Table Of ContentHandbook of Systems
Thinking Methods
Handbook of Systems
Thinking Methods
Paul M. Salmon
Neville A. Stanton
Guy H. Walker
Adam Hulme
Natassia Goode
Jason Thompson
Gemma J. M. Read
First edition published 2023
by CRC Press
6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742
and by CRC Press
4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
CRC Press is an imprint of Taylor & Francis Group, LLC
© 2023 Paul M. Salmon, Neville A. Stanton, Guy H. Walker, Adam Hulme Natassia Goode, Jason
Thompson, and Gemma J. M. Read
Reasonable efforts have been made to publish reliable data and information, but the author and publisher
cannot assume responsibility for the validity of all materials or the consequences of their use. The authors
and publishers have attempted to trace the copyright holders of all material reproduced in this publication
and apologise to copyright holders if permission to publish in this form has not been obtained. If any
copyright material has not been acknowledged please write and let us know so we may rectify in any
future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced,
transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter
invented, including photocopying, microfilming, and recording, or in any information storage or retrieval
system, without written permission from the publishers.
For permission to photocopy or use material electronically from this work, access www.copyright.com
or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-
750-8400. For works that are not available on CCC please contact mpkbookspermissions@tandf.co.uk
Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used
only for identification and explanation without intent to infringe.
ISBN: 978-0-367-22017-4 (hbk)
ISBN: 978-1-032-27238-2 (pbk)
ISBN: 978-0-429-28162-4 (ebk)
DOI: 10.1201/9780429281624
Typeset in Times
by SPi Technologies India Pvt Ltd (Straive)
Contents
Preface .......................................................................................................................xi
Acknowledgements .................................................................................................xiii
Author Biographies ..................................................................................................xv
SECTION I Introduction to Systems Thinking ������1
Chapter 1 Introduction to Systems Thinking in Human Factors and
Ergonomics and Safety Science ...........................................................3
The Call to Action ................................................................................3
A Short Introduction to Systems Thinking ...........................................4
Open Systems ............................................................................6
Complexity Theory ....................................................................6
Evolution of Systems Thinking .................................................8
The Systems Thinking Tenets ..............................................................8
How to Blow Up the Death Star .........................................................11
The Death Star .........................................................................13
The Empire Strikes Back .........................................................18
A Real-Life Thermal Exhaust Port to Find ........................................24
Note ....................................................................................................25
References ..........................................................................................25
SECTION II Risk Assessment Methods ���������������29
Chapter 2 The Networked Hazard Analysis and Risk Management System
(Net-HARMS) ....................................................................................31
Background ........................................................................................31
Domain of Application .......................................................................33
Procedure and Advice .........................................................................33
Advantages .........................................................................................40
Disadvantages .....................................................................................41
Related Methods .................................................................................42
Approximate Training and Application Times ...................................42
Reliability and Validity .......................................................................42
Tools Needed ......................................................................................42
Case Study Example: Railway Level Crossings.................................42
Recommended Reading ......................................................................48
References ..........................................................................................48
v
vi Contents
Chapter 3 The Event Analysis of Systemic Teamwork Broken Links
(EAST-BL) .........................................................................................51
Background ........................................................................................51
Domain of Application .......................................................................51
Procedure and Advice .........................................................................52
Advantages .........................................................................................62
Disadvantages .....................................................................................62
Related Methods .................................................................................62
Approximate Training and Application Times ...................................62
Reliability and Validity .......................................................................63
Tools Needed ......................................................................................63
Case Study Example: Darknet Marketplaces .....................................63
Recommended Reading ......................................................................68
References ..........................................................................................68
Chapter 4 The Systems Theoretic Process Analysis (STPA) Method .................71
Background ........................................................................................71
Domain of Application .......................................................................74
Procedure and Advice .........................................................................74
Advantages .........................................................................................83
Disadvantages .....................................................................................84
Related Methods .................................................................................84
Approximate Training and Application Times ...................................84
Reliability and Validity .......................................................................84
Tools Needed ......................................................................................85
Case Study Example: Elite Women’s Road Cycling ..........................85
Results ................................................................................................87
References ..........................................................................................88
SECTION III Systems Analysis and Design
Methods ��������������������������������������� 91
Chapter 5 Hierarchical Task Analysis (HTA) .....................................................93
Background and Applications ............................................................93
Domain of Application .......................................................................94
Procedure and Advice .........................................................................94
Advantages .......................................................................................100
Disadvantages ...................................................................................100
Related Methods ...............................................................................101
Approximate Training and Application Times .................................101
Reliability and Validity .....................................................................101
Tools Needed ....................................................................................101
Contents vii
Case Study Example: Identifying the Risks Associated with
Working at Heights in Aircraft Maintenance .........................101
Recommended Reading ....................................................................103
References ........................................................................................103
Chapter 6 Cognitive Work Analysis (CWA) .....................................................105
Background ......................................................................................105
Procedure and Advice .......................................................................106
Related Methods ...............................................................................114
Approximate Training and Application Times .................................114
Reliability and Validity .....................................................................115
Tools Required .................................................................................115
Case Study Example: Autonomous Vehicles ....................................115
