Health & Safety System Approaches

Health & Safety System Approaches
Systems are deeply embedded in the way an organisation manages health and safety
(H&S). Over the last century there are recognizable shifts in the approaches taken toward
H&S systems. Four Health and Safety System Approaches are identified and covered
showing how the perspective taken by each of H&S and related accident analysis differ.
These Health and Safety System Approaches are not substitutable options, rather they can
be viewed as progressively adding to ways in which H&S is improved by organisations, in a
sense reflecting a progression in the level of maturity of organisational H&S. The multilevel perspectives reflected in Health & Safety System Approaches can be similarly
reflected in the law of tort and in Commissions of Inquiry into H&S failures.
David Alman
Version 3.
November 2013


David Alman

Contents
Acknowledgements................................................................................................................................. 3
1. Systems of Work a basis for improved Health and Safety .................................................................. 4
2. What is meant by the terms Hazard and Risk in a systems context ................................................... 6
3. Four Health &Safety System Approaches ........................................................................................... 9
4. Health & Safety System Approaches Explored ................................................................................. 14
4.1 Transactional System Approach: Compliance based ................................................................. 14
4.2 Governance System Approach: Resilience based ...................................................................... 17
4.3 Referential System Approach: “Drift” affected systems ............................................................ 21
4.4 Interpretive System Approach: “Dissonance” and crisis............................................................ 26
5. Maturity of Health and Safely Systems, and Tort. ............................................................................ 29
Conclusion ............................................................................................................................................. 30
Notations............................................................................................................................................... 31
References ............................................................................................................................................ 35
About the author .................................................................................................................................. 38

Proventive Solutions

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Acknowledgements
This article arose from a LinkedIn Systems Thinking World (STW) Thread discussion. My thanks to
Gene Bellinger for encouraging such discussions on, and learning in, Systems Thinking, and through
the way he has managed and supported this LinkedIn Group. My Thanks to Frank Wood who raised
a Thread covering systems thinking in relation to the field of Health & Safety and, through the
Thread’s postings, for highlighting the lack of public information linking Systems Thinking to Health &
Safety.

My thanks to T.A. Balasubramanian who referenced Nancy Leveson and her e-book Engineering a
Safer World. This is not the first time that Tabby has referenced Leveson’s publications and from a
previous discussion and reference to Leveson I found online elsewhere that excellent article by Zahid
Qureshi A Review of accident modelling approaches for complex socio-technical systems. This article
highlights how the approach to Health & Safety has shifted over time; introduces the concept of
Complex Sociotechnical Systems; and leads to exploring the more recent authors in the field such as
Erik Hollnagel, Jens Rasmussen, Anthony Hopkins, and Peter Ladkin. In this respect my thanks too
to Frank Verschueren for his enthusiasm for Health & Safety and its link to Systems Thinking.
Through his interests I have picked up and included the work of Sydney Dekker.

My thanks also to Sanjiv Bhamre for referencing Karl Weick’s work in Health & Safety that
subsequently led me to a particular Karl Weick article which helped finalise the four Health & Safety
System Approaches applied in this article.

My thanks to all those who post on STW that helped develop my interests and musings; to others
across the world who I share my drafts with and who kindly review and offer comment; and, more
close to home, those who not only take the time to read, review, and offer feedback but who also sit
down with me and share and discuss their views such as my wife, Donna, and good friend Peter
Wojciechowski.

Non, in my view, receive the acknowledged appreciation they deserve.


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1. Systems of Work a basis for improved Health and Safety
According to the International Labour Organization (ILO) and the World Health Organization (WHO),
health and safety at work is aimed at the promotion and maintenance of the highest degree of
physical, mental and social well-being of workers in all occupations; the prevention among workers
of leaving work due to health problems caused by their working conditions; the protection of workers
in their employment from risks resulting from factors adverse to health; the placing and maintenance
of the worker in an occupational environment adapted to his or her physiological and psychological
capabilities; and, to summarise, the adaptation of work to the person and of each person to their job.
[1].

Health and Safety (H&S) at work is influenced by “hard” legislation that provides directives and
regulation about what is to be complied with by organisations and accountable persons, as well as
covering the means of its legal enforcement. In addition there is “soft” legislation that provides
unenforceable guidelines. It should be noted, however, in H&S matters before a court an
employer’s actual practices, for example when considering what are the causes of an accident, can
be compared to such published legislative guidelines and this is taken into account in a court’s
decision.

H&S is viewed as improved by considering H&S issues within a systems approach, and this is
confirmed as there is health & safety legislation where safety in a systems sense is specifically
referred to for employer application. This may be through “hard” legislation as in Australia and the
UK where “safe systems of work” are sought [2].

A safe system of work is a framework resulting from a systematic examination of work to identify
hazards and design specific work methods to eliminate or minimise hazards. A safe system of work
therefore refers to systems of work that have been assessed for safety and where hazards have been
identified and addressed. What is involved in making a system of work safe is based on Risk
Assessments [3], unless specifically a matter to be addressed in a manner covered by regulation.

Safe systems of work can be further supported, as in Australia, by “soft” legislation that provides
guidance through, for example, reference to the use of H&S Management Systems [4].

Despite some countries H&S legislation not referencing the application of safety in a systems context
there are large organisations in such countries that voluntarily set up and apply H & S Management


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Systems [5]. The voluntary implementation and application of Health and Safety systems at work
can also extend to and include, for example, the establishment of behavioural based safety systems.
Traditionally there has been a separate practice by some large organisations to focus on behavioural
based safety systems, however behavioural based safety systems can also be integrated with
procedurally based H&S Management systems [6].

Whether through procedurally based H&S Management Systems; behavioural based systems; or safe
systems of work, the intention is to better address risk of injury from hazard sources.

What is meant generically by an H&S system should be explained before proceeding further so there
is a common understanding of how the term is used in this article.

A system can be generally and broadly described as:
A purposeful organisation of its component parts, each with varying attributes, that results in
intended (and unintended) consequences resulting from its interactions. [7]
Within this context H&S systems can include, for example [8]:



A purpose such as to develop, maintain, and improve safe ways of working by identifying
hazards and addressing risks to the health and safety of employees and others <why>.



Components such as materials, people, plant, equipment, process(es), tasks and environment
<what>.



H&S influences and constraints that address system component hazards and the risks in their
interactions <how>.

What an H&S system is and what its component parts are, along with their interactions and
attributes, can be viewed in different ways. These different ways, or perspectives, are grouped
under the four H&S System Approaches described in this article.


