Safety Science, a Systems Thinking Perspective: From Events to Mental Models and Sustainable Safety

Round 1

Reviewer 1 Report

My compliments to the authors, who spent a great deal of time revising the manuscript. The specific examples of Mental Models add a lot, and I believe that this is now an excellent paper.

Author Response

We thank reviewer 1 for the kind words and thorough review, which helped greatly in improving this paper.

Author Response File: Author Response.pdf

Reviewer 2 Report

This paper is well written and reads very nicely. I think the paper lacks some identity, it is a nice safety science paper but I am not convinced that it addresses any real sustainability or security issues. I think that if you removed the security word the paper would read better, as I can't really see how you address any security issues.

I think it needs to state a clear aim and address what the research question is that you are proposing to deal with in this concept paper. The aim, purpose and objective could be enhanced. In essence I see it as a safety science paper which cover some of the elements of current safety science thinking especially around complex systems and Safety I Safety II. However, it does try to cover a lot of different aspects and I wonder if too many are presented, as there appears to be a lack of flow of how the information is linked from one element to the other.

Correct line 482 with Safety I and Safety II having capitals.

I would suggest stating the aim more clearly in the abstract and the research question being addressed early on in the paper to ensure the reader knows what you are trying to achieve in this paper.

Author Response

We thank reviewer 2 for his contribution to make this a better paper. In order to respond to the concerns raised, we have added the following paragraphs:

1.1.        Purpose of this paper

Every element and part in the universe can be regarded as a system. When humans and technology are involved one can also look at these elements as being socio-technical systems (STS). These systems range from very simple to ultra-complex. Hence, the purpose of this paper to look at safety from a systems thinking perspective and to indicate how such perspective can be used to consider safety and sustainability issues today.

4.8          Some examples of mental models influencing safety, security and performance

…

When mental models are different in different groups of people (societies), they can generate conflicting objectives. When this happens, security issues will arise. As an example, one only has to think of the governing mental models in a democratic open society, where equal rights, gender equality and women’s empowerment are very important aspects of life that possibly conflict with differing viewpoints ruling different societies. When these conflicts are very outspoken, terrorist action can be expected, as has been the case with Al Qaeda or Islamic State of Iraq and Syria (ISIS). Likewise there are the different mental models that go along with political systems, which can also cause deliberate harmful action of one group of people against another one, not adhering to the same values and belief systems (mental models). Understanding these governing mental models and their associated objectives provides information and directions on how to deal with these related security issues.

An example of the influence of one simple mental model on the performance of a complex socio-technical system can be found in the book “The Power of Habit”. In this book, Duhigg tells the story of the Aluminium Company of America (Alcoa) and how in 1987, at a time Alcoa was struggling, a new CEO was appointed. Paul O’Neal, the new CEO, drastically changed Alcoa’s performance by focussing on one simple idea regarding safety. This mental model was “zero injuries”. His ambition was to make Alcoa the safest company in America by reducing Alcoa’s injury rate. At that time this was something unheard of in the corporate world and at the beginning this approach was met with a lot of scepticism. But within a year Alcoa’s profits would hit a record high and by the time O’Neal retired in 2000, the company’s annual net income was five times larger than before he arrived. [58]

4.9          Mental models and a sustainable world

Safety is closely linked with sustainability. In a certain way they are almost synonyms. It is about achieving, maintaining and protecting what is valuable and important. How can something be safe when it isn’t sustainable or how can something be sustainable when it isn’t safe? Societal mental models governing sustainability are to be found in domains such as climate change, corporate social responsibility or world peace. Examples can for instance be found in the United Nations global compact principles (specific mental models) for corporate sustainability. One can read on the UN website: “By incorporating the Ten Principles of the UN Global Compact into strategies, policies and procedures, and establishing a culture of integrity, companies are not only upholding their basic responsibilities to people and planet, but also setting the stage for long-term success.” [59]

Author Response File: Author Response.pdf

Reviewer 3 Report

My previous comments still apply.

I also note in their response letter that the authors insist on making the readers follow through cited articles rather than the authors provide assurances of supporting literature through their own text. Again, this seems to be inconsistent with the approach of academic journals. As with my last review I will leave it to the editors of the journal to determine if this approach is appropriate.

Author Response

We understand and respect the position of reviewer 3. However, we remain convinced of the fact that innovative ideas and different perspectives on issues although less coveted, accepted or practiced in science today, also have their place in scientific journals. Certainly when the aim is to develop scientific thinking on issues and to explore new avenues of research.

Nevertheless we leave it to the appreciation of the editors whether this is a valid reasoning for the Sustainability journal.

