Subject Index

abilities

intrinsic 35, 140

organisation’s 130, 185, 188

abstract functions 6–8

associated 4, 6

accident frequency rate 71, 74

accident investigation 52, 94, 180

accountability 47, 49, 51, 53–5, 57, 59–61

act 41, 105–6, 108–10, 143, 154

actor

individual 130, 136

single 114, 120, 122

actors, local 115–16, 118, 120

adaptation reverberations 92, 94

adaptations, sharp-end 80, 85, 89–91, 95

adaptive capacity 33, 42, 89, 91–2, 127, 131, 140–1, 154, 159, 163

adverse events 6, 47, 59–61, 68, 72, 92, 140

agenda 136–7, 141, 182, 195

theoretical 128, 136–7

agents 19, 31, 69

air traffic management (ATM) 99, 199

American National Standards Institute (ANSI) 185, 208

anticipation 3–5, 8, 36, 46, 99, 189, 196

application 2, 12, 38, 77, 127, 131, 166, 199

approach

risk-based 116–18

traditional 97, 99, 108, 111

attention, limited 120–1

attitudes 10, 51–2, 101, 106–7, 129, 182, 184, 190

Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) 186, 208

authority

local 59, 116, 118

national 115–16, 120

aviation 14–15, 64, 179, 193, 204

behaviour 10, 26, 41, 83, 100, 103–4, 129, 136, 142

correct 131–2

behavioural markers 129, 134

boundaries 15, 21, 29, 46, 80, 114, 118, 147–8

brittleness 79, 81, 92–4, 139–41, 143–5, 147–9, 151–5, 198

bus driver 103–4, 107

business dimensions 66–7, 69, 76

capacity 7, 10–11, 45, 88, 132, 141, 147, 150, 152, 171, 174

assessments 8, 10

buffering 3, 147, 153, 159, 173

cognition 25, 130, 196, 199–201, 204–5

distributed 128, 134, 136

communication 10, 19, 31, 52, 59, 145, 152, 175, 206

complex

disasters 51–3

organisations 4, 45

systems 3, 40, 64–6, 77, 90, 134–6, 160, 196, 203–4

complexity 2, 5, 17, 79, 92, 128, 130–1, 140–2, 158, 193, 195, 197, 203–5

theory 130, 135–6

compliance, index of 72–5

constructions 11, 45, 64, 67, 116, 118, 135, 161, 175, 179

context 2, 4, 9, 19, 21, 27, 29, 59–60, 75, 79, 81–4, 91, 102, 104, 114, 124, 130, 132, 134, 139, 144, 146, 152, 176, 191

