradigm has shifted.
The 1989 Dryden air disaster
The publication of the Honourable Mr Justice Virgil P. Moshansky’s investigation into the 1989 Dryden, Canada, air disaster (Moshansky 1992) was a watershed moment for the systems-thinking-informed approach to accident investigation. In the years that followed, the methodology pioneered by Moshansky and his team permeated the aviation industry and the military (see ‘The 2006 Nimrod loss’ and ‘The 2017 US Navy collisions and grounding’ below), then migrated to other sectors such as maritime transportation, rail transportation, nuclear power generation and offshore oil and gas production.
On 10 March 1989, Air Ontario’s Captain George Morwood and First Officer Keith Mills were rostered to fly a four-sector day, shuttling between ← 19 | 20 → Winnipeg and Thunder Bay. Morwood had 24,000 flying hours under his...
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