Author Response File: Author Response.pdf

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

REVIEW OF “ Safety Science, a Systems Thinking Perspective: from  Events to Mental Models and Sustainable Safety”

 

Specific Comments:

 

Authors should review all wording for conciseness and redundancy. The Abstract especially needs revision. Here is an example of how it might be improved to flow more smoothly:

 

                                  [see attachment]

Other sections of the paper would also benefit from careful re-writing.

 

Line 37. Barry Richmond did not introduce the term “Systems Thinking.” Its origins may be traced back to Harvey (1969): Explanation in Geography, London: Arnold, and probably well before. Lines 47-52 are copied, word-for-word, from reference 5 and thus constitute plagiarism. Those lines must be enclosed within quotation marks. Similar for parts of lines 53-63. Lines 100-111 are good, but need to better relate “Mental Models” to the Ladder of Influence. I suggest that “Mental Models” are roughly equivalent to the “beliefs-conclusions-assumptions” levels of the Ladder. In Figure 2, I think that the word “System” should not appear on the Iceberg. In line 212, “HRO” must be spelled out. Lines 269-280 are cumbersome and should be re-worded to reduce redundancy. Lines 281-283. Does not follow logically. Just because a property is emergent does not mean that it needs to be “consciously and persistently pursued.” Lines 288-290. Is a very broad statement that may not be true in all cases. Line 295 does not follow logically. Risk is conventionally defined as the chance of an unwanted outcome or an asset exposed to a hazard, and is typically quantified as the product of Probability and Impact, which nicely ties into Figure 3. Risk itself is not an individual construct. Risk Attitude (on the other hand) in the form of Risk Aversion or Risk Propensity, is an individual construct. The entire paragraph lines 291-300 is confusing on this point and should be clarified. Line 351 is not a complete sentence. Lines 353-382 should be substantially condensed. As is, they are wordy and redundant. Line 414 contradicts line 410. 410 says that the future cannot be predicted, but line 414 prescribes how to do it. Lines 432-450. It’s not clear that the Swiss Cheese metaphor adds clarity to the thesis. Line 499-500 does not make sense. Objectives are not accidents.

 

General Comments:

 

The paper starts out with a good premise, but never actually ties together Systems Thinking and Risk Management; they are described as 2 separate entities. The paper also does not describe how Systems Thinking may be used to improve Risk Management other than to say “it’s important to discover how the sub-systems interact” which they do not demonstrate; therefore this is not a significant contribution. The promise of the Abstract---that Risk can be better managed via a deeper understanding of Mental Models is never demonstrated. I would encourage the authors to delve deeper into the utility of the Iceberg model in understanding Risk and Improving Risk Management—perhaps with some specific application examples.

 

Comments for author File: Comments.pdf

Author Response

Response to Reviewer 1

We would like to thank reviewer 1 for the thorough review and the many valid remarks and recommendations. They have certainly helped in making this a better paper. We have amended the abstract as suggested and reviewed /rewritten the paper accordingly.

Line 37

We have revised the sentence to convey more clearly the message it was supposed to convey.

Lines 47-52, 53-63

We have rewritten these parts of the section

Lines 100-111

We have made an effort to better relate Mental models with the ladder of inference.

Figure 2.

The word “system” is appropriate in this figure. Not only because it is also so on the original design of Bryan et al. but it should also be clear from the following sections why it is appropriate as a level of awareness.

Line 212

HRO has been spelled out.

Line 269-280

We have made an effort to re-word and reduce this section.

Line 281-283

When a property is not a property of the system itself, it doesn’t appear without effort. When this property needs to be present all the time, a continued effort needs to be invested. We amended this section to clarify this.

Line 288-290

We are convinced this is true for any system between the Brout-Englert-Higgs boson (so far smallest system known?) and the universe (so far the largest system known?). As it seems that boundaries of systems are only constrained by our ability to perceive them. However, we have amended the text to be less categoric about this statement.

Line 295

We have modified this section and have added the following reference:

45. Slovic, P. (1998). The risk game. Reliability engineering & system safety, 59(1), 73-77.

to provide more background for this more comprehensive approach to risk, which goes beyond the traditional way of looking at risk and is better aligned with the concept of mental models.

Line 351

The sentence has been amended

Line 414

This is not a contradiction. As this wasn’t clear we have amended the sentence to better convey its message.

Line 432-450

We have made an effort to better align this part of the paper with the general message

Line 499-500

Objectives are not accidents, this true. But that is not what has been written. It is the not achieving or safeguarding (maintaining) objectives that needs to be seen as accidents. We have amended the text to make this easier to understand.

