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.