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A manifesto for the systems-thinking-informed approach to incident and accident investigation, this accessible text is aimed at experts and generalists alike. A Glossary of Terms explains key concepts.

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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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CONTENTS: Systems-thinking - Systems-thinking in practice - A case study in systems-thinking.

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