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2. What is meant by the terms Hazard and Risk in a systems context
There are two common terms used when considering hazard sources and their effects on H&S:
Hazard and Risk [9].
A Hazard is a direct or indirect source of potential, harm. A hazard consequence is personal
injury or death resulting from a hazard.

A risk is a measure of the likelihood of personal injury or death.

Sources of hazards can come from three types of systems: Human Designed systems; Psychosocial
systems, and Natural Environment systems, as illustrated in Diagram 1.

Human Designed Systems
Process & practice systems
Built environment
Management Systems

PsychoSocial Systems
Interpersonal
Intrapersonal

Natural Environment
Systems
Physical
Biological
Chemical

Diagram 1. Types of Systems encompassing Health & Safety Hazards


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Examples of hazards arising from these three systems types are provided in Table 1.

SYSTEM TYPE
Human Designed

HAZARD AREA


HAZARD EXAMPLES

Process & practice systems
Dangerous processes & practices.



Built Environment
Plant & Equipment layout &
condition
Work area design



Management System
H&S Management System status
Communication system condition
Accountability structure design

Mechanical & electrical exposure;
excessive heat or noise.
Poor lighting; slippery surfaces;
entrapment – no exit.
Unaddressed identified risks.
Inadequate network support issues.
Lack of accountability or delegation,
or overlapping authority.

Psychosocial


Interpersonal relations



Intrapersonal values & priorities



Biological contamination

Exposure to infection from bacteria
and viruses.



Chemical containment

Acid, heavy metal, vapour exposure.



Physical environment

Extreme weather, unsafe landscape.

Harassment/bullying, interpersonal
conflict & relationship breakdowns
Emotional stressors, belief conflicts
in values and priorities.

Natural Environment

Table 1. Examples of hazards that can arise within the three System Types.

These three System Types are not separate in a work environment but interlinked along with their
potential hazards. The subsequent integration of these System Types results in another form of
System Type termed a Human Activity System (HAS) [10].

Diagram 2 illustrates how the three System Types merge within a Human Activity System (HAS)
Type. It is within this Human Activity System Type that all Health & Safety related systems discussed
on this article are considered.


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Human Activity System (HAS)

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Human Designed

• Process & practice systems
•Built environment
•Management Systems

Psychosocial

Natural
Environment

•Interpersonal
•Intrapersonal

•Biological
•Chemical
• Physical

Diagram 2. The Human Activity System (HAS) Type as an integration of three other System Types


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3. Four Health &Safety System Approaches
The approach taken to assessing and solving a problem situation, in systems terms - the” Systems
Approach” -is based on the paradigms of reality (the perspective) taken.

System approaches (also referred to as Systems Thinking Approaches) therefore reflect different
perspectives of reality applied to problem situations, in systems terms.

Within this context four Health & Safety System Approaches are explained in this article:


Transactional System Approach;



Governance System Approach;



Referential System Approach; and



Interpretive System Approach.

The following Diagram 3, Table 2, and Diagram 4 illustrate and outline these four distinct Health &
Safety System Approaches.

In Diagram 3 the four Health & Safety System Approaches (Transactional; Governance; Referential,
and Interpretive) are very briefly explained and also shown as interconnected yet separated by
considering them along two dimensions:

 The Work Level where the Health & Safety System Approach is either more focused at the
organisational level or more focused on specifics at the Workplace Level.

 The Socio-technical where the Health & Safety System Approach is either more focused on
(technical) issues, such as legislation, regulations, policies, and procedures to address health and
safety, or more focused on the specific (socio) needs of individuals and groups [12].


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Governance Approach
Plan, implement, and review
content reliability to a given
context.
Organisational

Work
Level

For example, develop and improve
reliability management control
systems, and rules.
(Analyse and Act)

Referential Approach
Identify and apply content values and
priorities in a context.
For example, appreciate and apply
what is valued and of priority to a
given situation.
(Probe and Act)

Transactional Approach
Ensure compliance within a given
context and content.

Interpretive Approach
Address dissonance in context and
content.

For example, compliance with
prescribed work practices.
(Categorise and Act)

For example, decide how to manage
issues in an unanticipated emergency
or injustice cases.
(Sense and Act)

Workplace

Regulatory

Needs

Socio-technical
Diagram 3. The four H&S System Approaches compared though two dimensions.

In Table 2 the four Health & Safety System Approaches are briefly explained, with a matching
column that highlights the H&S System Approach (i.e. Compliance; Reliability; Drift; and Dissonance).
The four H&S System Approaches are also aligned to the key H&S issue addressed; and each H&S
System Approach in the table is provided with further Descriptions of hazards identified and relevant
supporting methodologies.

The four Health &Safety System Approaches are more fully explained in the subsections of Section 4
of this article.


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H&S System Approach Characteristics
H&S System
Approaches

H&S Issue
addressed

Transactional.

Compliance
to H&S

Risk manage at
the event and
process activity
level

Descriptions
Hazards Identified


requirements
in Workplace
Systems

Governance.

Reliability in

Manage by
“structuring’
depth in
defences
through an H&S
Management
system.



H&S
Management
Systems

Methodologies

The “System of work” either
works as required, or fails to
meet preset standards. Stop
the direct “Domino” cause and
effect chain that results in
accidents.



Accidents and risks cannot be
managed at the workplace
without greater policy and
planning to handle “variation”.
More “defences” in a much
wider range of direct (“sharp
end”) and support policies,
processes and practices
(“blunt end”) to stop accidents
from getting through a “Swiss
Cheese” of holes in H&S
defences that end in accidents.











Referential.
Manage
culturally
influenced
issues to
improve H&S

Interpretive
Manage and
address
personal
experiences of
hazards
beyond those
addressed by
existing H&S
systems.

Drift in H&S
Culture.





Dissonance



in H&S
environment


Planning and preparation of
H&S Management System still
leaves risk exposures and
serious accidents.
Whatever is organised, there
can be a “drift” and lack of
recognition of how priorities
and values are influencing
H&S.



Crises caused by exposure to
hazards that are not covered
by previous experience, or
prescribed processes and
practices.
Social justice issues are outside
the cultural values and
priorities in the workplace.



The two above points create
crisis and/or conflict: mental
Dissonance between
individuals and group
experience of work
environment hazards.







