- 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
- 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
- PART II DEALING WITH THE CRITICAL
- Chapter 5 Monitoring – A Critical Ability in Resilience Engineering
- Chapter 6 From Flight Time Limitations to Fatigue Risk Management Systems – A Way Toward Resilience
- Chapter 7 Practices for Noticing and Dealing with the Critical. A Case Study from Maintenance of Power Plants
- Chapter 8 Cognitive Strategies in Emergency and Abnormal Situations Training – Implications for Resilience in Air Traffic Control
- PART III DEALING WITH THE POTENTIAL
- Chapter 9 Resilience and the Ability to Anticipate
- 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- Urban Fire-fighting and the Risk of Getting Stuck in Outdated Behaviours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
- Chapter 12 The Art of Balance: Using Upward Resilience Traits to Deal with Conflicting Goals
- 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
- Chapter 14 To Learn or Not to Learn, that is the Question
- Epilogue: RAG – The Resilience Analysis Grid by Erik Hollnagel
- Bibliography
- Author Index
- Subject Index
Resilience Engineering in Practice
A Guidebook
EDITED BY
ERIK HOLLNAGEL
MINES ParisTech, France
JEAN PARIÈS
Dédale SA, France
DAVID WOODS
Ohio State University, USA
JOHN WREATHALL
John Wreathall & Co., USA
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