In high-hazard industries like oil and gas, mining, construction, and renewable energy, safety is essential and regularly cited as an organisational value. Traditionally, safety has focused on compliance, policies, and checklists. While these measures provide structure, they can be insufficient in environments with complex, evolving risks. To enhance safety culture in such high-stakes settings, many organisations have adopted systems thinking; a powerful approach that views safety as a complex and interconnected system of people, processes, technology, and environment. This perspective shifts the focus from individual actions to a collective responsibility for safety.
Systems thinking encourages organisations to understand safety as a dynamic network where each component affects the others. In high-hazard industries, where even small failures can lead to significant consequences, identifying and addressing these interdependencies creates a proactive, resilient safety culture. This framework has proven particularly useful in anticipating risks rather than just reacting to them, as it recognises that organisational components cannot operate in isolation. Instead, they interact to influence outcomes, either mitigating or compounding risks (Dekker, 2011).
By examining the interconnected aspects of safety, systems thinking aligns well with Todd Conklin’s Human and Organisational Performance (HOP) principles and Prof. Patrick Hudson’s Cultural Maturity Model, and with the application of psychological safety it makes it a powerful and compelling concept when applied. Each of these frameworks adds depth to systems thinking, offering ways to structure safety culture so that it becomes resilient, adaptable, and generative. Together, these approaches create an organisational environment where safety is both a shared value and a practical, proactive process that continuously evolves to meet new challenges.
In high-hazard environments, systems thinking shifts the perspective on safety from a static set of rules to a complex, evolving structure. It recognises that people, processes, technology, and the environment are interconnected parts of a whole. When safety is viewed through this lens, each element’s influence on the others becomes clear. As an example, how well-maintained equipment is affects not only the performance of tasks but also the safety of the workers operating that equipment. Poorly maintained machinery can increase the likelihood of accidents, influencing everything from production processes to employee morale.
Systems thinking also recognises that error is part of complex systems. Rather than aiming to eliminate error entirely, it focuses on designing systems that can tolerate and adapt to errors without catastrophic consequences. This proactive approach is essential for high-hazard industries, where a single mistake can have far-reaching implications. By embedding adaptability into safety systems, organisations reduce their vulnerability to unexpected changes and create a more robust safety culture that is prepared to handle complexity.
Todd Conklin’s HOP principles provide a practical framework for applying systems thinking to safety. HOP shifts the focus from individual blame to understanding how the system can better support human performance. Conklin’s view is that human error is inevitable and should be anticipated rather than punished. This approach is particularly effective in high-hazard environments, where creating resilient systems is more practical than expecting error-free performance from individuals (Conklin, 2019).
HOP principles align with systems thinking by emphasising that most errors stem from systemic issues rather than individual failings. For example, if workers are consistently circumnavigating safety steps, HOP encourages examining the system to identify why this behaviour is occurring. Are processes overly complex? Is equipment difficult to use or prone to malfunction? By addressing these underlying issues, organisations can adjust systems to make safer behaviours easier to adopt, ultimately reducing error rates.
HOP also introduces the concept of “work-as-imagined” versus “work-as-done.” This distinction helps organisations understand that how work is planned often differs from how it is executed. In high-hazard industries, unexpected challenges often require workers to adapt processes in real time. HOP encourages organisations to listen to employees and learn from these adaptations, recognising that frontline workers often have insights into system flaws that management might overlook. This principle ties back to systems thinking, as it highlights the importance of incorporating feedback loops into safety systems, allowing organisations to adapt and refine processes based on real-world experiences.
To assess and advance safety culture, Patrick Hudson’s Cultural Maturity Model (or Safety Culture Ladder) offers a structured approach. According to Hudson, safety cultures evolve across five stages: pathological, reactive, calculative, proactive, and generative (Hudson, 2007). These stages represent a progression from a culture where safety is minimally considered to one where safety is deeply embedded as a core value and an integral part of every operation.
The pathological stage represents an organisation where safety is a low priority. Leaders at this level often view safety measures as a hindrance to productivity and only address safety concerns when forced by incidents or regulations. As the organisation moves toward a reactive culture, safety is addressed only after incidents occur. Calculative cultures focus on compliance, relying on safety metrics and procedures to manage risk. In proactive cultures, safety becomes embedded in planning and processes, with leadership actively involved in fostering safety initiatives. Finally, in a generative culture, safety is seen as a core value that guides every aspect of the organisation, and employees at all levels feel a shared responsibility for maintaining a safe environment.
