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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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List of figures


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Figure 1. The network space: how systems theory conceptualises socio-technical systems

Figure 2. Actor-network theory (ANT) conceptualises a socio-technical system as a hybrid-collectif of stories and things

Figure 3. Almost 80 per cent of China’s coal mines are unregulated. Entrance to a small mine

Figure 4. Dryden: the causal soup (not an exhaustive list of actants)

Figure 5. In happier times: Nimrod XV230 at the 2005 Waddington Air Show, England

Figure 6. RAF Nimrod XV230 loss: the causal soup (not an exhaustive list of actants)

Figure 7. Possible depths of analyses in a systems-thinking-informed investigation

Figure 8. The USS John S. McCain

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