multi-actor 113, 123

societal 1, 4–7

control 15, 105, 108, 134, 141, 145–6, 157, 196, 198, 200–1, 203–4

level of 134, 136

coordination 10, 19, 23, 133, 142, 204

heightened state of 151–2

cost 67, 69, 76, 78–80, 102, 117, 158, 182, 191

crisis

management 50, 52, 81, 193, 195, 203

situation 176, 207

crisis management

system 51–2

team 85, 151

critical incidents 33–4, 42

cues 84, 189

data collection 63, 65, 68, 75, 176, 206

debris 157, 161, 166, 168, 172

removal 157, 161–2, 169, 172–3

removal equipment 163, 168–9, 172

removal operations 161–2

removal work 165–6

decision-making process 24–5, 113–21, 157, 173

defence-in-depth 59–60, 92–3

design 9, 30, 65, 69–70, 75, 92, 116, 118, 121, 132, 146–8, 153–4, 173–5, 208

of resilient systems 123, 139

disaster risk management 8–11

effectiveness 40, 65, 69, 73, 78, 80, 159, 166, 185, 187

efficiency 64–6, 69, 73, 80, 90, 102

emergent property 4, 7, 130, 132–4

engineering

perspective 111, 116, 123, 175–6, 199

work 22–4

engineers 164–5, 175

environment 13, 26, 60, 64, 84, 117, 129, 136, 141, 157–8, 188

dynamic 25, 82, 92

working 83, 180

errors 45, 199

evaluation 6, 8, 10, 66, 68, 72–3, 75, 77, 84, 176, 199

events

disastrous 5–6

informal 69–70

triggering 37, 39

unforeseen 94–5, 186

evidence 68, 77, 117, 135, 197

expert 24–5, 27, 144, 151

expertise 19, 23–4, 26–7, 31, 86, 116, 173

individual 23–5, 27, 31

factors, organisational 180–1

failure points 146, 148–9

faults 37, 39, 45

feedback 11, 30, 69, 75–6, 82–3, 134, 173

framework

analysis 85, 90–1

categories 81–2, 84

Fukushima Daiichi nuclear accident 49, 198

Fukushima Nuclear Accident

Independent Investigation

Commission 49, 198

Functional Resonance Analysis Method

(FRAM) 104–5, 199, 202

functions

constituent 186, 190–1

proactive 4–5

reactive 4–6

fundamental surprise 33–6, 39–43, 45–6, 197

ground, common 133, 135–6, 204

Ground Zero 157, 160, 172

groups 4, 25, 44, 49, 146–8, 151, 182, 201, 205, 207

hardware failure 37, 39, 43

hazards 34, 39, 45, 65, 74, 77–8, 158–9, 194

process safety 69, 75

healthcare 44, 81, 179, 197, 201

High Reliability Organizations (HROs) 140, 154, 185

hospitals 37–8, 44, 131, 204

maternity 88–9

human activities 179–80

imagination 46, 57, 99, 109, 189

impact assessment 5–6, 8, 10

indicators 6, 66, 68–78, 150, 189

input 6, 9, 25, 82, 85, 146

interactions

blunt-end 83, 89, 91, 93

cross-scale 122–3

interdependencies 6, 9, 11, 142, 154, 176

interference, external 15–18, 21–2, 27, 31–2

International Air Transport Association (IATA) 129, 203

International Nuclear Safety Advisory Group (INSAG) 208

investigation reports 47, 50, 57, 59

joint cognitive system 136, 193, 200, 203–4

laws 53, 116

levels

generative 181–2

local 9, 122

managerial 20, 85, 89, 91

national 21, 123

organisational 127

various 113, 122–3

loads 147, 149, 162, 166, 168, 171, 173–4

management, prior 108, 111

managers 14, 18–19, 24, 69, 77, 81, 141, 151

top 14, 30, 70–1

measures

additional 58–60, 118

preventive 18, 50–1

mechanisms 45, 69, 76, 140, 153

methodologies 18, 26, 61, 127, 159

metrics 65, 67–9, 73

monitor hazards 65–6, 69–70, 74, 77

National Aeronautic and Space

Administration (NASA) 125, 203

negotiations 119–20, 122–3

networks 14–15, 29, 205

normal work 64–8, 72, 132, 159

analysing 68, 73

nuclear power plant 15, 101, 109, 180, 200

nuclear power station 48–50, 55, 58–9, 198

nuclear safety 52, 59–61

objectives 77, 82–3, 89, 91

on-site risks 170, 173

operating capacity 162–3

operators 14, 27–8, 31, 129

organisation

dysfunctional 187, 190

resilient 185–7, 189, 191

organisational

cultures 182, 184, 208

memory 40, 42

units 38, 114, 117

outcomes 79, 83, 94, 117–18, 122, 139, 141, 143, 182

paradigm, information-processing 128, 134

patients 37–9, 43, 88–9, 91, 98, 108

performance

measurement systems 64, 66–7, 77–8

organisational 36, 166, 173, 185

personnel 56, 77, 158, 160

pipelines 15, 17–18, 21–3, 25

planning 38, 73, 143, 145–6, 148, 163, 171–4, 190

