Systems Thinking

摘要

There are two ways to investigate accidents. First, identify the single most important failure. Secondly, identify as many failures and contributory factors as time and resources allow. Sociologists call the first method the reductionist approach and the second the systems approach. In recent years the systems approach has gained traction, partly because it produces more insights. On September 2, 2006 RAF Nimrod MR2 XV230 crashed in Afghanistan, killing all on board. On September 3, 2006 a Board of Inquiry (Bol) was convened. Besides identifying the 'probable physical causes' of the accident, the Bol also identified possible contributory factors, including an under-estimation of the risks associated with airframe modifications. Put simply, the Nimrod Safety Case (NSC) was found wanting. Building on the Bol report, Mr Charles Haddon-Cave QC's 2009 Independent Review into the Broader Issues Surrounding the Loss of the RAF Nimrod MR2 Aircraft XV230, identified a range of systemic factors, including the following.