Systems Thinking: Aviation Accidents, Complexity, and Cause

This paper distinguishes between two approaches to systems thinking in accident investigations: Systems Thinking 1.0 and Systems Thinking 2.0. The first approach, 1.0, focuses on identifying broken components, even those distantly related to the event, while the second, 2.0, considers the emergent properties and complex relationships within a system. Using the Alaska Airlines Flight 261 crash as a case study, the paper contrasts these perspectives. It argues that Systems Thinking 2.0, informed by complexity science, provides a more comprehensive understanding of accidents by acknowledging path-dependence, open systems, and the potential for small changes to have large effects. Ultimately, the piece advocates for a shift towards Systems Thinking 2.0 to improve aviation safety by addressing the normal social processes that can contribute to disaster.