Check and control through linear “Root
cause” Analysis at the workplace.
Check and investigate against standards
using direct root cause analysis methods.
Standards of H&S practice tightened
through procedural rule changes, and
through behavioural based programs.
Variations in risk exposures and accidents
require greater planning and preparation
to identify hazards and improve the
management of risks.
A “Swiss Cheese” approach used through
additional OH&S defences in both direct
and indirect support areas by anticipating
hazards and risks and developing and
improving a “resilient” OH&S
Management System.
Check and investigate using audits and
non linear root cause analysis.
Reengineer for High Reliability in system
processes and behaviours.
Resolution of conflicting emergent
influences.
Systems can be dynamic and
unpredictable where what was safe one
day is now unsafe. Hazards and risks are
“emergent” from “drift” in processes and
practices due to competing priorities.
Influence of values and priorities to be
checked and investigated through
multiple perspective root cause analysis.
Reframe work practices and values
(Transactional, Governance, Referential
Levels) to address the issues that
Dissonance raises.
This involves organisations being open to
changing existing H&S systems to
accommodate experiences viewed as
inadequately coped with through existing
processes, practices, values, and
priorities.

Table 2. The four Health & Safety System Approach characteristics compared.


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In Diagram 4 the four Health & Safety System Approaches that influence the way H&S is practiced
are aligned to the “ages of work”, reflecting an evolution of both in Western Society [13]:


An Industrial Age going back to the 18th Century where mechanical equipment and mechanistic
systems of work in manufacturing were common, and at a workplace level health and safety and
accident investigations fitted in by comparing “compliance” failures to preset standards.



A Technological Age going back to the mid 20th Century where industries sought to coordinate
and organise safe systems of work at an organisational level, where H&S Management Systems
built incompliance defences to improve “reliability” against accidents and incidents;



An Information Age, or knowledge based age, starting in the latter part of the 20th Century
sought team or individual flexibility in responding quickly and effectively to emergent situations.

In a Referential Systems Approach ‘drifts” in priority and values have overridden laid down
prescribed H&S practices. Where “drifts”, because of hazards and accidents, have caused a
difference, and discretion, between “what ought to be done” (as prescribed) and “what needs to
be done” to address current work pressures and influences (Referential System Approach
issues).

Also in certain situations, such as where there is a health & safety crisis faces a team or
individual, a difference between “what ought to be done” and “what needs to be done” can
result. Where, for example, emergent emergency issues cause personal “dissonance” between
inadequacies in what (prescriptively) ought to be done compared to “what needs to be done” to
survive and be safe (Interpretive Systems Approach issues).


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Interpretive System Approach
Addressing “Dissonance” issues
e.g. Personal distressors
Need Focus
Referential System Approach
Addressing “Drift” issues
e.g. Priority & value influenced

H&S System
Approaches

Regulatory Focus

Governance System Approach
Addressing “Reliability” issues
e.g. H&S Management Systems

Transactional System Approach
Addressing “compliance” issues
e.g. physical equipment, human failure
Industrial Age

Technological Age

Information Age

“Ages of work” aligned to the start of certain H&S System Approaches

Diagram 4. An evolution in “Ages of work” and H&S System Approaches


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4. Health & Safety System Approaches Explored
4.1 Transactional System Approach: Compliance based
A “Transactional” System Approach refers to linked and interrelated activities (procedural, technical,
behavioural) at the workplace where the focus is on producing something providing a service, or
building something, or making something. Within this Transactional System Approach, H&S
workplace practices are identified and built into the way activities are carried out to develop “safe
systems of work”.

Diagram 5 illustrates a three stepped process for identifying and addressing workplace hazards [14].

Identify Hazards

Assess the risks

Control the risk

Diagram 5. Three Stepped Risk Management Process

Within this Transactional Systems Approach, hazards are identified, for example, through a Job
Safety Analysis; inspection checks on compliance to standards; and through incident and accident
reports. Incident and accident reporting, as shown in Diagram 6, can include a “root cause” analysis
of an accident/incidence that has occurred, and is carried out by asking, for example, a number of
“why” questions of the cause of the accident or incident. Through this Root Cause Analysis levels of
direct cause and effect are established.

Service or production Transactional System based on employee & technical interactions

Root Cause Analysis of accident

Diagram 6. Root Cause Analysis of a Safe System of Work Failure.

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In the Transactional System Approach once hazards are identified the level of H&S risk can be
assessed (based on Consequences and Likelihood of harm), as exampled in Table 3.

Consequences
Likelihood
Insignificant

Minor

Moderate

Major

Critical

Medium

Medium

High

Extreme

Extreme

Likely

Low

Medium

High

High

Extreme

Possible

Low

Medium

High

High

High

Unlikely

Low

Low

Medium

Medium

High

Rare

Low

Low

Low

Low

Medium

Almost certain

Table 3. A H&S Risk Assessment Matrix Example [15]

Having identified hazards, and assessed their risks, the means of controlling those risks are then
considered and actioned.

Both hazard management and accident analysis in a Transactional System Approach take a common
view based on compliance. That is, safe systems of work provide preset standards of safe work
activity that are to be complied with, where causes of accidents can be a failure to comply with
preset safe systems of work.

Whether a single event or a chain of events causes an incident or accident, the relationship between
an event’s cause and effect is direct (linear) within workplace (Transactional) systems of work. Root
Cause analyses can indicate multiple direct chains of causes, as illustrated in Diagram 6. In Diagram
7 a single sequential chain of direct events causing an accident or incident is visually shown and
described as the “Domino Effect” [16].

Diagram 7. Domino Effect


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In reality, however, accidents and incident have more than one contributing factor and have
multiple root causes.

To support safe systems of work based on compliance two different methods can be taken and
integrated:



Compliance of work practices to a system of work, as discussed above.



Compliance of work practices to a Behaviour Based Safety program. Behaviour Based Safety
programs focus on identifying “at risk” behaviours and developing ways to encourage safe
behaviours, and include using behaviour observation checklists [17].

A limitation of the Transactional System Approach to health & safety is that an accident or incident
investigation based on direct (linear) causes and effects at the workplace level can be an incomplete
analysis by excluding relevant additional causal factors influencing and affecting work level practices,
for example from an established Health & Safety Management System; from management decisions;
and an organisation’s culture that are identifiable through other Health and Safety System
Approaches [18].


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4.2 Governance System Approach: Resilience based
The Transactional System Approach refers to “safe systems of work” based on risk assessed preplanned and pre-set activities along with associated compliance standards that work together to
safely produce some output and outcome. Safe systems of work based on the Transactional System
Approach may stand alone at the workplace level, or may be part of larger Governance System
Approach to H&S that covers a wide range of issues that support the safety of a transactional system
of activities, such as training, incentive schemes, IT support, life cycle maintenance, replacement of
plant etc.

