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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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Chapter3 A case study in systems-thinking


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A case study in systems-thinking


In the same way that technologies reflect our values and priorities (a motorway scything through the countryside reflects society’s prioritisation of economic growth over conservation), near-misses, incidents and accidents are a product of the social, economic, political and techno-scientific milieu (see Figure 20).

Figure 20. Adverse events have complex origins (after Challenger, Clegg and Robinson (2009)). ← 99 | 100 →

A systems-thinking-informed analysis of the 2017 Grenfell Tower, London, fire disaster


In the small hours of 14 June 2017, a fire spread rapidly through a London tower block, killing seventy-one people (see Figure 21). On 14 December 2017, a memorial service to honour the victims of the Grenfell Tower fire disaster was held at London’s St Paul’s Cathedral, a venue synonymous with public expressions of grief and thanksgiving. Attendees included victims’ relatives and friends, the Prince of Wales, the Duke and Duchess of Cambridge, the Prime Minister and the Leader of Her Majesty’s Opposition.

Figure 21. An obscenity in the world’s fifth largest economy? (Wikimedia Commons 2018l). ← 100 | 101 →

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