Subject Index

Accident investigation, 81, 96, 192, 226, 317, 330

Adaptability, 13, 21, 123

Adaptive capacity, 21-23, 69, 72-75

Adjustment, 13, 16, 88, 156, 158, 163, 294, 297, 305

Agent, 48, 49, 51, 52, 241

Aircraft maintenance, 87, 88, 160-164, 167-169, 173, 175, 177, 186, 192

Assertiveness, 228-230, 232, 233

Auditing, 90, 158, 169, 170, 289, 290, 293, 295, 301, 304, 306, 312, 313

Automation, 4, 23, 159, 262

Barings plc, 235, 243, 245-250, 252, 342

Barriers, 3, 11, 14, 81, 130, 135, 139, 180, 192, 248, 280, 281, 291-296, 299-304, 312, 329, 330, 331, 348

Boundary conditions, 22, 24, 46, 69, 71, 72, 75, 315

Brittleness, 6, 23, 69, 71, 75, 79, 87, 90, 92, 317, 321, 329

Broadening check, 24, 90

Buffer, 24, 33, 71, 73

capacity, 23, 315

Business system, 235-244, 247, 249, 251, 339

Challenger, 97, 106, 107, 142, 226, 227, 277, 300, 308, 310, 318

Chemical industry, 145, 258, 261, 304

Cognition

distributed, 50, 220

Columbia accident, 27, 28, 60, 61, 97, 103, 104, 106, 107, 123, 142, 174, 224, 226, 300, 308, 310, 315-318, 322, 324

Common pool resources, 322, 323, 324

Competence envelope, 22, 24, 75

Complexity, 3, 5, 6, 13, 30, 43, 44, 47, 49, 52, 53, 84, 96, 103, 108, 110, 116, 174, 201, 277, 299, 330, 348

Compliance, 23, 160, 161, 175, 177, 190, 192, 200, 257, 258, 259

Concurrence, 12, 15, 17

Conflict resolution, 297, 298, 310, 312

Control

business system, 243, 244, 245, 248, 252

centralised or distributed, 134

loop, 74, 89, 102, 103, 246, 301, 302

loss of, 36, 130, 292, 300, 341, 342, 348

supervisory, 72, 73, 74

Crew Resource Management

(CRM), 233, 261

Cycles of stability, 51, 87, 172, 174

Decision making, 228

Decompensation, 72, 73, 75

Diagnosis, 25, 30, 164, 227, 229, 303, 305

Disruptions, 3, 21, 23, 69, 71, 73, 74, 226, 329, 347

Distancing through

differencing, 331, 336, 338

Disturbances, 3, 16, 23, 72-75, 97, 156, 179, 236, 249, 342, 356

Drift, 36, 41, 77, 78, 82-85, 89, 95, 96, 122, 228, 316, 318, 354, 355

into failure, 77, 82-84, 89

to danger, 36, 354

Dynamic instability, 15

Dynamic stability, 15, 16, 17

Emergence, 7, 43, 44, 46, 47, 50, 53, 77, 252, 256, 263

emergent phenomenon, 13, 84, 85

Emergency, 57, 139, 140, 206, 207, 209, 211-216, 220, 232, 281, 291, 296, 297, 305, 306, 343, 344

Equilibrium, 13, 96

Erosion of safety margins, 16, 138

European Transport Safety Council, 127

Event tree, 14, 15, 302

Faster, better, cheaper, 24, 25, 26, 27, 28, 30, 228, 315, 317

Fault tree, 14, 15

Flexibility, 13, 23, 24, 35, 61, 133, 134, 144, 159, 160, 163, 164, 167, 179, 279, 280, 284, 299, 302

Foresight, 6, 59, 65, 324, 349

Fragmentation, 29, 30, 141, 144

GAIN, 193, 194, 197

Goal

acute, 27-30, 32, 33, 318

business, 230, 238, 240

chronic, 26-29, 33, 34, 315

conflict, 23, 24, 29, 228, 324

Healthcare, 26, 206

Heuristics, 13, 53

Hindsight, 1, 2, 28, 32, 83, 89, 188, 192, 316, 331, 344

ICAO, 185, 186, 190, 191, 194

Independence, 121, 180, 278, 287, 319, 320, 321

Institute of Medicine, 26, 58

Leadership, 48, 61, 86, 88-90, 176, 227, 231-233, 319, 320

Learning, 24, 59, 61, 89, 111, 116, 118, 145, 159, 190, 193, 199, 200, 225, 235, 242, 247, 279, 280, 297, 298, 300-302, 306-308, 312, 329-331, 333, 338, 350, 357