The Governance System Approach to H&S can include established Health & Safety Management
System frameworks such as ISO 18001, AS/NZS 4801, SafetyMap, 5 Star.

Health & Safety Management System frameworks tend to cover similar areas, the performances of
which are auditable (by internal or external Auditors) which assess compliance [19]. Table 4
examples areas that can be covered.

Example Elements found in Health & Safety Management Systems



Responsibility and accountability



Consultation, communication and reporting



Hazard identification, risk assessment and control measures



Safe work practices, including in normal and abnormal circumstances



Training and competency



Managing contractors



Equipment integrity



Reporting and investigating incidents – internal systems



Emergency planning



Procurement



Management of change and its affect on the Health & Safety System



Documentation and data control


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Table 4. Example of elements of a Health & Safety Management System
In addition Health & Safety Management Systems are designed to apply a concept of a continuous
improvement cycle (from Policy & objective through to Review), as exampled in Diagram 8.

Policy &
objectives
Planning &
prioritising

Review

Audit

Continuous improvement

Corrective action

Standards &
targets

Implementation

Monitoring

Diagram 8. Example of continuous improvement areas in a Health & Safety Management System

Through the development and application of a Health and Safety Management System two aspects
of H&S can be considered relevant beyond the idea of “compliance”: Reliability and Resilience.

While reliability and resilience are interconnected ideas their emphasis is different:



Reliability relates to increasing the reliability in parts of, and the whole of, a Health & Safety
Management System so accidents do not occur.



Resilience relates to improving the depth of defences built (through multiple layers of defences,
barriers, and safeguards) into a Health & Safety Management System against incidents and
accidents occurring.


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Diagram 9 illustrates this idea of defences against accidents and incidents [20]. First it shows that
defences can be forms of “sharp end” health and safety protection such as equipment used, human
practices, procedural processes, workplace conditions. ThIs also shows that defences can have
depth in terms of “blunt end” support factors, such as policies, purchasing practices, training
programs.

Accidents can occur at a point in time where potential hazards slip through “gaps” in these layered
defences, analogous to the holes in a “Swiss Cheese”.

A Governance System Approach H&S Management System
Organisational Level Safety factors
e.g. OSH 18001, AS/NZS 4801, SafetyMap, 5 Star
(includes “Blunt end” factors)

CAUSES

Workplace Level H&S factors
e.g. workplace conditions and practices
(“Sharp end” factors)

INVESTIGATIONS

Accidents

DEFENCES

Accident

Diagram 9. Adaptation of a “Swiss Cheese” Model developed by Reason

Improved reliability is therefore by adding defences that fill “gaps”.


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A limitation with focusing on reliability and “High Reliability” is that health and safety is not
necessarily improved by increasing reliability of, for example, Health & Safety Management Systems.
Nor by improving their resilience by improving the defences built into Health & Safety Management
Systems. This is because accidents can result from unanticipated interactions. So whilst a Health &
Safety Management System can continue to satisfy auditable safe performance requirements, as a
Governance System Approach, it is system interactions and not system elements/system parts that
can also fail [21].

To further improve H&S a move toward identifying and addressing “emergent” and “emerging”
hazards and risks is beneficial. This involves applying a Referential System Approach.


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4.3 Referential System Approach: “Drift” affected systems
There are three aspects about a Referential System Approach that can be recognised in their
application:



They are based on an organisation’s cultural values and priorities; group “norms”; and individual
values and priorities, and assumptions, in decision making.



They involve the influence of values and priorities on, and through, perspectives that are
common and consistent within other Health & Safety System Approaches.



They include and combine the “multi-level” perspectives found in different Health & Safety
System Approaches. This multi perspective level, and how they interrelate within the
Referential System Approach, is shown in Diagram 10.

Referential
Perspective Level
Values and priorities that
give “meaning” to what is
decided.

Governance Perspective
Level
Organisation of “rules” to
manage, control, and
coordinate what is done

Transactional Perspective
Level
Technical & social activities
&
Physical conditions such as
equipment and work layout

Outcomes
Diagram 10. Multi-level perspectives of the Referential System Approach

Diagram 11 shows an accident investigation, based on a Referential System Approach, using a
Human Activity System (HAS) Map. The HAS Map highlights the application of multi-level
perspectives (Referential, Governance, Transactional) [22].

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+

Human Activity System (HAS) Map
Purpose: Accident investigation
Referential
Level
H&S risk management
practices not reinforced

Priority on efficiency &
cost cutting

Management priority
on production
outcomes

Governance
Level
Machine maintenance
schedules affected by cost
cutting decisions

H&S checks not
carried out

Delays in routine
machine maintenance
schedules

Transactional
Level
Machine guard sensor
not operating

Machine guard not
functioning

Slip on oil leak on
machine platform

Employee rushing to
complete job

Outcomes

Press operator injured by
machine

Time off on
Workers
Compensation

Injury subject
to external
investigation and
penalty

Diagram 11. HAS Map of an Accident Investigation.


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In terms of a Referential System Approach Diagram 12 also illustrates the analysis of multi-level
perspective relationships to incidences occurring at a workplace level [23].

Contributory Factors
Supervisor and certain team
Supervisor & certain team members

members coercive and
disrespectful to female staff.

Referential Level (values & intentions)
Female employees part of set
work teams and affected by
Team
Team

attitudes of certain other
team members and by

Team

Supervisor style and attitudes.

Governance Level (organisation structure)

METHODOLOGICAL
CONSIDERATIONS IN

Female employees ostracised

USING ACCIMAPS AND

breakdowns in relationships

THE RISK
MANAGEMENT
Transactional Level (role activities and behaviours)

FRAMEWORK TO

and belittled, with

and loss of coordination of
work.
Loss of attendance of female
staff, poor resulting
performance, drop in
workplace productivity.

ANALYSE
LARGE
Diagram 12. Workplace Level Example of a Referential System Approach

-

SCALE SYSTEMIC


FAILURES
P.E. Waterson

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On a broader sense the Referential System Approach highlights the importance of checking for
“emergent” issues and emerging shifts in H&S that can expose organisations and humans to hazards
and risks. A way of exampling these shifts, or Drifts, as it relates to the Referential System Approach
with its multi-level perspectives is exampled in Diagram 13.

