Systems Thinking for Safety/Narratives: Systems Thinking in the Wild
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In this section, you will find number of narratives provided by people in real environments, which illustrate the principles and the interactions between them, and give an impression of how people have tried to practise systems thinking. The bank of narratives will grow over time.
An unusual cluster of level busts at the transition altitude was thought to be linked to incorrect altimeter setting on departure into the London TMA. A temporary operating instruction was introduced to try to mitigate the risk of incorrect altimeter setting. The experience showed that problems, as well as solutions, are often far more complex than imagined, and require a systemic approach.
The ‘independent parallel new departures procedures’ at Frankfurt Airport were introduced together with the new runway to ensure the capacity of the two departure runways, which are interdependent with the landing runway. A subsequent incident between a missed approach and a departure showed that work-as-done did not turn out as imagined, but was as designed. Eventually, the independent parallel new departures procedures were withdrawn, but this then created more serious problems.
A pilot of a small aircraft had navigational difficulties and was running short on fuel. He wanted to land at a nearby aerodrome, but his instruments no longer worked properly for an IFR approach. The pilot requested to descend below the MRVA to come below the clouds and approach the aerodrome visually and descended below the minimum on his own. Why did the controller tolerate a descent below the minimum altitude?
Confusion between two aircraft with similar callsigns resulted in one performing an uncoordinated descent through another aircraft's level. But for the controller, in the context of the information available and reasonable his expectations, it made sense to act as he did. This case also illustrates an interesting fact about the equivalence of success and failure in ordinary work; the same sorts of processes that enable efficient performance can also contribute to unwanted events.
Source: Systems Thinking for Safety: Ten Principles. A White Paper. Moving towards Safety-II, EUROCONTROL, 2014.
The following Systems Thinking Learning Cards: Moving towards Safety-II can be used in workshops, to discuss the principles and interactions between them for specific systems, situations or cases.