Systems thinking the foundation of an effective management system.

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“Without systems thinking, the seed of vision falls on harsh soil.” Peter Senge

Bibliography and learning tools

Safety and health are properties that emerge from the system.  When we think about system structure and properties, it is helpful to think about our bodies.  Our bodies have many properties.  We can see, think, walk, write, etc.  These are properties of the whole. No single part of our body can perform these functions.  Only our complete bodies have these properties.  In the same way, safety and health are properties of the workplace system.  Safety is not found in an individual part of the system a person, device, procedure or training program.  Safety and health are a product of the interaction of parts of the system – the management system, people, work methods, hazard controls, procedures, supervision, tools, equipment, and many other factors including culture, production pressure, resource constraints, goal conflicts and system deficiencies and weaknesses.  

The old view of safety has led us to believe that we can inspect, audit, investigate, and proceduralize safety into our systems.  Outdated quality systems were based on the notion that quality could be inspected in.  The concept destroyed many companies. Ultimately companies that transformed quality realized that leadership must mobilize the entire organization from senior staff to engineers, planner, middle management, maintenance and production workers, and supervisors. Safety and health today is where quality was 30 years ago.  Many organizations are working hard to move health and safety forward.  They are making significant progress. 

"Emergent, or type II, properties are the property of the whole, not the property of the parts, and cannot be deduced from properties of the parts. How ever, they are a product of the interactions, not a sum of the actions of the parts, and therefore have to be understood on their own terms. Furthermore, they don't yield to any one of the five senses and cannot be measured directly. If measurement is necessary, then one can measure only their manifestation."

Page 45, Systems Thinking: Managing Chaos and Complexity, Jamshid Gharajedaghi 

“…safety is not found in a single person, device or department of an organization. Instead, safety is created and sometimes broken in systems, not individuals. The issue is finding systemic vulnerabilities, not flawed individuals.”

Page 244-245 Behind Human Error

Sidney Dekker, professor at Griffith University in Australia, David Woods at Ohio State 




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