Increasing organisational Performance
Referential
Governance
Transactional
Multi-Levels

Past work processes and role requirements
based on balancing performance & H&S
requirements
(“What ought to be done”)

Past
Safety Net

DRIFT

Current work & role processes and practices
based on an emphasis on improving
performance needs yet affecting H&S wellbeing
(“What needs to be done”)

D
R
I
F
T

Current
Safety Net
Transactional

Legend

Governance

= Safety Net

Referential

= Accidents &
Incidents

Multi-Levels

Supporting Employee wellbeing
Diagram 13. Example of a “drift” in work practices beyond pre planned safety nets.

A key concept inherent in Diagram 13 is one of “drift” toward increased incidents and accidents.


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David Alman

The concept of “drift” and the “emergence” of incidents and accidents from apparently safe work
systems can be discussed in terms of four associated concepts:
1. Hollnagle’s “ETTO” Principle”;
2. The term “Drift” coined by Dekker;
3. Rasmussen’s shift through influencing constraints in his Dynamic Safety model; and
4. Hopkins AcciMap examples:

The insights that can be gained from these four associated concepts are:

1. The ETTO Principle relates to “Efficiency- Thoroughness Trade Off”. If thoroughness dominates,
there may be too little time to carry out the actions efficiently. If efficiency dominates, actions
may be badly prepared or wrong for lack of thoroughness. Making an efficiency – thoroughness
trade-off is never wrong in itself. Employees are expected to be both efficient and thorough at
the same time – or rather to be thorough, when with hindsight it was wrong to be efficient and
where the consequence was an accident. The greater the need of performance adjustments is,
the less thorough they are likely to be as demands to increase efficiency may overrule
thoroughness and health and safety [24].

2. Dekker defines “drift” as the “slow, incremental movement of systems operations towards the
edge of their safety envelope”. Drift occurs as small deviations from accepted practice that build
upon one another to a become a huge deviation from stated (safe) practices [25]

3. Rasmussen developed a Dynamic Safety Model of which Diagram 13 is a simplified and adapted
version of his model that demonstrates how three influencing constraints cause drift into
accidents [26].

4. Hopkins has developed a number of AcciMaps that provide an easy visual description of the
causes underlying major accidents. This work is based on Jens Rasmussen’s work on AcciMap
that recognises multi-levels of perspective. Diagrams 11 and 12 are illustrative of this [27].

A limitation with using AcciMaps and HAS Maps is that it is possible to develop different multilevel
causal maps of the same accident, showing different sets of causes depending on the analyst’s focus
[28].


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David Alman

4.4 Interpretive System Approach: “Dissonance” and crisis.
The Interpretive System Approach is similar to the Referential Approach in that both apply a
multilevel perspective. They differ, however, as the Interpretive System Approach relates to:



Situations at the workplace level only;



Individual and group personal beliefs and assumptions in the circumstances they find
themselves.



Interpretive System Approach that is separate from organisation based Health & Safety System
Approaches previously described.

Diagram 14 provides a comparison between a Referential and Interpretive System Approaches and
illustrates how they can interact.

Referential System Approach
Referential
Perspective

Organisation
Level

Governance
Perspective

Interpretive System Approach
Workplace Level

Transactional
Perspective

Organisation focus

Referential
Governance
Transactional
Perspectives

Employee focus

Diagram 14. Comparison of Referential and Interpretive System Approaches

The Interpretive System Approach is relevant to employee health & safety in the areas such as:


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

David Alman

An emergency where existing practices fail to address serious hazard exposures and risks to
employees. For example where in a forest firestorm, fighting equipment and practices fail to
keep employees safe and they are left to their own devices to work out survival solutions [29].



A “secondary victim” where an employee or ex-employee suicides or gives up career as a result
of being blamed as the cause of an accident, such as a nurse or doctor over a patient’s death or
an airline pilot as a result of a crash. In such instances organisations could seek a just culture
that protects people's honest mistakes from being seen as culpable [30].



A violation of valued expectations in relation to, for example, social justice as in the way an
accident is treated. For example where there is harassment or bullying of employees
unrecognised by management. Also where the workplace environment causes high levels of
employee stress.

In such cases “dissonance” and a personal crisis can occur.

An example is illustrated in the following formal employee harassment complaint that “Maps”
causes through a multi-level perspective from outcomes at the Transactional Level, to causes at
Governance Level, then the Referential Level. See Diagram 15.


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David Alman

Human Activity System Map
Purpose: Identify causes of workplace harassment complaint
Work Group

Employee

Management

Referential Level
Long term employees in an
established team, providing
consistent service

New employee to
team with history of
providing new ideas
that improve services

Inexperienced manager
with attention on senior
management relationships

Governance Level
No regular meetings or
planning meetings with work
group to address work issues

Transactional Level

Work group rejects
suggestion

Employee raises a
suggested improvement
to group work practices

New idea implemented into
work group by manager

Work group criticises
employee and makes
repeated fun of a
disfigurement

Outcomes

Employee informally raises
harassment concerns

Improvement
suggestion raised with
manager in front of an
executive, who
supports the idea.

Manager dismisses and
ignores employee
concerns

New employee to team
with history of
Employee raises formal
providing new ideas that
harassment complaint
improve services

Diagram 15. Human Activity System (HAS) Map of an Employee Workplace Harassment


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David Alman

5. Maturity of Health and Safely Systems, and Tort.
From Commissions of Inquiry into H&S related issues, such as accidents, it can be seen that multilevels of perspective are taken in examining and assessing the evidence. This is illustrated through a
number of AcciMaps and supporting publications around AcciMaps published by Hopkins [31]. In
this document those differing multi-levels of perspective found in AcciMaps are reflected in the
Referential System Approach, such as in Diagram 11 and 15 HAS Maps.

In the AcciMaps of Hopkins a “but for” approach is used to analyse serious accidents and develop
their cause and effect relationships across the different multi-levels of perspective within the
AcciMaps. The “but for” rational is that it is also applied in law to work out liability based on Tort
[32]. This “but for” legal liability for accidents can be traced through multi-level perspectives in the
Referential Approach to H&S, because both AcciMaps and HAS Mapping can apply and trace causal
relationships through a “but for” (tort) analysis. Alternatively HAS Maps can be developed using a
“why-because” analysis across the multi-level perspectives [33].

This article also proposes that the Health & Safety System Approaches applied in supporting
organisational H&S can be viewed as building up from a Transactional System Approach, with a
particular transactional perspective level, through to the Governance System Approach with a
particular governance level perspective (and also includes the Transactional System Approach
perspective), to the Referential System Approach where its perspective includes all perspectives
from the other Health and Safety System Approaches.

