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Resilience Engineering in Practice

Author Jean Pariès , John Wreathall , Erik Hollnagel
Release Date: 2017/05/01
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Book Description


Resilience engineering has since 2004 attracted widespread interest from industry as well as academia. Practitioners from various fields, such as aviation and air traffic management, patient safety, off-shore exploration and production, have quickly realised the potential of resilience engineering and have became early adopters. The continued development of resilience engineering has focused on four abilities that are essential for resilience. These are the ability a) to respond to what happens, b) to monitor critical developments, c) to anticipate future threats and opportunities, and d) to learn from past experience - successes as well as failures. Working with the four abilities provides a structured way of analysing problems and issues, as well as of proposing practical solutions (concepts, tools, and methods). This book is divided into four main sections which describe issues relating to each of the four abilities. The chapters in each section emphasise practical ways of engineering resilience and feature case studies and real applications. The text is written to be easily accessible for readers who are more interested in solutions than in research, but will also be of interest to the latter group.

Table of Contents

  1. Cover
  2. Half Title
  3. Title Page
  4. Copyright Page
  5. Table of Contents
  6. List of Figures
  7. List of Tables
  8. List of Contributors
  9. PART I DEALING WITH THE ACTUAL
    1. Chapter 1 Resilience and the Ability to Respond
      1. Resilience in ‘Real Time’
      2. Readiness and Anticipation
      3. Being Prepared to Be Unprepared
      4. Adapted or Adaptive?
    2. Chapter 2 Lessons from the Hudson
      1. Miracle on the Hudson River?
      2. The Bird Hazard
      3. Bird Strike Protection Strategy
      4. From Anticipated Emergency to Real Time Response
      5. From ‘Satisficing’ to ‘Sacrificing’ Decisions
      6. From Safety Strategies to Resilience Engineering at the System Level
      7. When Systemic Resilience Efforts Undermine Resilience at the Sharp End
      8. In Conclusion: Two Lessons and a Wish
    3. Chapter 3 Coping with Uncertainty. Resilient Decisions in Anaesthesia
      1. States of Resilience and Uncertain Events
      2. Describing How Anaesthesiologists Manage Uncertainty
      3. Unforeseen Situations: Potential Variability and Unthought-of Variability
      4. Resilience as the Ability to Define an Envelope of Potential Variability
      5. Resilience as the Ability to Diagnose that the System Leaves the Envelope of Potential Variability
      6. Enhancing Resilience: Paths for Progress
      7. Acknowledgements
    4. Chapter 4 Training Organisational Resilience in Escalating Situations
      1. Introduction
      2. Generic Competencies in Management of Unexpected and Escalating Situations
      3. Scenario Design
      4. Training Generic Competencies
      5. Discussion
  10. PART II DEALING WITH THE CRITICAL
    1. Chapter 5 Monitoring – A Critical Ability in Resilience Engineering
      1. The Role of Indicators in Measurement
      2. Selection and Basis for Indicators
      3. Nature of Indicators
      4. Leading and Lagging Indicators
    2. Chapter 6 From Flight Time Limitations to Fatigue Risk Management Systems – A Way Toward Resilience
      1. Introduction
      2. Fatigue and Safety
      3. The Development of Fatigue Risk Management System
      4. Safety Policy and Objectives
      5. Fatigue Risk Management
      6. Safety Assurance
      7. Monitoring Process
      8. Safety Promotion
      9. Conclusion
      10. Acknowledgements
      11. Disclaimer
    3. Chapter 7 Practices for Noticing and Dealing with the Critical. A Case Study from Maintenance of Power Plants
      1. Introduction
      2. Business Background
      3. Loss Control Philosophy
      4. Highly Resilient Organizations
      5. Anticipate
      6. Notice
      7. Planning
      8. Adapting
      9. Conclusion
    4. Chapter 8 Cognitive Strategies in Emergency and Abnormal Situations Training – Implications for Resilience in Air Traffic Control
      1. Introduction
      2. Method
      3. T2EAM Model
      4. Results
      5. T2EAM Model and Cognitive Task Analysis
      6. Conclusion
  11. PART III DEALING WITH THE POTENTIAL
    1. Chapter 9 Resilience and the Ability to Anticipate
      1. Patterns of Anticipation
    2. Chapter 10 Basic Patterns in How Adaptive Systems Fail
      1. The Optimist-Pessimist Divide on Complex Adaptive Systems
