Systems Thinking Part II: Using Theory To Drive More Effective Risk Management Work
5 lessons from contemporary safety science that program directors, school administrators, and risk managers can use to improve their work.
Not exactly sure what “the systems thinking approach” is? Start with Systems Thinking Part I: What is the Systems Thinking Approach?, where I outline the leading, contemporary model of accident causation (Rasmussen, 1997), and the evolution of thinking safety scientists underwent to understand how significant incidents occur.
Part II of this introduction to systems thinking outlines two risk management methods that are underpinned by the theory; both methods are gaining more traction in outdoor and wilderness risk management circles. These are the two methods I’ve used the most in my work as a program and risk management director.
Feel free to skip around or skip ahead to my 5 takeaways on how the theory informs practice. The goal of this two-part article is that you walk away with a new or more informed understanding of why you should subscribe to a contemporary and leading theoretical framework, and how this knowledge can guide your risk management work to be more informed and effective.
Risk Management Methods: How the theory informs what methods to use
Program and school administrators who are aware of the frameworks adopted by contemporary safety science are positioned to select and use specific methods intentionally.
These professionals are more effective in their work. Two contemporary risk management methods that are perhaps most used in outdoor programs are directly underpinned by Rasmussen’s framework and the systems thinking approach:
Incident Analysis: AcciMap
AcciMap (Svedung & Rasmussen, 2002) is an incident analysis method used to identify the relationships among the multiple contributory factors preceding an incident.
AcciMaps are used to:
a) Describe and illustrate a single incident.
b) Analyze multiple incidents by identifying trends and patterns, such as recurring factors and their relationships across these incidents.
c) Illustrate the factors underlying a general issue or problem.
Developed as a direct response to Rasmussen’s RMF (1997), AcciMap was created to analyze the mechanisms behind significant incidents in high-risk, industrial environments. It is highly versatile and can be applied to a wide range of incidents (even extending beyond safety-related events).
The method is accessible to folks with a range of skills and abilities, and it helps to articulate a story of incident causation to decision-makers with diverse ranges of risk literacy and safety science knowledge.
The AcciMap method has been used to study high-profile incidents related to school-based outdoor programs; such as the Lyme Bay canoeing incident in the UK, in which four students perished at sea (Salmon et al., 2010); and the Mangatepopo gorge trekking tragedy in New Zealand when six students and their teacher tragically died in a flash flood (Salmon et al., 2012). Perhaps most notably, AcciMap is the basis for a national incident reporting system and database for Led Outdoor Activities in Australia, UPLOADS.
AcciMaps are gaining popularity among industry professionals seeking to improve their organization’s learning. Practitioners in the outdoor programming sector are becoming more aware and knowledgeable of the thinking and practices that are widely discussed among contemporary safety science circles.
Risk Assessment: The Networked Hazard Analysis Risk Management System (Net-HARMS)
Net-HARMS (Dallat et al., 2017) is a risk assessment method used to predict and assess risks before they contribute to mishaps.
Net-HARMS is unique for several reasons, namely that it is one of the very few systems-based methods (in a sea of hundreds or more) and was specifically developed for the led outdoor activity sector.
It analyzes the “whole system” to help analysts predict how the system behaves, instead of focusing just on front-line actors like participants, field staff, equipment, and the environment.
A key feature of Net-HARMS is the taxonomy, which is a series of prompts used to systematically identify hazards. The risk taxonomy includes things like timing, adequacy, and completion, and the physical object used to complete the task itself (like a checklist or a paddle).
This feature is an improvement from many risk assessment methods traditionally used by programming professionals, where analysts rely solely on brainstorming or prior experience.
These prompts help identify emergent risks, or, the risks that result from normal work and work tasks interacting.
For example:
If the task of “inventory equipment” is incomplete, what is the likely effect on the downstream task, “issue equipment?”
Or,
if the key details necessary for an effective exchange of medical information are communicated too early or too late, what are the likely effects on the subsequent downstream tasks, like providing staff with information, resource planning, and incident response?
Example of Linked Tasks
Work tasks are linked and interact with one another. Emergent risks can arise as part of normal task interaction.
In summary, Net-HARMS provides a comprehensive and systematic approach to risk assessment that offers significant improvements from traditional methods.
Administrators and risk managers who are knowledgeable about systems thinking and who utilize the methods that are underpinned by these principles are clearer and more effective in their risk analyses. Subsequently, their work to improve risk and safety issues is more robust and effective.
How can you practice systems thinking in your work?
Perhaps the question I hear the most is, how do I put safety science and systems thinking into practice? How does it change my work?
In my previous work as both an international program and national risk management director, I’ve been thinking about and applying systems thinking frameworks and methods for a while.
This is what I’ve learned:
First and foremost, let’s remember that it is a framework– not a prescription.