Beyond this is the manner in which the multi-level perspectives of the Referential System Approach
also supports employee wellbeing by identifying and addressing “dissonance” and crises issues they
face through an Interpretive System Approach.

From this it could be argued that the “maturity” of organisational H&S relates to which Health and
Safety System Approaches they apply. This highlights two points, that:



The “maturity” of an organisation’s H&S can be assessed based on what Health and Safety
System Approaches are applied;



An organisation’s potential tort liability can be tried to be addressed through the application of a
Referential System Approach or an organisation can take a higher risk by not recognising and
addressing its liability exposure by managing H&S through limited or no use of Health and Safety
System Approaches.


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David Alman

Conclusion
H&S is associated, historically, with the way organisations perceive and manage themselves using
one or more Health and Safety System Approaches. Different Health and Safety System Approaches
can also be viewed as developing across four “ages of work” during the last century in the western
world: From industrial; to technological; to knowledge Ages, as illustrated in Diagram 4.

Through Health and Safety System Approaches several aspects about H&S can be recognised:


Health & Safety System Approaches, progressively and systemically, extend addressing H&S from
the immediate, tangible and direct (“sharp end”) workplace H&S issues that effect people, to
include (“blunt end”) organisational Health and Safety Management support that are indirect
and intangible influences such as priorities and values on H&S;



Health and Safety System Approaches are Human Activity Systems (HAS). HAS integrate and
include three system Types: Natural Environment; Human Designed; and the Psychosocial
systems.



The Transactional, Governance, Referential, and Interpretive Health and Safety System
Approaches each reflect a different perspective, or paradigm, in thinking about H&S. H&S
improves by adding and integrating the different Health and Safety System Approaches, as each
adds a different level of H&S perspective until creating multi-level perspectives. In this sense an
organisation’s level of maturity in health and safety can be reflected based on which Health and
Safety System Approaches (and perspectives) are applied.



Health and Safety System Approaches, overall, include considering both a “unitary” (i.e.an
organisation focus) and a “pluristic” one to address “dissonance” and crises affecting individuals
and groups.

Because later Health and Safety System Approaches (e.g. Referential and Interpretive) are not widely
understood there is a very real question regarding the “maturity” of Health and Safety System
Approaches applied by organisations, and through this their level of risk exposure, and their ability
to manage tort liability at senior management levels: Those who are accountable for organisational
H&S.


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David Alman

Notations
[1] The Eurofound Dictionary provides explanations and definitions for the term Health and Safety.
Ref
http://www.eurofound.europa.eu/areas/industrialrelations/dictionary/definitions/healthandsafety.
htm
[2] Safe System of Work Division 2.2 Clause 19(3)(c) Work Health & Safety Act 2011 Ref
http://www.legislation.act.gov.au/a/2011-35/current/pdf/2011-35.pdf and Safe Systems of Work
(p2) Ref http://www.britishfootwearassociation.co.uk/wp-content/uploads/2011/10/SAFESYSTEMS-OF-WORK.pdf
[3] An OH&S Risk Assessment can be found in How to manage work health and safety risks from Safe
Work Australia. Ref
http://www.safeworkaustralia.gov.au/sites/SWA/about/Publications/Documents/633/How_to_Man
age_Work_Health_and_Safety_Risks.pdf
[4] A Safety Management Systems explanation is provided by Safe Work Australia. Ref
http://www.safeworkaustralia.gov.au/sites/SWA/about/Publications/Documents/127/OHSManage
mentSystems_ReviewOfEffectiveness_NOHSC_2001_ArchivePDF.pdf
[5] References to specific Health & Safety Management Systems from a Wikipedia on Safety
Management Systems. Ref http://en.wikipedia.org/wiki/Safety_management_systems and OHSAS
18001 Occupational Health and Safety from the bsi group. Ref http://www.bsigroup.com.au/enau/Assessment-and-Certification-services/Management-systems/Standards-and-schemes/OHSAS18001/ AS/NZS 4801 Safety Management Systems. Ref http://www.ncsi.com.au/as-4801-OHSCertification.html The 5 Star Health & Safety Management System and others are discussed in
Pomfret In Occupational Health and Safety Management System Auditing. Ref
http://www.ccohs.ca/hscanada/contributions/ohs_auditing_pomfret.pdf
[6] SafeMap . Ref http://www.safemap.com/english/cb_safety.html and Beyond the behaviourbased safety plateau . Ref http://pipeliner.com.au/news/beyond_the_behaviourbased_safety_plateau/067203/
[7] Armson in Growing wings on the way: Systems Thinking for messy situations (p 134) sates “A
system is a collection of elements connected together to form a purposive whole with properties that
differ from those of its component parts”.
Also “A system can be defined as “a set of objects together with relationships between the objects
and between their attributes” (Hall & Fagen, 1969, p. 81) referenced by Hollnagel in Modelling of
failures: From chains to coincidences (p 8). Ref http://www.resist-noe.org/DOC/Budapest/KeynoteHollnagel.pdf
[8] Armson in Growing wings on the way: Systems Thinking for messy situations (p 215) indicates, in
simple terms, that a system can be viewed as containing three aspects, as shown in this template
“A system to do < what> by means of <how> in order to contribute to achieving <why>” this template
is exampled in the text.
[9] In terms of Terminology covering “Hazard and Risks in the workplace”; “Hazard”, and “Hazard
consequences” is provided in ref http://www.engica.com/engica-terminology.aspx


