Using Systems Thinking to Understand Operational Risk
Operational risk in safety-critical environments rarely comes from a single failure, isolated error, or one bad decision. In complex systems like aviation, risk emerges from the interactions between people, processes, technology, organisational structures, and external influences. If you want to manage risk effectively, you need to understand how these pieces fit together.
That's where systems thinking comes in. Rather than examining individual components in isolation, it encourages a holistic view of how a system functions as a whole, and how risk can develop in ways that aren't obvious when you're looking at things too narrowly.
Moving beyond linear thinking
Traditional risk assessment often follows a linear path: hazard leads to failure, failure leads to outcome. For simple systems, this works reasonably well. For complex operational environments? Not so much.
In aviation and similar safety-critical systems, multiple barriers interact simultaneously, human performance is shaped by organisational context, technology adapts or degrades in unexpected ways, and decisions made far from the front line can fundamentally shape risk exposure.
Systems thinking recognises that outcomes rarely have a single cause. Instead, they emerge from combinations of conditions, decisions, and interactions that evolve over time.
Understanding systems, not just events
One of the real strengths of systems thinking is how it shifts focus from individual events to underlying system behavior.
Instead of asking "Who made the mistake?" systems thinking asks "How did the system create the conditions in which this outcome occurred?"
This perspective is invaluable when examining near-misses, deviations, or emerging safety concerns. It enables learning without defaulting to blame and helps organisations identify systemic weaknesses that might otherwise stay hidden beneath the surface.
People and organisations matter
Operational risk is heavily influenced by organisational and human factors: workload and resource constraints, competing priorities and operational pressures, how information flows and who has decision-making authority, training and competence levels, and cultural norms and informal practices that exist alongside formal procedures.
Systems thinking treats these factors as integral to understanding risk, not as afterthoughts or secondary considerations. In environments where human performance is central to system reliability, this integration is essential.
Risk isn't static
In complex systems, risk changes. Operations evolve, equipment gets modified, procedures are adapted, external conditions shift. Risk moves with all of this.
A systems-based approach acknowledges that controls can degrade over time, workarounds become normalised and eventually invisible, success can mask emerging vulnerabilities, and past performance doesn't guarantee future safety.
Understanding risk requires ongoing attention to how the system is actually functioning, not just periodic checks against fixed criteria.
Better decisions through better understanding
One of the most practical benefits of systems thinking is how it supports better operational and strategic decision-making. By considering interactions and dependencies, decision-makers can better anticipate potential unintended consequences.
This becomes particularly valuable when managing operational change, introducing new technology or procedures, responding to emerging risks, or balancing safety with operational efficiency.
Systems thinking doesn't eliminate uncertainty, nothing does, but it helps organisations make more informed, resilient decisions despite it.
The value of external perspective
Independent safety assurance can support systems thinking by providing an external view of how the system actually functions in practice. Independence enables challenge of assumptions, identification of blind spots, and examination of interactions that might be overlooked internally.
When applied well, independent assurance complements internal safety management by testing whether system design aligns with operational reality, assessing how controls interact across organisational boundaries, and identifying patterns rather than just isolated issues.
This broader perspective is essential for understanding and managing operational risk in complex environments.
Final thoughts
Systems thinking encourages a fundamental shift: from asking "what went wrong?" to asking "how does our system create the conditions in which risk emerges?"
In safety-critical organisations, this shift matters. It enables deeper learning, more effective risk management, and more resilient operations. By embracing systems thinking, organisations can move beyond surface-level explanations and develop a more meaningful understanding of operational risk, one that actually reflects the complexity of the systems they operate.
Because at the end of the day, understanding how your system works as a whole is the first step to keeping it working safely.