A systems-thinking approach supports organisations as they move up this ladder, promoting a shift from reactive to proactive and, eventually, generative safety cultures. As organisations mature, they focus less on punishment and compliance and more on learning and improvement. Hudson’s model aligns closely with HOP principles, as both frameworks advocate for moving beyond blame to create systems that anticipate and prevent incidents. In a generative culture, safety is deeply embedded in decision-making, and employees feel empowered to contribute to safety efforts, knowing their input is valued and will lead to meaningful change.
Psychological safety, introduced by Amy Edmondson, is essential for a generative safety culture. It refers to an environment where employees feel safe to speak up about errors, concerns, or potential improvements without fear of punishment (Edmondson, 1999). In high-hazard industries, psychological safety encourages employees to report hazards, share near-misses, and suggest changes, which are all critical for continuous improvement. When employees trust that their insights will be respected and addressed, they are more likely to engage actively in safety processes.
Psychological safety is essential for advancing along Hudson’s Cultural Maturity Model. In a generative culture, psychological safety enables open communication, where employees feel comfortable identifying risks or system flaws. This open dialogue is essential for creating feedback loops, allowing the organisation to refine its systems continuously. In some high-hazard industries, where work conditions vary daily, psychological safety enables employees to report new risks promptly, allowing the organisation to respond in real time.
By fostering psychological safety, organisations also reinforce HOP principles, which advocate for understanding system weaknesses rather than focusing on individual fault. In psychologically safe environments, employees are more likely to report errors, providing valuable insights into potential system adjustments that could prevent future incidents. In high-hazard environments, these insights are invaluable, as they allow organisations to adapt to emerging risks effectively.
Leading Indicators and Continuous Improvement
Leading indicators, such as participation in safety training, frequency of hazard reports, and near-miss reporting rates, provide critical insights into an organisation’s safety culture. Unlike lagging indicators, which measure incidents after they occur, leading indicators provide early signals of potential risks. In a systems-thinking approach, leading indicators help identify weak points in the system, allowing organisations to adjust before incidents happen (Provan et al., 2020).
High rates of hazard and near-miss reporting indicate a workforce that feels safe to speak up, reflecting psychological safety and an engaged safety culture. Regularly tracking these indicators helps organisations monitor their progress in real-time, supporting continuous improvement. In a high-maturity safety culture, these indicators are part of a feedback loop where employees’ insights drive ongoing adjustments, creating a dynamic system that adapts to new challenges.
As an example, tracking the frequency of safety equipment inspections can reveal trends in equipment maintenance needs. By acting on these indicators, organisations can prevent potential breakdowns, failures and incidents. Similarly, near-miss reports can highlight recurring hazards, prompting a re-evaluation of processes or safety protocols to minimise risk.
Applying Systems Thinking, HOP, Cultural Maturity, and Psychological Safety in Practice
By integrating systems thinking with HOP principles, Hudson’s Cultural Maturity Model, and psychological safety, organisations in high-hazard sectors can cultivate a proactive safety culture that not only anticipates and mitigates risks but also leverages human performance and collective resilience to create safer, more adaptable operations. This approach is transformative in high-hazard environments, where safety is often dynamic and complex.
Real-time equipment monitoring combined with a psychologically safe environment allows employees to report issues without hesitation, leading to timely interventions and preventive maintenance. These concerns can be about site-specific risks, enabling organisations to adapt their practices on-site. Employees who experience a psychologically safe environment can also contribute to a continuous improvement process by reporting hazards and sharing insights, which informs operational adjustments. In effect, people become a powerful feedback loop within the cultural system.
With systems thinking, HOP principles, and a focus on psychological safety, organisations embed resilience into the core of their safety practices. This proactive, interconnected approach empowers high-hazard industries to move beyond compliance, creating sustainable safety cultures that adapt and evolve in response to emerging risks and challenges. A truly resilient safety culture is one where safety is an inherent part of every decision and action, ensuring the wellbeing of employees and the stability of operations.
Conklin, T. (2019). “The 5 Principles of Human Performance: A Contemporary Update of the Building Blocks of Human Performance for the New View of Safety.”
Dekker, S. (2011). “Drift into Failure: From Hunting Broken Components to Understanding Complex Systems.”
Edmondson, A. C. (1999). "Psychological Safety and Learning Behavior in Work Teams." “Administrative Science Quarterly”, 44(2), 350-383.
Hudson, P. (2007). Implementing a Safety Culture in a Major Multi-National.
Provan, D., Woods, D., Dekker, S., & Rae, A. (2020). "Safety II professionals: How resilience engineering can enhance safety."
