Designing System Reforms: Using a Systems Approach to Translate Incident Analyses into Prevention Strategies

Abstract

Advocates of systems thinking approaches argue that accident prevention strategies should focus on reforming the system rather than on fixing the “broken components.” However, little guidance exists on how organizations can translate incident data into prevention strategies that address the systemic causes of accidents. This article describes and evaluates a series of systems thinking prevention strategies that were designed in response to the analysis of multiple incidents. The study was undertaken in the led outdoor activity (LOA) sector in Australia, which delivers supervised or instructed outdoor activities such as canyoning, sea kayaking, rock climbing and camping. The design process involved workshops with practitioners, and focussed on incident data analyzed using Rasmussen's AcciMap technique. A series of reflection points based on the systemic causes of accidents was used to guide the design process, and the AcciMap technique was used to represent the prevention strategies and the relationships between them, leading to the creation of PreventiMaps. An evaluation of the PreventiMaps revealed that all of them incorporated the core principles of the systems thinking approach and many proposed prevention strategies for improving vertical integration across the LOA system. However, the majority failed to address the migration of work practices and the erosion of risk controls. Overall, the findings suggest that the design process was partially successful in helping practitioners to translate incident data into prevention strategies that addressed the systemic causes of accidents; refinement of the design process is required to focus practitioners more on designing monitoring and feedback mechanisms to support decisions at the higher levels of the system.

Maritime accident prevention strategy formulation from a human factor perspective using Bayesian Networks and TOPSIS

“…There is a discussion that accident prevention strategies should focus on reforming the system by systematic thinking approaches rather than on fixing the broken poles. Although little guidance exists on how to translate incident data into accident prevention strategies that address the systematic causes of accidents (Goode et al, 2016), it has been a feasible approach to develop strategies by the statistical analyses of accidents or incidents. This study generates strategies for accident prevention based on the contributory factors analysis by conducting MCA associated with HC and CT.…”

A sociotechnical design toolkit for bridging the gap between systems‐based analyses and system design

“…For example, insights gathered from the Event Analysis of Systemic Teamwork (EAST) framework (Stanton et al, ) were used, in combination with CWA for road intersection design (Read, Salmon, & Lenné, ). In a further adaptation of the CWA‐DT, it was used with the Accimap technique (Rasmussen, ; Svedung & Rasmussen, ), to inform the design of injury prevention strategies in the led outdoor activity domain (Goode, Read, van Mulken, Clacy, & Salmon, ). Finally, in a recent application, we used insights from causal loop models from systems dynamics (Sterman, ) to develop systemic interventions to address the “fatal five” road safety issues (drink and drug driving, speeding, fatigue, distraction and inattention, and failure to wear a seatbelt).…”

Why do road traffic collision types repeat themselves? Look back before moving forward

“…Most existing research has focused on investigating collisions to identify the only road, vehicle, and road user‐related factors and selecting and implementing standard preventive measures (Katsakiori et al, 2009; Le Coze, 2013; Lundberg et al, 2010, 2012; Pidgeon & O'Leary, 2000; Ramanujam & Goodman, 2011; Vastveit et al, 2015). Although safety researchers have argued that to prevent collisions, reformation should come from a systems perspective rather than be characterized by a focus on individual component failures, very little research has taken a systems approach to link the countermeasures that have been proposed, something that could demonstrate to policymakers and practitioners the usefulness of implementing interconnected intervention measures (Goode et al, 2016). It is assumed that the lack of systems analyses of prevention strategies showcasing the web of necessary actions required at different levels of the system is due to the belief that the analysis of the collision data alone is sufficient to recommend intervention measures for improving safety (Carroll & Fahlbruch, 2011; Drupsteen et al, 2013; Lundberg et al, 2010); however, collision investigation manuals have been argued to provide little guidance in the proposal of effective systems‐based countermeasures (Lundberg et al, 2009; Rollenhagen et al, 2010).…”

“…Systems‐based sociotechnical methods exist which are capable of representing the complex and nonlinear causal factors contributing to the occurrence of collisions (e.g., STAMP, Leveson, 2011; Accimap, Rasmussen, 1997; FRAM, Hollnagel, 2012). Prevention strategy development models should also focus on identifying contributory factors across system levels (Dekker, 2011; Goode et al, 2016, 2018; Rasmussen, 1997).…”

“…Where the Accimap can guide road safety practitioners in their investigation of collisions, proposed countermeasures can be represented through a Preventimap (Goode et al, 2016), thus aiding policymakers in deciding the appropriate steps to be taken to reform the system. The Preventimap is similar to the Accimap insofar as it uses the same structure and has a similar appearance; however, where the Accimap displays the factors (e.g., decisions, actions, and events) that led to a system failure, the Preventimap displays the proposed interventions and countermeasures aimed at varying levels of the system and can display how those measures are (or could/should be) connected.…”