      2. Assessing Future Resilience from Studying the History of Adaptation (and Maladaptation)
      3. Patterns of Maladaptation
      4. Illustration of the Basic Patterns
      5. Urban Fire-fighting and the Dynamics of Decompensation
      6. Urban Fire-fighting and Coordination over Multiple Groups and Goals
      7. Urban Fire-fighting and the Risk of Getting Stuck in Outdated Behaviours
      8. Recognising what is Maladaptive Depends on Perspective Contrasts
    3. Chapter 11 Measuring Resilience in the Planning of Rail Engineering Work
      1. Introduction
      2. Measuring Resilience Factors
      3. Questionnaire Design
      4. Questionnaire Implementation
      5. Principal Components Analysis
      6. Interpretation of the Extracted Components
      7. Extracted Factors and the Potential for Resilience
      8. Acknowledgements
    4. Chapter 12 The Art of Balance: Using Upward Resilience Traits to Deal with Conflicting Goals
      1. Introduction
      2. The Art of Balance
      3. Downward and Upward Resilience
      4. Traces of Balancing Within the Norwegian Aviation Transport System
      5. Conclusion
    5. Chapter 13 The Importance of Functional Interdependencies in Financial Services Systems
      1. Introduction
      2. The Financial Services System 2007–2009
      3. What is the Financial Services System?
      4. What Creates the Dynamic Interactions?
      5. The Modelling Steps
      6. Identifying the Core Functions
      7. Identifying Potential for Functional Resonance
      8. Identifying How Performance Variance can be Monitored and Controlled
      9. Example: The Demise of Northern Rock
      10. Concluding Remarks
  12. PART IV DEALING WITH THE FACTUAL
    1. Chapter 14 To Learn or Not to Learn, that is the Question
      1. The Conditions for Learning
      2. The Impact of Learning
      3. What Should Be Learned?
      4. Chapter 15 No Facts, No Glory
      5. Introduction
      6. Case 1: Before, During and After the Event; the Boeing 747 Case Study
      7. The Reason for Building such Aircraft
      8. The Bijlmermeer Crash
      9. Case 2: ERTMS. An Inquiry into the Safety Architecture of High Speed Train Safety
      10. Emergent Properties
      11. Transparency
      12. Towards a New Train Control Concept
      13. Lessons Learned
      14. Discussion
      15. What Do We Need to Design Resilient Systems?
      16. What has Created Opportunities for Resilience in these two Cases?
    2. Chapter 16 From Myopic Coordination to Resilience in Socio-technical Systems. A Case Study in a Hospital
      1. Introduction
      2. Coordination as a Component of Resilience in Socio-Technical Systems like Hospitals
      3. The Organisation’s Approach to Coordination
      4. Vertical Coordination Tools
      5. Lateral Coordination Tools
      6. Longitudinal Coordination Tools
      7. A Catastrophic Experience
      8. Case Analysis: An Emergence-through-use Approach of Coordination
      9. Discussion
      10. Conclusions – ‘Enhancing Projection outside the Local Immediate’
    3. Chapter 17 Requisites for Successful Incident Reporting in Resilient Organisations
      1. Introduction
      2. A Success and a Failure Story: Reporting Systems in Aviation and Healthcare
      3. Handle with Care: All Reporting System are Different
      4. The Pass Criterion
      5. Degree of Standardisation
      6. Visibility
      7. Understand the Characteristics of your Community
      8. Assess Safety Culture
      9. What Happens When Key Structural Properties are Missing?
      10. Proactive Risk Monitoring
      11. Conclusion
    4. Chapter 18 Is the Aviation Industry Ready for Resilience? Mapping Human Factors Assumptions across the Aviation Sector
      1. Paradigms in Safety and Human Factors
      2. Diversity in Aviation
      3. The Safety Assumptions and Resilient Attitudes (SARA) Survey
      4. The Business of (not) Measuring Resilience
      5. Developing the SARA Survey
      6. The Survey Respondents and Interview Participants
      7. Analysis of the SARA Survey Results
      8. Differences between National and Occupational Cultures
      9. Discussion of Differences between National/Societal Cultures
      10. Discussion of the Differences between Occupational Cultures
      11. Cultural Bias in Culture Research
      12. Ambiguity and Contradictions
      13. Discussion: Integrating and Interpreting Ambiguity and Contradictions
      14. The Limitations of Attitude Measurement
      15. Two Explanations, One Conclusion
      16. Is Resilience Ready for the Aviation Industry?
      17. Acknowledgements
  13. Epilogue: RAG – The Resilience Analysis Grid by Erik Hollnagel
  14. Bibliography
  15. Author Index
  16. Subject Index