Reviewer 2 Report

This is an well written paper on the systems view of safety as it is at present. Many of the ideas are not new however but are re-stated already well known concepts.

The placing of the ideas in the iceberg model is interesting but getting to the depth of mental models is somewhat questionable in respect of trying to place just one cognitive concept to the understanding on humans in the system and culture. This might be a little lost on the reader as there is no link to later writing on what one is to do with the concept of mental models other than strive for attention to detail at the sub-systems level.

I think revisiting the Swiss Chees Model does not instil confidence that this work presents modern day system thinking views as new models have already been developed in the safety sciences which use concepts like (social) network theory to detect complex socio-technical patterns (as you discussed) which relate to accident phenomenology and system theory. These types of very modern models should be presented and discussed to demonstrate you are driving theory forward, not backwards into the 1990's again. (see the work of Klockner & Toft).

Overall for a reader who is not a serious student of the safety sciences the paper will provide good oversight on some contemporary thinking. Otherwise it might be a point of further discussion for the safety sciences and I congratulate you on your work and efforts in this space.

Author Response

Response to Reviewer 2

We would like to thank reviewer 2 for reviewing this paper and the suggestions and remarks made. They allowed for a critical look at the manuscript and certainly provided ideas to improve this paper.

Comments and Suggestions for Authors

This is an well written paper on the systems view of safety as it is at present. Many of the ideas are not new however but are re-stated already well known concepts.

It is true that many ideas are not new, although we think we are introducing new ways on how to look at these sometimes older concepts. We bring them together, linking them in an original way.

The placing of the ideas in the iceberg model is interesting but getting to the depth of mental models is somewhat questionable in respect of trying to place just one cognitive concept to the understanding on humans in the system and culture. This might be a little lost on the reader as there is no link to later writing on what one is to do with the concept of mental models other than strive for attention to detail at the sub-systems level.

Thank you for this comment. We have rewritten many parts of the paper to make this link more apparent.

I think revisiting the Swiss Cheese Model does not instil confidence that this work presents modern day system thinking views as new models have already been developed in the safety sciences which use concepts like (social) network theory to detect complex socio-technical patterns (as you discussed) which relate to accident phenomenology and system theory. These types of very modern models should be presented and discussed to demonstrate you are driving theory forward, not backwards into the 1990's again. (see the work of Klockner & Toft).

Thank you for suggesting the social network theory as an element to consider, however, this is not a theory that is generally used in safety science, nor is it a very modern concept, as it roots also go back to the 1970’s. (e.g. Travers and Milgram (1969)). Recent work ties it to leadership, which is indeed important. Although leadership is an important topic (as a way to align mental models in organisations and society), we didn’t consider the social network theory as a way to go and consider this beyond the scope of this paper. We only use the Swiss cheese as a metaphor, we don’t present it in the way it is traditionally used (barrier thinking). The focal point of the paper is attention to (governing) mental models in society, organisations and individuals and how they influence risk, safety and performance.

Overall for a reader who is not a serious student of the safety sciences the paper will provide good oversight on some contemporary thinking. Otherwise it might be a point of further discussion for the safety sciences and I congratulate you on your work and efforts in this space.

Thank you for this encouraging remark.

Author Response File: Author Response.docx

Reviewer 3 Report

I found some of the writing simplistic and overly general and without appropriate literature to substantiate comments - these couple of sentences demonstrates this, "Reality, as it is, is significantly more complex than what the human mind can process and comprehend at any given moment. Therefore, in order for the human mind to deal with reality, individuals must conceptualise reality by using more abstract notions. This leads to concepts that can have different meanings and that can apply to different situations." I would expect there to be several references included here.

This is a comment that can be applied to the whole draft. The content itself is well written, however it lacks an 'academic' approach, one that is based on literature and evidence. It seems more like a desk review of sorts.

I also wonder what the main argument that is being presented here is, as the conclusion does not tie together all the different methodologies and personal reflections of the authors.

 

And this paragraph, seems more like a reflection by the authors, than a discussion informed by the literature. 

"However, in taking action to pursue an objective – and not taking action is also to be understood as taking action – the objective and its value will also be linked to different risk sources that can generate positive and negative effects, adding or subtracting value of the objective. These are the risks that one runs. Taking risk is active, deliberate and in the pursuit of value, but running risks is passive, un-deliberate and with the prospect of loss. Because certain people are afraid of these losses, they immediately think of the possible losses when thinking of taking risk, they focus on the loss instead of considering the possible gains when the outcome of an endeavour is uncertain. They have a so- called risk-averse attitude. Other people, with a focus on gain, have a risk-seeking attitude. Even if most people have a so-called risk-tolerant attitude."

