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Applying systems thinking to analyze and learn from events

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Author(s)
Leveson, Nancy G
Date Issued
January 2010
Journal
Safety Science
Publisher
Elsevier
Citation
Leveson, Nancy G. “Applying Systems Thinking to Analyze and Learn from Events.” Safety Science 49, no. 1 (January 2011): 55–64. © 2010 Elsevier Ltd
Version
Author's final manuscript
Abstract
Major accidents keep occurring that seem preventable and that have similar systemic causes. Too often, we fail to learn from the past and make inadequate changes in response to losses. Examining the assumptions and paradigms underlying safety engineering may help identify the problem. The assumptions questioned in this paper involve four different areas: definitions of safety and its relationship to reliability, accident causality models, retrospective vs. prospective analysis, and operator error. Alternatives based on systems thinking are proposed.
MIT Department
Massachusetts Institute of Technology. Department of Aeronautics and Astronautics
Terms of Use
Creative Commons Attribution-NonCommercial-NoDerivs License
http://creativecommons.org/licenses/by-nc-nd/4.0/
Persistent DSpace Link
http://hdl.handle.net/1721.1/108102
DOI of Published Version
https://doi.org/10.1016/j.ssci.2009.12.021
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