Mechanistic thinking about failures, that is, the Newtonian-Cartesian approach, means going down and in.  Understanding why things went wrong comes from breaking open the system, diving down, finding the parts, and identifying which ones were broken.  The approach is taken even if the parts are located in different areas of the system, such as procedural control, supervisory layers, managerial levels, regulatory oversight. 

In contrast, systems thinking about failures means going up and out.  Understanding comes from seeing how the system is configured in a larger network of other systems, of tracing the relationships with those, and how these spread out to affect, and be affected by, factors that lie far away in time and space from the moment things went wrong.

 

"Drift into Failure - From hunting broken components to understanding complex systems"  Sydney Dekker, Ashgate 2011.  Page 132