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

This week, 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 White Paper is below, with links to some of the SKYbrary sections, where you will find the content of White Paper.

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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 (The Foundation: System Focus). 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 We therefore continue to rely on outdated ways of thinking in our attempts to understand and influence how sociotechnical systems work.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


For further information, see or download the White Paper on SKYbrary.

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About stevenshorrock

I am a systems ergonomist/human factors specialist and work psychologist with a background in practice and research in safety-critical industries. My main interest is human and system behaviour in the context of safety-related organisations. I seek to enable improvement via a combination of systems thinking, design thinking and humanistic thinking. I am a Chartered Ergonomist and Human Factors Specialist with the CIEHF and a Chartered Psychologist with the British Psychological Society. I currently work as a human factors and safety specialist in air traffic control in Europe. I am also an Adjunct Senior Lecturer at the University of New South Wales, School of Aviation. I blog in a personal capacity. Views expressed here are mine and not those of any affiliated organisation, unless stated otherwise. You can find me on twitter at @stevenshorrock
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7 Responses to Systems Thinking for Safety: Ten Principles (A White Paper)

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