# Systems Thinking for Safety: Ten Principles. A White Paper — Moving Towards Safety-II

*Shorrock, Leonhardt, Licu & Peters · Safety & Error, Complexity & Systems, Voice & Silence · EUROCONTROL (White Paper) · 2014 · Open access*

This EUROCONTROL white paper does something the safety literature rarely manages: it takes the sprawling body of systems thinking and complexity theory and distils it into ten workable principles, written for the people who actually run systems rather than for other academics. The foundation is system focus, the insistence that to understand how organisations work you must look at the interactions between parts (human, social, technical, informational, political, economic and organisational) in the light of the system's goals, rather than at components in isolation. The ten principles then unfold across three groups. The first three concern how we see the people inside systems: field expert involvement (you cannot understand work-as-done without the people who do it), local rationality (their actions made sense given their goals, knowledge and attention at that moment), and just culture (assume people act with good intent, and cultivate openness, trust and fairness). The next two concern the conditions of work, demand and pressure, and resources and constraints. Three more concern how systems behave: work flows as interacting activities rather than discrete events, people must make trade-offs to resolve goal conflicts under uncertainty, and performance variability is not a defect but a necessity. The last two are the most complexity-inflected: outcomes are emergent rather than the sum of component performance, and success and failure are equivalent, arising from the same source, which is everyday work and the variability within it. For this map the paper is unusually valuable as connective tissue, because it is where the complexity cluster and the safety cluster meet, and because psychological safety is not an add-on to its argument but a precondition for it. Field expert involvement requires that the people at the sharp end can speak candidly about how work is really done; local rationality requires the willingness to explain why something made sense rather than defend oneself against blame; and just culture is named outright as one of the ten. Its limits are those of the form: a white paper written to translate theory into practice for a specific industry, offering principles and illustrations from air traffic management rather than new evidence, so it synthesises and persuades rather than tests. (Text drawn from the 2014 EUROCONTROL white paper and its accompanying SKYbrary toolkit.)

- **This page:** https://explore.psychsafety.com/n/shorrock-et-al-2014/
- **View the source paper:** https://skybrary.aero/sites/default/files/bookshelf/2882.pdf
- **Interactive map:** https://explore.psychsafety.com/?mode=papers&node=shorrock-et-al-2014

## Connected concepts (13)

- [More Is Different](https://explore.psychsafety.com/n/anderson-1972.md) (paper)
- [Risk Management in a Dynamic Society: A Modelling Problem](https://explore.psychsafety.com/n/rasmussen-1997.md) (paper)
- [A Leader's Framework for Decision Making](https://explore.psychsafety.com/n/snowden-boone-2007.md) (paper)
- [A New Accident Model for Engineering Safer Systems](https://explore.psychsafety.com/n/leveson-2004.md) (paper)
- [From Safety-I to Safety-II: A White Paper](https://explore.psychsafety.com/n/hollnagel-wears-braithwaite-2015.md) (paper)
- [The Criminalization of Human Error in Aviation and Healthcare: A Review](https://explore.psychsafety.com/n/dekker-2011-criminalisation.md) (paper)
- [HOP](https://explore.psychsafety.com/n/hop-human-and-organisational-performance-training.md)
- [Just Culture](https://explore.psychsafety.com/n/just-culture.md)
- [Principles of Adaptive Management in Complex Safety-Critical Organizations](https://explore.psychsafety.com/n/reiman-et-al-2015.md) (paper)
- [State of Science: Evolving Perspectives on 'Human Error'](https://explore.psychsafety.com/n/read-et-al-2021.md) (paper)
- [The Deepwater Horizon Explosion: Non-Technical Skills, Safety Culture, and System Complexity](https://explore.psychsafety.com/n/reader-oconnor-2014.md) (paper)
- [Resilience Engineering](https://explore.psychsafety.com/n/psychological-safety-resilience-engineering.md)
- [Resilience is a Verb](https://explore.psychsafety.com/n/woods-2018.md) (paper)