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