By being knowledgeable and articulate about your frame of thinking, you are clearer and more articulate about your risk/safety questions. For example, systems thinking helps to identify questions about which tasks or levels of work are necessary to understand better and assess risk context, or to make sense of the many facets involved in an incident’s outcome. In turn, the methods you employ to explore those questions will help you hone into meaningful and actionable answers.
Ultimately, using contemporary theory to inform your work improves the decisions and guidance you pass to others.
In some ways, you may already be practicing systems thinking. In other ways, by understanding the theoretical framework and using its associated methods, such as AcciMap or Net-HARMS, your risk management work will become more clear and more intentional.
Here are my 5 takeaways from the systems thinking approach to accident causation for programming professionals, risk managers, and administrators:
1. Incidents are caused by multiple contributory factors, not a single root cause. It’s one thing to know this, and it’s another to do this. As a practitioner, this core principle of systems thinking tells us to go and look for several influencing variables. I often hear, “But I can’t do everything to fix or prevent all these risks; some of these are beyond our control… so what’s the point?”
The point is, if you don’t look for the multiple factors that led to an incident and how those factors influence one another, one intervention alone won’t prevent the same incident from happening again. Without awareness of how factors interact together to produce emergent risks, we have no chance of identifying and mitigating these new risks.
2. Look for and utilize feedback loops. Purposeful feedback loops can help stabilize a situation or an organization. They can also serve as resistors to change– a helpful hint for those who are working to usher new changes into their school. Feedback loops are key, and they offer a good point of reference in understanding and improving an organization’s safety context.
3. Be intentional about the risk management methods you use. You are probably intentional about the outdoor activities your program conducts to deliver its mission, and you are likely thoughtful about the gear list you put together for participants before they arrive to your program. Outdoor activities and equipment are safety critical; why wouldn’t you also be intentional about the methods you use to identify and assess safety risks, or the methods you use to learn from incidents and improve safety at your organization?
Select methods that are informed by contemporary science for more complete assessments and more effective improvements.
4. Identify and consider factors beyond the front-line level of work. A popular phrase among systems thinkers is to look “up and out of the system, not down and in.” For example, instead of asking, “Why did you do that?” Ask instead, “Why did it make sense to do that at the time?” In my experience, this is easier said than done. Looking up and out requires continual reflection and improvement on the part of the investigator or analyst.
5. Seek and utilize multiple perspectives. If you conduct a risk or safety analysis and utilize only one person’s or only your own perspective, what’s the point? In designing and testing Net-HARMS, Clare Dallat (2023) highlights statistical data that indicates how utilizing multiple perspectives improves the accuracy of the analysis.
To incorporate multiple perspectives, consider interviewing or shadowing actors within each level of the work system. Seek out a variety of demographic and historical perspectives, and people with varying self-identities. Think about how a range of cultural factors could influence risk perception and safety outcomes.
Incorporating systems thinking into your risk management work requires knowledge and practice. As a thoughtful and just program administrator or professional, you are likely already aligned with the systems thinking approach.
Grounding your work in contemporary safety science and employing the frameworks and methods these experts provide will help clarify your risk management lens and hone your skills. Professional improvement, like all things, takes continual practice and reflection– much like the experiential ed cycle we use with our students!
References
Dallat, C., Salmon, P. M., & Goode, N. (2017). Identifying risks and emergent risks across sociotechnical systems: the NETworked hazard analysis and risk management system (NET-HARMS). Theoretical Issues in Ergonomics Science, 19(4), 456–482. https://doi.org/10.1080/1463922X.2017.1381197
Dallat, C., Salmon, P. M., & Goode, N. (2023). Testing the validity of the Networked Hazard Analysis and Risk Management System (Net-HARMS). Human Factors and Ergonomics in Manufacturing and Service Industries, 33(4), 299-311. https://doi.org/10.1002/hfm.20984
Rasmussen, J. (1997). Risk management in a dynamic society: A modeling problem. Safety Science, 27(2–3), 183–213. http://doi.org/10.1016/s0925-7535(97)00052-0
Salmon, P., Williamson, A., Lenné, M., Mitsopoulos-Rubens, E., & Rudin-Brown, C. M. (2010). Systems-based accident analysis in the led outdoor activity domain: application and evaluation of a risk management framework. Ergonomics, 53(8), 927–939. https://doi.org/10.1080/00140139.2010.489966
Salmon, P. M., Cornelissen, M., Trotter, M. J., (2012). Systems-based accident analysis methods: A comparison of Accimap, HFACS, and STAMP. Safety Science, 50(4), 1158-1170. https://doi.org/10.1016/j.ssci.2011.11.009
Svedung, I., J Rasmussen, J. (2002). Graphic representation of accident scenarios: Mapping system structure and the causation of accidents. Safety Science, 40(5), 397-417. https://doi.org/10.1016/S0925-7535(00)00036-9
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