practitioners 29–30, 79, 93–4

precedents 119–20, 122–3

precepts 124–5, 177, 193–6, 198, 202–3, 205, 208

preconditions 104–5, 109

prediction 94, 142–3

preparation 58, 108, 124–5, 194, 199–200, 202–3, 208

preparedness 5–6, 8, 10, 58–60, 142–3

prescriptions 12–13, 29, 31–2

pressures 17, 56, 82, 163

prevention 6, 10, 15–16, 18, 31, 56, 208

principles, defense-in-depth 58–9

Probabilistic Safety Assessment (PSA) 50, 176, 199

processes

cognitive 26, 128, 176

informal 120, 122

production 68, 76, 78, 82, 188

quality 31, 46, 66, 69, 102, 188, 191, 193, 197, 201

railway tunnels 114, 116–20

railways 98, 124, 194, 202

rebuilding 51–2

recovery 6, 8, 41, 159–61, 166

regulations 21, 66, 68, 71–2, 78, 109, 116, 127, 134

reorganisation 88–9

resilience

abilities 83, 187

analysis grid 186, 191, 208

approach 97, 99, 108, 110–11, 130, 132

behaviour 100–1, 107

capabilities 100–1, 109, 187

characteristics 18, 80, 125, 203

civil 106–7

engineering 18, 140, 195

measures 160

organisational 4, 39, 46, 124, 136, 160, 172, 174, 202–3, 206

perspective 94, 134–5

position of 106–7

system’s 35, 113–14, 123

Resilience Engineering

approaches 1, 12

methodology of 48, 60

principles of 61, 137, 146

resilient

behaviour 100, 102, 104–5, 107–9, 129

control 141, 147

organizations 5, 150, 193

systems 3, 6, 55, 63, 123, 139–41, 148

resources

critical 145, 148, 151

organizational 173–4

responsibilities 10, 75, 86–7, 101, 107

reverberations 86, 94

review 40, 47, 61, 110, 182, 197, 208

risk

assessments 5, 8, 10, 21, 115–17, 119–20, 122, 142–3, 180

communication 51–2, 54

level 116, 150

risk management 1, 8–11, 122, 139–40

safety

activities 16, 71–4, 76

efforts 179–80

industrial 179–80

measures 22, 51–2, 57–8, 102, 116, 118–20

paradigm 66–7

resilient 101, 110

societal 1–3, 12

safety-critical computing 44, 197

safety culture 51–2, 98, 180–6, 190–1, 208

development 183, 186

levels of 181–2, 184, 187, 189

Safety II 48, 59–60, 100, 185, 193, 202, 208

safety management

system (SMS) 17, 67, 74, 110, 175

systems 17, 67, 74, 110, 175

safety research 13, 196

safety specialists 70–2, 75–6

safety staff 68, 71, 73–4, 76–7

scales 62, 160, 168, 172–3

situation assessment 83–4, 173

situational awareness 100, 134

situational surprise 33–7, 39, 41–3, 45–6

situations

decision-making 117, 122

escalating 131–3, 203

new 86, 88

pre-defined 127–8

unexpected 24, 127, 130–1, 134, 188

skills 10, 23, 100, 131, 133, 139, 144–5, 147, 153

societal resilience 1–2, 4, 7–9, 11–12

analysing 1, 12

socio-technical systems 3, 62, 65–6, 69–70, 74, 77, 97–9, 102, 111, 113, 122–3, 204

large-scale 61–2, 122–3

various 97–8

space 2, 14, 31, 65, 149

staff 37, 68–70, 73, 88, 98

stakeholders 2, 9–11, 117, 119

state 57, 59–60, 143, 176, 183, 186

strategies, sharp-end 91–2

stresses 2, 113, 149, 174

surprise 33–6, 41, 46, 187, 197

sustainability 1–4, 12, 194

system resilience 79, 89, 94, 125, 203

team

command 86–7, 91, 93

individual 113–14, 122–3

performance assessment 132, 134

team performance 127–9, 131–3, 135–7, 204

team training 127–8, 130, 132–3, 136

threats 5, 15, 17, 31, 34, 38, 40, 42–3, 97–100, 108–9, 141

human 98–9

natural 51, 98–9

Three Mile Island (TMI) 50, 180, 198

Tokyo Electric Power Company

(TEPCO) 48–9, 51–2, 54–9

trade-offs 23–4, 80, 84, 208

training

focus of 131, 134

index of 71, 73–5

training programs 109, 131

tunnel 114–17, 120–1

tunnel types 120–1

uncertainty 26, 60, 64, 132, 142–5, 148–9, 154, 158, 200, 205

utilities 10–11, 39, 58–9, 75

variability 13, 20–1, 27–8, 30–2, 68, 73, 128, 130–2, 137, 139–41, 143, 145, 154, 170, 200

ambiguous 20–1

vulnerabilities 33, 44, 80, 82, 84–6, 90–1, 93–4, 195, 200

warnings 55, 76, 140

water pipe systems 118–19

work

actual 131, 180

emergent 148, 153

environment 90, 93, 139

stoppages 166, 172, 174

work-as-done 32, 94–5

workers 70–1, 74, 102, 150, 152

workload 23, 91

workshop 139, 146–7, 154, 182

World Trade Center 176, 207