Results ..............................................................................................116
Work Domain Analysis ..........................................................116
Control Task Analysis – Decision Ladders ......................................119
Strategies Analysis ...........................................................................121
Social Organisation and Cooperation Analysis ................................123
Worker Competencies Analysis ........................................................123
Recommended Reading ....................................................................126
References ........................................................................................126
Chapter 7 The Event Analysis of Systemic Teamwork (EAST) .......................129
Background ......................................................................................129
Domain of Application .....................................................................129
Procedure and Advice .......................................................................130
Advantages .......................................................................................140
Disadvantages ...................................................................................140
Approximate Training and Application Times .................................141
Reliability and Validity .....................................................................141
Tools Needed ....................................................................................141
Case Study Example: Submarine Control Room Design .................141
Task Network Analysis .....................................................................141
Social Network Analysis ..................................................................145
Information Network Analysis .........................................................147
Combining Network Models ............................................................148
Task and Social Networks ................................................................149
Information and Social Networks .....................................................151
Information and Task Networks .......................................................152
Combined Task, Social, and Information Networks ........................153
Recommended Reading ....................................................................155
References ........................................................................................155
viii Contents
Chapter 8 Causal Loop Diagrams (CLDs) ........................................................157
Background ......................................................................................157
Procedure and Advice .......................................................................157
Advantages .......................................................................................164
Disadvantages ...................................................................................165
Related Methods ...............................................................................165
Approximate Training and Application Times .................................165
Tools Needed ....................................................................................166
Case Study Example: The Fatal Five Causes of Road Trauma ........166
Behaviours Analysed ........................................................................166
CLD Development ............................................................................167
Results ..............................................................................................168
CLDs for Each Fatal Five Behaviour ...............................................169
The Role of Societal Issues in Road Trauma ...................................177
The Role of Work Pressures in Road Trauma ..................................177
Reducing the Requirement to Drive .................................................178
Recommended Reading ....................................................................178
References ........................................................................................178
SECTION IV Accident Analysis Methods ����������181
Chapter 9 The Accident Mapping (AcciMap) Method .....................................183
Background ......................................................................................183
Domain of Application .....................................................................185
Procedure and Advice .......................................................................186
Advantages .......................................................................................194
Disadvantages ...................................................................................194
Related Methods ...............................................................................195
Approximate Training and Application Times .................................196
Reliability and Validity .....................................................................196
Tools Required .................................................................................196
Case Study Example (Single Incident): Air France 447...................196
Case Study Example (Multiple Incidents): Injury Causation
in Led Outdoor Activities ......................................................197
Recommended Reading ....................................................................203
References ........................................................................................203
Chapter 10 The Accident Network (AcciNet) .....................................................207
Background and Applications ..........................................................207
Domain of Application .....................................................................208
Procedure and Advice .......................................................................209
Advantages .......................................................................................218
Disadvantages ...................................................................................220
Contents ix
Related Methods ...............................................................................220
Approximate Training and Application Times .................................221
Reliability and Validity .....................................................................222
Tools Needed ....................................................................................222
Case Study Application: Uber Volvo Incident Analysis ...................222
References ........................................................................................228
Chapter 11 The Systems Theoretic Accident Model and Process-Causal
Analysis based on Systems Theory (STAMP-CAST) Method ........229
Background ......................................................................................229
Domain of Application .....................................................................231
Procedure and Advice (STAMP-CAST) ..........................................231
Advantages .......................................................................................237
Disadvantages ...................................................................................238
Related Methods ...............................................................................238
Approximate Training and Application Times .................................238
Reliability and Validity .....................................................................239
Tools Needed ....................................................................................239
Case Study Example: Medication Administration Error ..................239
Medication Administration Control Structure .......................239
Prescribing Operating Process..........................................................245
Preparation and Administration Operating Processes ......................245
STAMP-CAST Analysis of a Medication Administration Failure ......246
Recommended Reading ....................................................................249
References ........................................................................................249
SECTION V Computational Modelling
Methods ��������������������������������������251
Chapter 12 Agent-Based Modelling (ABM) .......................................................253
Background ......................................................................................253
Domain of Application .....................................................................253
Can You Please Just Tell Me What ABMs Are? ...............................255
Thinking ABM-Style ........................................................................256
Procedure and Advice ............................................................258
Training and Application Times .......................................................262
Reliability and Validity Evidence .....................................................262
Tools Required .................................................................................263
Case Study Example: Autonomous Vehicle and Vulnerable
Road User Crashes ................................................................263
Background ......................................................................................263
Method .............................................................................................265
Results ..............................................................................................265