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David Alman

[10] In Practical Soft Systems Analysis (p8) Patching states Human Activity Systems are “systems
where humans are undertaking activities that achieve some purpose. These systems would normally
include other types, such as social, man-mad, natural systems.”
[11] The explanation of what “Systems Approaches” means is based on, and adapted from, the Flood
& Jackson book Problem solving: Total System Intervention (1991, p 32) and technically equates to
the terms “Systems Thinking Approaches”.
[12] In Diagram 3 the four H&S System Approaches can be variously considered as a Framework or
illustrating differing perspectives or paradigms or domains, or “ways of thinking”. There is some
resonance in this diagram’s explanation of the difference in H&S System Approaches to Dave
Snowden’s Cynefin in that both can be viewed as different forms of sensing in that there is a brief
reference to “Categorise & Act”, “Analyse & Act”; “Probe & Act’; “Sense & Act” though clearly there
are differences to Cynefin’s “Sense Making” Domains, refer to The Origins of Cynefin. Ref
http://cognitive-edge.com/uploads/articles/Origins_of_Cynefin.pdf .
[13] Hollnagel in Resilience Health Care slide 7 outlines Three Types of Accident Models over time
and the explanation within this article is intended to be consistent with this. Age or time is not
necessarily the key factor, rather that certain industries arose at different times in the Western
world that is reflected in the time lines and these industries have influence on H&S Approaches that
are considered relevant. Ref http://www.resilienthealthcare.net/RHCN_2012_materials/Tutorial.pdf
[14] There are a number of fairly typical risk assessment processes that can be accessed. Two have
been drawn on in this paper as they provide additional supporting information. The Risk
Management Process of the Northern Territory Government ref
http://www.education.nt.gov.au/__data/assets/pdf_file/0011/4106/risk_management_process.pdf
and Safe Systems of Work of the Footwear and Leather Industries ref
http://www.britishfootwearassociation.co.uk/wp-content/uploads/2011/10/SAFE-SYSTEMS-OFWORK.pdf
[15] There can be variants in the formatting of a H&S Risk Assessment Matrix. This example is from
the Queensland Government, Department of Education, Training and Employment document
“Health & Safety Risk Assessment Template” issued in August 2012 ref http://bit.ly/1bcCqm7
[16] The Domino Effect is described in this paper as a linear causal chain that results in an accident.
The term originally has more specific causal factors based on the Domino Theory by Heinrich. Ref p5
in A Review of Accident Modelling Approaches for Complex Socio-Technical Systems by Zahid Qureshi
ref http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA482543
[17] Behaviour Based Safety programs are broadly explained on this Wiki ref
http://en.wikipedia.org/wiki/Behavior-based_safety. With more detail in terms of their
effectiveness in Behavioural Safety Interventions by M.D. Cooper ref http://www.behavioralsafety.com/articles/behavioral_safety_interventions_a_review_of_process_design_factors.pdf
[18] Nancy Leveson in Chapter 2 of her e-book Engineering a safer world identifies the weakness
and limitation of relying on event chain models for accident investigation (p36-49).
https://mitpress.mit.edu/sites/default/files/titles/free_download/9780262016629_Engineering_a_S
afer_World.pdf
[19] COMCARE have produced a booklet that covers Safety Management Systems in major hazard
facilities that can be viewed as relevant to Health and Safety Management Systems in general. Ref

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David Alman

http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&ved=0CF0QFjAD&url=ht
tp%3A%2F%2Fwww.comcare.gov.au%2F__data%2Fassets%2Fword_doc%2F0003%2F39387%2FSafet
y_Management_System.doc&ei=AczUUdDFDdCyiQfJh4HACA&usg=AFQjCNHuCyz6RYJ9hJyzI2JSzIouF
yAsOQ&sig2=5wj8vL9UGlqfOLQ4LcbfEw
[20] Reason developed a “Swiss Cheese” model of accident causation where accidents emerged due
to holes (failures) in barriers and safeguards. The model used in this paper is an adaptation of
another adaptation of the model Reason used in his publication Managing the Risks of
Organizational Accidents (1998). The “Swiss Cheese “model is drawn from URL reference found here
http://dkv.columbia.edu/demo/medical_errors_reporting/site/module2/swiss-cheese-model.html
[21] Nancy Leveson in her e-book Engineering a safer world explains how safety is not increased
with increased H&S system reliability (p 28-35).
afer_World.pdf
[22] Reference to Human Activity System (HAS) can be found in Human Activity System (HAS)
Mapping article by D. Alman ref http://en.calameo.com/read/0014509349aed27553fc3.
[23] Work Level Referential System example is an adaptation based on Rasmussen & Svedung
publication Proactive Risk Management in a Dynamic Society (2000 p 53) figure 7.3 ref
https://www.msb.se/RibData/Filer/pdf/16252.pdf . To this has been added a “Contributory Factors”
table, as exampled in Figure 1 Risk Management (ActorMap) Framework in Methodological
considerations in using AcciMaps and the Risk Management Framework to analyse large scale
systemic failures by P.E. Waterson and D.P. Jenkins ref https://dspace.lboro.ac.uk/dspacejspui/handle/2134/7944?mode=full
[24] The ETTO Principle -Efficiency-Thoroughness Trade-Off Or Why Things That Go Right, Sometimes
Go Wrong Erik Hollnagel ref http://www.abdn.ac.uk/iprc/uploads/files/Aberdeen_ETTO.pdf
[25] Modeling drift in the OR: A conceptual framework for research by Richard Severinghaus, Taryn
Cuper, and C. Donald Combs. Ref
http://scs.org/upload/documents/conferences/autumnsim/2012/presentations/mpms/4_Final_Sub
mission.pdf
[26] ‘‘Going solid’’: a model of system dynamics and consequences for patient safety R Cook, J
Rasmussen. Ref http://qualitysafety.bmj.com/content/14/2/130.full.pdf+html and The role of error
in organizing behaviour by J Rasmussen ref
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743771/pdf/v012p00377.pdf
[27] AcciMaps in use by Anthony Hopkins ref
http://www.efcog.org/wg/ism_pmi/docs/Safety_Culture/Hopkins_ACCIMAPS_in_use.pdf
[28] In Root Cause Analysis: Terms and Definitions, Ladkin (p10) explains the limitations (and
strengths) of AcciMaps ref http://www.rvs.unibielefeld.de/publications/Papers/LadkinRCAoverview20130120.pdf by Peter Ladkin.
[29] Karl E. Weick The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster ref
http://www.nifc.gov/safety/mann_gulch/suggested_reading/The_Collapse_of_Sensemaking_in_Org
anizations_The_Mann_Gulch.pdf


