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Systems thinking is a way of approaching complex systems by considering how they function as a whole, rather than focusing solely on individual parts. It involves understanding the relationships and interdependencies between the parts of the system, and how they contribute to system behaviour. Incidents and accidents in complex systems do not come down to a single cause or factor. Instead, they involve multiple and complex factors that interact on the day. Through understanding these interactions through learning reviews, it becomes possible to identify opportunities for intervention and improvement, as well as potential unintended consequences of changes made to the system.

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People do what makes sense to them given the information they had within the context at the time. If it didn't make sense to them, they wouldn't have done it! Reports often cite that people 'failed to/ should have/ didn't follow procedure'. This is describing something that never happened or 'work as imagined'. Instead, we use the Learning Review to understand how events unfolded and the factors shaping behaviour, decisions and performance. By examining the context in which the event occurred, we gain a deep understanding of the performance shaping factors that contributed to the event. We then apply this knowledge to develop more effective safety strategies and make the system more robust in the future. 

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Nobody wakes up in the morning and decides to put themselves or others at risk. What happens on the front line and how procedures are used are often not how we think work happens. People make trade-offs and have to adapt to challenges, pressures and dynamic conditions to get their work done on a daily basis. Because of this, we assume people come to work with the intention of doing a good job. This mindset shifts the focus from blaming individuals for mistakes or errors to addressing the underlying systemic factors that contribute to events. It creates a positive environment that puts the human at the centre, a psychological safe space where people can open up and share. Rather than assuming people are the problem, we consider them the solution and seek to learn from their experience. 

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Safety systems and risk assessments are based on assumptions of how our procedures and practices are carried out, 'work as imagined'. In practice, these idealised assumptions may or may not always be valid. We work in complex systems which are constantly evolving and outcomes are not entirely predictable. Frontline 'work as done' is shaped by a range of factors that influence how workers approach their tasks, make decisions, and interact with others in the system as they adapt to the conditions on the day. By learning about the actual work practices and behaviours, we gain a far more realistic picture of how the system operates in practice and identify mitigations that are more effective for a complex and dynamic world.

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"What were they thinking?" is a common initial reaction to a safety-related event, but approaching investigations with a mindset of curiosity without judgment can lead to a more productive analysis. By asking questions such as "How did they come to their decisions?" and "What was influencing their behaviour?". investigators can gain a deeper understanding of the underlying factors that contributed to the event. This approach allows for a more objective and comprehensive analysis of the incident, minimizes biases and initial reactions, and promotes a genuine discovery of what happened.