Applying systems thinking to analyze and learn from events

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 assumption...

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Bibliographic Details
Published in:Safety science Vol. 49; no. 1; pp. 55 - 64
Main Author: Leveson, Nancy G.
Format: Journal Article
Language:English
Published: Elsevier India Pvt Ltd 2011
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ISSN:0925-7535, 1879-1042
Online Access:Get full text
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Summary: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.
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ISSN:0925-7535
1879-1042
DOI:10.1016/j.ssci.2009.12.021