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Systems Based Learning Modules
Major accidents are rarely the result of one failed component, safeguard or decision. They emerge when weaknesses across the system develop in parallel, interact and remain unrecognised.
Each facilitated module uses a major accident to develop the ability to diagnose systemic vulnerability, connect technical, human and organisational conditions, and identify where intervention remains possible.
The focus is not on repeating what happened, but on translating the learning into questions participants can apply within their own industry.
Developed by Dr Zsuzsanna Gyenes, drawing on experience across major accident regulation, incident learning, process safety, nuclear safety and construction safety.
Explore the series
Each module uses a major accident to build capability in systems thinking
No 1
── Process Safety
BP Texas City
Diagnosing vulnerability before the event
What did the combined warning signs reveal about the condition of the system?
No 2
── NUCLEAR SAFETY
Chernobyl
Recognising when a system is losing control
When did changing conditions require the activity to stop and be reassessed?
No 3
── CONSTRUCTION SAFETY
Lacrosse Tower
Assuring the safety of the completed building
Who assured the safety of the completed building when responsibility was divided?
This series will continue to grow. Each module provides a different lens on how systems behave and what we can learn to prevent the next major accident.