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Toolkit:Systems Thinking for Safety: Ten Principles

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Executive Summary

System Focus
"To understand and improve the way that organisations work, we must think in systems." Image: NATS Press Office CC BY-NC-ND 2.0

To understand and improve the way that organisations work, we must think in systems. This means considering the interactions between the parts of the system (human, social, technical, information, political, economic and organisational) in light of system goals. There are concepts, theories and methods to help do this, but they are often not used in practice. We therefore continue to rely on outdated ways of thinking in our attempts to understand and influence how sociotechnical systems work. This White Paper distills some useful concepts as principles to encourage a ‘systems thinking’ approach to help make sense of – and improve – system performance. It is hoped that these will give new ways of thinking about systems, work and safety, and help to translate theory into practice.

Principles 1, 2 and 3 relate to the view of people within systems – our view from the outside and their view from the inside. To understand and design systems, we need to understand work-as-done. This requires the involvement of those who do the work in question – the field experts. (Principle 1. Involvement of Field Experts). It follows that our understanding of work-as-done – past, present and future – must assimilate the multiple perspectives of those who do the work. This includes their goals, knowledge, understanding of the situation and focus of attention situated at the time of performance (Principle 2. Local Rationality). We must also assume that people set out to do their best – they act with good intent. Organisations and individuals must therefore adopt a mindset of openness, trust and fairness (Principle 3. Just Culture).

Principles 4 and 5 relate to the system conditions and context that affect work. Understanding demand is critical to understanding system performance. Changes in demands and pressure relating to efficiency and capacity, from inside or outside the organisation, have a fundamental effect on performance. (Principle 4. Demand and Pressure). This has implications for the utilisation of resources (e.g. staffing, competency, equipment) and constraints (e.g. rules and regulations) (Principle 5. Resources and Constraints), which can increase or restrict the ability to meet demand.

Principles 6, 7 and 8 concern the nature of system behaviour. When we look back at work, we tend to see discrete activities or events, and we consider these independently. But work-as-done progresses in a flow of interrelated and interacting activities (Principle 6. Interactions and Flows). Interactions (e.g. between people, equipment, procedures) and the flow of work through the system are key to the design and management of systems. The context of work requires that people make trade-offs to resolve goal conflicts and cope with complexity and uncertainty (Principle 7. Trade-offs). Finally, continual adjustments are necessary to cope with variability in system conditions. Performance of the same task or activity will and must vary. Understanding the nature and sources of variability is vital to understanding system performance (Principle 8. Performance Variability).

Principles 9 and 10 also relate to system behaviour, in the context of system outcomes. In complex systems, outcomes are often emergent and not simply a result of the performance of individual system components (Principle 9. Emergence). Hence, system behaviour is hard to understand and often not as expected. Finally, success and failure are equivalent in the sense that they come from the same source – everyday work, and performance variability in particular (Principle 10. Equivalence). We must therefore focus our attention on work-as-done and the system-as-found.

Each principle is explained briefly in this White Paper, along with ‘views from the field’ from frontline operational staff, senior managers and safety practitioners. While we are particularly interested in safety (ensuring that things go right), the principles apply to all system goals, relating to both performance and wellbeing. It is expected that the principles will be relevant to anyone who contributes to, or benefits from, the performance of a system: front-line staff and service users; managers and supervisors; CEOs and company directors; specialist and support staff. All have a need to understand and improve organisations and related systems

Systems Thinking for Safety: Ten Principles.


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.