organisational, 242, 331

Line Operations Safety Audit (LOSA), 161, 178

Macroscopic behaviour, 47, 49

Management

control, 239, 246

information, 196, 277, 278

quality, 80, 193, 200

Model

accident, 9-12, 14, 77, 80, 81, 84, 96, 301

complex linear, 11, 12, 14

Domino, 10, 11, 353

epidemiological, 14

functional resonance accident model, 15, 17

simple linear, 10, 14

Swiss cheese, 11, 12, 353, 354

system dynamics, 103, 106, 108, 120, 122

systemic accident, 12, 17

NASA, 24-27, 33, 57, 61, 76, 96, 106, 107, 112, 113, 116-118, 123, 223, 226, 285, 315, 318, 324

NASA/ESA Investigation Board, 107

National Commission on Terrorist Attacks, 63

NRC, 278

NTSB, 190, 330

Organisational change, 121, 159, 174, 176, 177, 297, 308-310, 314

Performance indicators, 126, 283, 307, 314

Perturbations, 9, 21, 22, 24, 33, 51, 74, 75, 265

Piper Alpha, 226, 229, 300

Planning, 160, 162, 241

Proactive impact analysis, 246, 249

Probabilistic safety assessment (PSA), 275, 277, 278, 281, 282, 356

Professionalism, 155, 162, 164-166, 227

Prorail, 139, 140

Railways, 38, 125, 126, 129, 130, 132, 134, 136, 137, 139-141, 143-147, 175, 310

Reframing, 5, 24, 316, 318, 324

Requisite imagination, 2, 59, 89, 90, 349

Resilience

definitions, 6, 14, 16, 36, 95, 281

nominally emergent (NER), 48

organisational, 43, 48, 53, 88, 92, 126, 180, 223, 225, 233, 235, 357

strongly emergent (SER), 52

weakly emergent (WER), 49

Risk

assessment, 9, 14, 15, 39, 96, 99, 100, 118, 127, 137, 140, 142, 146, 189, 202, 232, 289-291, 298, 300, 308

exposure to, 39, 147

management, 53, 95, 96, 98, 106, 122, 175, 176, 249, 250, 261, 263

model recalibration, 79, 92

proactive management, 173, 251, 279

Sacrifice, 3, 32, 33, 84

decisions, 1, 78, 83, 355

Safety

boundaries, 22, 32, 78, 85, 316, 317

climate, 230, 231, 311

culture, 2, 30, 40, 53, 81, 96, 98, 106, 107, 113, 118, 141, 144, 188, 229, 230, 233, 254, 261, 280, 283, 297, 311, 313

management, 3, 6, 53, 75, 125, 128-130, 137, 142, 145, 155, 159, 169, 184–186, 193, 197, 200, 231, 275, 276, 290, 296, 299, 313, 316–319, 321, 322, 357

margins, 77, 84, 85, 157, 181, 315, 317, 322

organisation, 78, 91, 112, 123, 317, 318, 319, 320, 321, 323, 324

rules, 125, 127, 129, 130, 143, 144

Scripts, 230, 232

Self-fulfilling prophecy, 53

Senior managers, 144, 226, 227, 231

STAMP, 96-98, 101, 103, 105, 106, 122, 123

Standardisation, 80, 158, 159, 167, 260, 261, 262, 271

State

catastrophic, 240, 248, 252, 339, 341

space, 339, 342

transition, 247, 342, 343, 344

transition rules, 343

variable, 103, 238, 239, 250, 252

Stiffness, 23, 284

Strategy

feedforward, 246, 250

System

as-designed, 89

as-imagined, 89, 90

open, 157, 237, 242, 248, 252

safety, 9, 10, 14-16, 81, 98, 104, 112-117

socio-technical, 13, 82, 96, 97, 99, 100, 110, 156, 170, 178, 180, 206, 265, 352

theory, 53, 96, 98, 236, 238

Systemic view, 13, 15

Taxonomy, 4, 48, 53, 347

Tolerance, 23, 24, 228, 270

Trade-off, 3, 5, 13, 25, 27-30, 32-34, 51, 78, 84, 88, 134, 137, 140, 147, 199, 201, 218, 219, 226–228, 232, 318, 319, 322, 355

efficiency-thoroughness, 355

Tragedy of the commons, 322

Triggering condition, 345

Upward appraisal, 230, 231

VACS, 130

Variability

endogenous, 12

exogenous, 12, 248

Variety, 49, 56, 65, 161, 168, 175, 176, 178, 181, 210, 253, 265, 323

Vasa, 223, 224, 225, 227

Vectors of change, 26, 72, 320

Work

as done, 79, 92

as imagined, 79, 92, 320, 321, 357

Workarounds, 23, 71, 357