Systems Learning

Organizations managing hazardous operations face persistent challenges that are tied to human fallibility and the unpredictable nature of complex adaptive systems. Traditional management responses such as retraining, procedure revisions and disciplinary action often fail because they focus on frontline workers rather than examining the organizational structures that shape workplace performance. This book offers a different approach: a risk-informed management discipline that helps leaders understand how their organizations actually work, moving beyond the question "who did it?" to ask "what conditions allowed this to happen?"

Building on the principles established in Risk-Based Thinking (9781138302495, 2018) and Critical Steps (9781032115078, 2022), this title applies systems thinking to the continuous learning cycle essential for operational success. It guides managers through three iterative phases of systems learning: discovery, understanding, and realignment. Early chapters establish foundational concepts about organizations, systems, and complex adaptive systems, then introduce the Iceberg Model; a framework for examining events, patterns, structures, and mental models. Practical systems thinking tools help managers analyze how organizational functions interact to influence human performance in real-world conditions. The final chapter demonstrates systems learning in action through analysis of the 2019 Ethiopian Airlines Flight 302 crash, revealing how organizational structures contributed to pilot performance and the subsequent tragedy. Readers will gain the ability to make effective, adjustments to their systems by getting more of what they want and less of what they don't want.

Systems Learning: Managing Human and Organizational Performance is for anyone responsible for managing high-risk industrial operations where human performance is essential to the operation of technical systems. Other managers of various organizational functions will find help in optimizing various system goals, such as safety, quality, productivity, and efficiency, through people.