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David Alman

[30] Sidney Dekker identified and coined the term “secondary victim” in recognising that not only
are there victims as a result of an accident, but that those blamed by organisations and others can
end up consequentially as “secondary victims” and in this organisations need to seek A just culture
to protect employee honest mistakes from being seen as culpable. Explained in “Just culture:
Balancing safety and accountability” ref
http://xa.yimg.com/kq/groups/18351986/1360486422/name/Just+Culture+Balancing+Safety+and+A
ccountability.pdf
[31] An AcciMap of the Esso Australia Gas Plant Explosion by Anthony Hopkins ref
http://www.qrc.org.au/conference/_dbase_upl/03_spk003_Hopkins.pdf An AcciMap overview can
be found in Root Cause Analysis: Terms and Definitions by Peter Ladkin at http://www.rvs.unibielefeld.de/publications/Papers/LadkinRCAoverview20130120.pdf .
[32] “but for” test discussed with an example ref http://www.mcmillan.ca/The-Crucial-but-for-Testin-Determining-Causation
[33] Peter Ladkin in “Why-Because Analysis of the Glenbrook, NSW Rail Accident and Comparison
with Hopkins’s AcciMap”, examples the application of “Why-Because Analysis” on a “But-for”
AcciMap, and provides two methodologies to cross check the accuracy and adequacy of HAS Maps.
In effect this means that on a HAS Map one could:
 Apply a Why-Because Analysis approach to Governance and Transactional Perspective
Levels;
 Apply, subsequently, a Cultural – Causal Analysis to the Referential Perspective Level.
Ref Ladkin, P. Root Cause Analysis: Terms and Definitions. AcciMap overview. URL reference
http://www.rvs.uni-bielefeld.de/publications/Papers/LadkinRCAoverview20130120.pdf


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David Alman

References
D. Alman 2013 Human Activity System (HAS) Mapping
http://en.calameo.com/read/0014509349aed27553fc3
Armson, R. (2011). Growing wings on the way: Systems Thinking for messy situations. Axminster,
UK: Triarchy Press
AS/NZS 4801 Safety Management Systems. URL reference http://www.ncsi.com.au/as-4801-OHSCertification.html
Eurofound Dictionary of Health and Safety. URL reference
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Behaviour Based Safety programs Wiki URL reference http://en.wikipedia.org/wiki/Behaviorbased_safety
Beyond the behaviour-based safety URL reference. plateau
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But for test http://www.mcmillan.ca/The-Crucial-but-for-Test-in-Determining-Causation
COMCARE Safety Management Systems in major hazard facilities. URL reference
http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&ved=0CF0QFjAD&url=ht
tp%3A%2F%2Fwww.comcare.gov.au%2F__data%2Fassets%2Fword_doc%2F0003%2F39387%2FSafet
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safety. URL reference http://qualitysafety.bmj.com/content/14/2/130.full.pdf+html
Cooper M.D. Behavioural Safety Interventions. URL reference http://www.behavioralsafety.com/articles/behavioral_safety_interventions_a_review_of_process_design_factors.pdf
Dekker, S. (2007). Just culture: Balancing safety and accountability. URL reference
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England: John Wiley & Sons Ltd.
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Sometimes Go Wrong. URL reference
http://www.abdn.ac.uk/iprc/uploads/files/Aberdeen_ETTO.pdf


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David Alman

Hollnagel, E. Modelling of failures: From chains to coincidences. URL reference http://www.resistnoe.org/DOC/Budapest/Keynote-Hollnagel.pdf
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How to manage work health and safety risks Safe Work Australia. URL reference
http://www.safeworkaustralia.gov.au/sites/SWA/about/Publications/Documents/633/How_to_Man
age_Work_Health_and_Safety_Risks.pdf
Ladkin, P. Root Cause Analysis: Terms and Definitions. AcciMap overview. URL reference
http://www.rvs.uni-bielefeld.de/publications/Papers/LadkinRCAoverview20130120.pdf
Leveson, N.G. (2011) Engineering a safer world: Systems Thinking applied to safety. E-book URL
reference
afer_World.pdf
OHSAS 18001 Occupational Health and Safety. URL reference http://www.bsigroup.com.au/enau/Assessment-and-Certification-services/Management-systems/Standards-and-schemes/OHSAS18001/
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Qureshi.Z, H. (2008) A Review of Accident Modelling Approaches for Complex Socio-Technical
Systems. URL reference http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA482543
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The Risk Management Process Northern Territory Government. URL reference
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mentSystems_ReviewOfEffectiveness_NOHSC_2001_ArchivePDF.pdf

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David Alman

SafeMap. URL reference http://www.safemap.com/english/cb_safety.html
Safe Systems of Work Footwear and Leather Industries. URL reference
http://www.britishfootwearassociation.co.uk/wp-content/uploads/2011/10/SAFE-SYSTEMS-OFWORK.pdf
Severinghaus, R. Cuper, T. & C. Combs, D. Modeling drift in the OR: A conceptual framework for
research . URL reference
http://scs.org/upload/documents/conferences/autumnsim/2012/presentations/mpms/4_Final_Sub
mission.pdf
Snowden, D. The Origins of Cynefin. URL reference http://cognitiveedge.com/uploads/articles/Origins_of_Cynefin.pdf
Swiss Cheese model. URL reference
http://dkv.columbia.edu/demo/medical_errors_reporting/site/module2/swiss-cheese-model.html
Waterson , P.E. & Jenkin D.P. Risk Management (ActorMap) Framework in Methodological
considerations in using AcciMaps and the Risk Management Framework to analyse large scale
systemic failures. URL reference https://dspace.lboro.ac.uk/dspacejspui/handle/2134/7944?mode=full
Weick, K E. The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster. URL reference
http://www.nifc.gov/safety/mann_gulch/suggested_reading/The_Collapse_of_Sensemaking_in_Org
anizations_The_Mann_Gulch.pdf
Work Health & Safety Act 2011 Division 2.2 Clause 19(3)(c). URL reference
http://www.legislation.act.gov.au/a/2011-35/current/pdf/2011-35.pdf


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About the author
David Alman lives in Brisbane, Queensland, Australia, and is the business owner of
Proventive Solutions, which offers services in Organisational Health.
Organisational Health is a broad overview term that refers to assessing and improving performance
and well being of both an organisation and its employees, recognising there is a nexus between the
two.

Further explanation through various articles, blogs, slides, on different subjects can be found on
Proventive Solutions at WordPress, along with contact details. Please refer to:
http://proventivesolutions.wordpress.com/2012/07/13/about-proventive-solutions/

This article is part of a body of work on Systems Thinking with a common base around the idea of
looking at, and addressing, situations through different “Perspective Levels”. Other articles in this
body of work include:
Multilevel System Analysis: An introduction to Systems Thinking at
http://www.slideshare.net/davidalman/multilevel-system-analysis and
http://en.calameo.com/read/001450934d8a5a5d9b090

Human Activity Systems (HAS) Mapping at http://www.slideshare.net/davidalman/human-activitysystem-has-mapping and http://en.calameo.com/read/0014509349aed27553fc3


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Health & Safety System Approaches

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