Tag Archives: systems thinking

Understanding and Adding to the Investigation Toolbox

For the last century, the evolution of accident investigation can be tied to research and the scientific advancements in how we view our work systems[1]. Three major lenses of scientific research emerge as we begin to examine key influences on accident investigation processes: Classic mid-century faith in engineering was termed, Scientific Management, which was followed by Systems Thinking and, ultimately, an emerging understanding of Complex Adaptive Systems.   Continue Reading ››

Case study: Timing is everything; FRAM for train departures

photo-1415368893216-efb8c4fb04e0In this case study I would like to show a practical application of the Functional Resonance Analysis Method (FRAM) to investigate the process of trains departing the station. The reason for analyzing this process, is that Signal Passed At Danger (SPAD) incidents have a specific category that deals with situations where this incident happens just after leaving the station. So in that case, the first signal seen from the station platform is passed while it shows … Continue Reading ››

FRAM and System Principles in Practice

OLYMPUS DIGITAL CAMERAA client approached us about a recent incident in a process involving three organizations. They asked for an independent investigation into the incident. During the initial meeting it became clear that there was some relevant history to the process in which the incident happened. A year ago, some of the operational personnel in the process were relocated to a central location to improve the process in terms of use of personnel and other resources such … Continue Reading ››

If it weren’t for the managers…

Photo: W_Minshull CC BY 2.0 https://flic.kr/p/9oAXAK
There is some evidence that authoritarian, bureaucratic management styles are still at large, but that does not license stereotyping and overgeneralisation. Photo: W_Minshull CC BY 2.0 https://flic.kr/p/9oAXAK
“If only it weren't for the managers, the goddamned managers, always getting tangled up in the system. If it weren't for them, the world would be a systems thinker's paradise.”

In a previous post, an article for an … Continue Reading ››

What are you reading for?

Reading booksThe comedian Bill Hicks died just over 20 years ago. He was not 'just a comedian'. He was  a social critic and stand-up philosopher. There were few others like him at the time, and few others have come near him since. Freedom of thought and speech were at the core of what Hicks did. He believed that popular culture was a passive, silenced and dumbed-down culture - one that is easier to control. He encouraged people to think, to question everything: "Folks, … Continue Reading ››

Empathy for the Devil

devilThe other night I attended a meeting of safety practitioners. This is your typical monthly meeting that local chapters of safety societies have – where we get together to network, eat typically mediocre food (admittedly, I’m a picky eater), and hear a presentation on some topic of interest to the safety industry. This particular presentation focused on an insider from the state regulatory body exposing the flaws in the current regulatory structure. The advertisement for the presentation … Continue Reading ››

Systems Thinking for Safety: Ten Principles (A White Paper)

10principlesIn September, a EUROCONTROL Network Manager White Paper was released, entitled Systems Thinking for Safety: Ten Principles. The White Paper was a collaboration of EUROCONTROL, DFS, nine other air navigation service providers and three pilot and controller associations. The purpose is to encourage a systems thinking approach among all system stakeholders to help make sense of – and improve – system performance. The Executive Summary of the … Continue Reading ››

The ‘failed state’ of safety

The ancient city of Sabratha, LibyaI recently gave a talk about Safety Differently to a group of, mostly, safety professionals. As usual, I offended some people with my spontaneous jokes (this is easier to do in some places than in others, believe me), and made those who have vested interests in the old paradigm squirm or look shell-shocked (“but, but, my posters saying that ‘safety is our number ONE priority’ actually work…!”). Also, as usual, I divided … Continue Reading ››

Recovery from Command-and-Control: A Twelve-Step Program

OLYMPUS DIGITAL CAMERAMost of us in democratic countries would hate to see the rise authoritarianism. When we hear about authoritarian regimes around the world, we feel lucky not to live there. We know that people do not thrive under authoritarianism, where high levels of control suppress the human connectivity, freedom and creativity that give meaning and purpose to life. The same is true of organisations, but here we seem to have to put up with it. In 2012, the UK’s Chartered Management Institute released a report … Continue Reading ››

Goats in sheep pens

file0001763601813When I was younger, my family had a smallholding with a few animals including chickens, ducks, geese, and few goats - one or two billies and several nannies. Thinking back to these goats made me think about what they can teach us about work in command-and-control organisations. The characteristics of goats, especially curiosity, independence and foraging behaviour, highlight to me how command and control organisations need goat thinkers - constructive rebels including systems thinkers, design thinkers, and humanistic … Continue Reading ››