Author Response

Response to Reviewer 3

We would like to thank reviewer 3 for reviewing this paper and the suggestions and remarks made. They allowed for a critical look at the manuscript and certainly provided ideas to improve this paper.

Comments and Suggestions for Authors

I found some of the writing simplistic and overly general and without appropriate literature to substantiate comments - these couple of sentences demonstrates this, "Reality, as it is, is significantly more complex than what the human mind can process and comprehend at any given moment. Therefore, in order for the human mind to deal with reality, individuals must conceptualise reality by using more abstract notions. This leads to concepts that can have different meanings and that can apply to different situations." I would expect there to be several references included here.

As we assumed that the limitations of human cognition was a well-known fact, since this research is already more than half-a century ago, we didn’t include any references. To cater for this concern, we included the following reference

12. Buschman, T. J., Siegel, M., Roy, J. E., & Miller, E. K. (2011). Neural substrates of cognitive capacity limitations. Proceedings of the National Academy of Sciences, 108(27), 11252-11255.

which itself also holds various references of studies on this subject.

This is a comment that can be applied to the whole draft. The content itself is well written, however it lacks an 'academic' approach, one that is based on literature and evidence. It seems more like a desk review of sorts.

Sometimes, science is served with the proposal of new ideas, creativity and innovative thinking. At that time, it is often difficult to find meaningful references that add value to the novelties being introduced. We believe that adequate and sufficient references have been added that support the ideas proposed in this paper. Much of the references used hold themselves further references on the subjects discussed.

I also wonder what the main argument that is being presented here is, as the conclusion does not tie together all the different methodologies and personal reflections of the authors.

We have substantially reviewed the paper with the comments received from three reviewers. We think the cohesion between the different sections has now been improved. Making more clear how mental models are the focal point of this paper and a future avenue for safety as a science.

And this paragraph, seems more like a reflection by the authors, than a discussion informed by the literature.

"However, in taking action to pursue an objective – and not taking action is also to be understood as taking action – the objective and its value will also be linked to different risk sources that can generate positive and negative effects, adding or subtracting value of the objective. These are the risks that one runs. Taking risk is active, deliberate and in the pursuit of value, but running risks is passive, un-deliberate and with the prospect of loss. Because certain people are afraid of these losses, they immediately think of the possible losses when thinking of taking risk, they focus on the loss instead of considering the possible gains when the outcome of an endeavour is uncertain. They have a so- called risk-averse attitude. Other people, with a focus on gain, have a risk-seeking attitude. Even if most people have a so-called risk-tolerant attitude."

Papers need to be innovative. It is a requirement for scientific papers. However, innovation can also be reached by challenging current beliefs (mental models), providing new, sometimes personal, insights (mental models) one develops over time and with a lifetime of experience. When this is truly innovative, it is often difficult to find references. Yet, it can then be the onset of new research to provide evidence for or contradict such ideas, offering deeper understanding of the subject.

As such, this paragraph is a result of deep reflection on the subject, informed by a life of experience, but also rooted in the increasing awareness on risk and safety, as indicated in section 2.

Round 2

Reviewer 1 Report

Specific Comments

 

1. Lines 38-70. Poor sentence structure and grammar.
2. Line 266. At what time?
3. Lines 290-291. Poor sentence structure and grammar.
4. Lines 332-333. Poor sentence structure and grammar.
5. Lines 343-344. Delete one “also.”
6. Line 334 (Section 2.5). It would help to explain what is meant by “systemic structure.”
7. Lines 348-349. Not a sentence.
8. Lines 728-735. This is a very good paragraph. Some examples of safety-inducing mental models (and vice versa) would significantly help give the paper some impact.
9. Lines 852-857 are very good because they tie together the Swiss cheese metaphor with Systems Thinking (specifically, Mental Models.) But what, precisely, were the mental models that led to the Fukushima disaster?

General Comments

My compliments to the authors on a significantly improved paper. Systems Thinking and Risk Management are now much better tied together via Mental Models. But the paper still remains mostly philosophical. Providing some specific examples of Mental Models that contribute to safety and Mental Models that contribute to lack of safety would help a great deal. These should not be terribly difficult to develop and would add a lot of “punch” to the paper.

Reviewer 3 Report

thank you authors - I can see you have undertaken many edits to the original draft. This certainly assists with readability. However my original concerns about the presence of blocks of text that are not supported by literary evidence (i.e. published and cited), is still relevant. I will leave it to the journal's editors to determine if they see this as an issue - certainly most academic science journals would not support such a style of writing. You may also want to submit the paper to a publication that embraces a more discursive approach to your subject.