Systemic Analysis – The Key to Effective Risk Mitigation

By: John Westphal, Senior Advisor

The achilles heel of high consequence industries I have worked in over the years is the over reaction to a single event. In other words, we allow one event to drive systemic changes throughout the organization when that one event may not necessarily tell us enough about the risk that existed within that particular socio-technical system, or the learning system lacked the sophistication to offer a robust enough view of the risk within the identified system.

The question then becomes, which one is it, the sophistication of the learning system or the insignificance of the event? Generally, the failure resides in the learning systems capability to fully explore the richness of the single event.  Failing to combine that learning with other event investigations and developing an accurate view of the inherent and system risk existing within the operation.

The described failure within the learning system generally occurs because of two reasons. First, our single event investigation struggles to define the appropriate cause and effect relationships that existed within the event. Often we insert non-causal data or non-duties into the event causing such significant noise we are unable to articulate the actual risk. Secondly, due to this failure in our single event investigations, we become limited in our ability to do precise common cause failure analysis when looking across multiple events. Simply put it becomes a “garbage in/garbage out” learning system.

In addition to the stated failures above, our learning systems often fail to correctly identify causes related to a class of events. In other words, the causal factor is not relevant to what occurred yesterday but is relevant to what may happen tomorrow or six months from now. A great example of this was played out in the movie, “Flight,” starring Denzel Washington. In the movie, Washington plays an airline captain with a significant drug and alcohol problem.  In an aircraft emergency, Washington engages in extraordinary actions saving hundreds of lives on board even though he was intoxicated while flying the aircraft. The question becomes, was his intoxication causal in regards to the loss of the aircraft? No. It was a mechanical failure that caused the loss of the aircraft. However, does a pilot who is willing to fly under the influence of alcohol and drugs represent a risk to the system? Yes!

At the end of the day our learning systems must exhibit three layers of examination. First, we must be able to identify the relevant cause and effect relationships within a single event. Secondly, once the cause and effect relationships are identified within these single events, we conduct the proper systemic analysis to identify risk mitigation strategies. A general rule of thumb is 70% to 80% of our interventions should come from systemic analysis. Third, our learning system must also assess causal factors related to the class of event. Working to move from the reactive realm to proactive and eventually a predictive learning system.

Bringing Just Culture to the Streets


Making judgments without an understanding of the root cause(s) of the situation quenches both growth and learning culture. It is absolutely necessary for us to remain impartial in our judgments until we can adequately discern the root cause(s) of the event.

Recently, a pastor who played a major role in the Boston Miracle, Jeffrey Brown, presented a Ted talk testifying to the power of this.

In the late 1980s, violence on the streets of Boston was increasing at alarming rates, and by 1990 Boston’s homicide rate reached a peak of 152. But by 1999, that number dropped down to 31 thanks to the key leaders within the Boston community. The Boston Miracle, simply stated, was this unprecedented 79 percent drop in the city’s homicides over the span of 10 years from 1990–1999.

In his Ted Talk, Brown shared that after a multitude of tragic events, he realized that it was not enough for him to build programs for the at-risk youth. He began to search for the youth actively involved in violence. He soon found himself walking the streets of Boston during the hours of the night, and by 1992 he and other area pastors had formed the Ten Point Coalition to combat youth violence in the streets of Boston.

Over time, these pastors began developing relationships on the streets of Boston during the night hours. They discovered that the individuals, who many dismissed as cold and heartless, were the exact opposite of their labels, and were simply trying to “make it on the streets.”  By not rushing to judgment, the pastors were able to engage with the youth and partnered with them to change the culture on the streets.

But this journey took time. It was only when these youths viewed the Ten Point Coalition and the law-enforcement as legitimate, fair and just that the culture on the streets began to change. This meant the Ten Point Coalition and law enforcement had to consistently take the time to discern what justice meant for each person involved, determining who needed to be helped, who needed to be coached and who needed to be punished. In turn, the Boston area pastors were able to help the Boston police focus on the truly reckless and intentionally harmful behaviors.

This began the transformation of the street culture, and cultivated a cultural atmosphere ripe for justice. With cooperation at all levels, the Boston Miracle occurred, becoming a powerful testimony to the fruit of not rushing into judgment over a situation. Even now, others are inspired by the result of Boston’s street transformation in the 1990’s. In fact, a group of Baltimore pastors have decided to devote the summer of 2015 to walking the streets of Baltimore at night in hopes of the cultural transformation of the streets of Baltimore.

Creating a Just Culture

These recommendations are a great starting point to understand what may be expected.

However, the integration of a Just Culture is something that looks a little different for many organizations. It all depends on where you are now and where the strategy and framework need to be focused at the onset and implemented along the way. Figuring out this first part is easier than you think. Just start with what we call The Organizational Benchmark™ Survey. It's only a $99.00 investment to gain a world of information about what you think your leaders think about the organization, what they really think about it and how your employees perceive their role, the organizational values and more.

The Organizational Benchmark™ Survey