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Toolkit:Systems Thinking for Safety/Principle 1. Field Expert Involvement

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The people who do the work are the specialists in their work and are critical for system improvement

To understand work-as-done and improve how things really work, involve those who do the work

System Focus
"We need to understand people as part of the system, and understand the system with the people." Image: EUROCONTROL © (All rights reserved)

To understand system behaviour, the most fundamental requirement is the involvement of the people who are part of the system. This first principle acknowledges that those who actually do the work are specialists in their work and a vital partner in improving the system. We refer to these people as ‘field experts’ to emphasise that they possess expertise of interest if we are to understand work-as-done. We need to understand people as part of the system, and understand the system with the people. So people are not simply subjects of study or targets of interventions, but rather partners in all aspects of improving the work. Seddon (2005) summarises: “The systems approach employs the ingenuity of workers in managing and improving the system. It is intelligent use of intelligent people; it is adaptability designed in, enabling the organisation to respond effectively to customer demands.” [1] Everyone therefore has two jobs: 1) to serve the customer and 2) to improve the work.

‘Field experts’ is meant as an inclusive term to consider people relative to their own work. Procedure writers, airspace designers, trainers, engineers, safety specialists, unit managers, regulation specialists, legal specialists, etc, are also specialists in their work, and need to be involved when trying to understand and improve the system. But they are not necessarily specialists in the work of front-line operational staff. What all need is a working understanding of the system, including the end-to-end flow of work.

In safety management and design activities, the involvement of front-line field experts varies widely. Experience suggests that, in conventional safety investigation for instance, there are several levels of involvement of relevant operational staff. The first is in raising the issue. There is almost universal involvement of field experts at this level because of mandatory reporting processes. In practice, the involvement sometimes stops here. The second level is the explanation of the event, for instance via interviews, discussions, and commentary on replays and recordings. The third level is in analysis and synthesis, both for the specific event and for the work more generally. The fourth level is in safety improvement, where recommendations and improvements are proposed. As these levels progress, the involvement of operational field experts seems to decrease. But without such involvement, the validity and usefulness of data gathering, analysis, synthesis, and improvement will be limited.

A further level is learning. This comprises both formal and informal activities. Following an occurrence, operational and other field experts will learn through informal conversations and stories. There may also be more formal lesson-learning activity. But relevant field experts (which may include system actors, designers, influencers and decision makers), can most usefully be involved in learning about the system, perhaps using an event as an opportunity to get a better understanding of ordinary work and system behaviour (Principle 10).

For other activities that concern work (e.g. safety risk assessment, procedure writing, rostering, organisational change, technology design), the involvement of the right field experts helps to understand and reduce the tension and the gap between work-as-imagined (in documentation and the minds of others) and work-as done (what really happens).

The perspectives of field experts need to be synthesised via the closer integration of relevant system actors, system designers, system influencers and system decision makers, depending on the purpose. The demands of work and various barriers (organisational, physical, social, personal) can seem to prevent such integration. But to understand work-as-done and to improve the system, it is necessary to break traditional boundaries.

Practical advice

  • Enable access and interaction. Managers, safety specialists, designers, engineers, etc., often have inadequate access and exposure to operational field experts and operational environments. To understand and improve work, ensure mutual access and interaction.
  • Consider the information flow. Field experts of all kinds (including system actors, designers, influencers and decision makers), need effective ways to raise issues of concern, including problems and opportunities for improvement, and need feedback on these issues.
  • Field experts as co-investigators and co-researchers. Field experts should be active participants – co-investigators and co-researchers – in investigation and measurement, e.g. via interviews, observation and discussions, data analysis, and synthesis, reconstruction and sense-making.
  • Field experts as co-designers and co-decision-makers. Field experts need to be empowered as co-designers and co-decision-makers to help the organisation improve.
  • Field experts as co-learners. All relevant field experts need to be involved in learning about the system.

View from the field

Yves Ghinet Air Traffic Control Specialist & Psychologist, Belgocontrol, Belgium

Prescribed working methods and procedures never take account of all situations, and with time passing and the changing context, they can become obsolete. It is a jungle out there and local actors must adapt in order to make the system work. They know the traps and the tricks to find a way through. Without them you are lost; they are the only scouts able to guide you in their world. So go to them, humbly, because they are the experts and you are only trying to understand what’s going on. Observation and discussion are key to understanding the way people work.”


  1. ^ Seddon, J. (2005). Freedom from command and control (Second edition). Vanguard.

Source: Systems Thinking for Safety: Ten Principles. A White Paper. Moving towards Safety-II, EUROCONTROL, 2014.

The following Systems Thinking Learning Cards: Moving towards Safety-II can be used in workshops, to discuss the principles and interactions between them for specific systems, situations or cases.