Those at the cutting edge of improving safety – and particularly some people around safetydifferently.com – are some of the most practical and sophisticated systems thinkers, combining theory and praxis and sensemaking and much else…
two good summaries
http://www.safetydifferently.com/why-do-things-go-right/ (this one links to Deming et al)
and a couple of good sources:
(I think there was an excellent Australian podcast, but it must have stopped releasing as I haven’t heard it recently; will add if I find it)
Published on 2 Oct 2018
When James Titcombe is hit by the biggest tragedy imaginable to any parent, he and his wife need to confront a tragedy on a bigger scale still: the structural learning disabilities of the organization that robbed them of their child. The ‘complexity of failure’ documents the struggle to get the largest employer of the land to account for what was lost. Behind the bureaucracy and posturing, the lies and denials, it discovers a humanity and a richly facetted suffering by many others. It drives a determined James Titcombe to change how we learn from failure forever.