Contents
Prologue: The Scope of Resilience Engineering by Erik Hollnagel
PART I DEALING WITH THE ACTUAL
Chapter 1 Resilience and the Ability to Respond
Jean Pariès
Being Prepared to Be Unprepared
Chapter 2 Lessons from the Hudson
Jean Pariès
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
Lucie Cuvelier and Pierre Falzon
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
Chapter 4 Training Organisational Resilience in Escalating Situations
Johan Bergström, Nicklas Dahlström, Sidney Dekker and Kurt Petersen
Generic Competencies in Management of Unexpected and Escalating Situations
PART II DEALING WITH THE CRITICAL
Chapter 5 Monitoring – A Critical Ability in Resilience Engineering
John Wreathall
The Role of Indicators in Measurement
Selection and Basis for Indicators
Leading and Lagging Indicators
Chapter 6 From Flight Time Limitations to Fatigue Risk Management Systems – A Way Toward Resilience
P. Cabon, S. Deharvengt, I. Berechet, J.Y. Grau, N. Maille and R. Mollard
The Development of Fatigue Risk Management System
Elizabeth Lay
Highly Resilient Organizations
Stathis Malakis and Tom Kontogiannis
T2EAM Model and Cognitive Task Analysis
PART III DEALING WITH THE POTENTIAL
Chapter 9 Resilience and the Ability to Anticipate
David D. Woods
Chapter 10 Basic Patterns in How Adaptive Systems Fail
David D. Woods and Matthieu Branlat
The Optimist-Pessimist Divide on Complex Adaptive Systems
Assessing Future Resilience from Studying the History of Adaptation (and 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Urban Fire-fighting and the Risk of Getting Stuck in Outdated Behaviours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
P. Ferreira, J.R. Wilson, B. Ryan and S. Sharples
Interpretation of the Extracted Components
Extracted Factors and the Potential for Resilience
Chapter 12 The Art of Balance: Using Upward Resilience Traits to Deal with Conflicting Goals
Berit Tjørhom and Karina Aase
Downward and Upward Resilience
Traces of Balancing Within the Norwegian Aviation Transport System
Chapter 13 The Importance of Functional Interdependencies in Financial Services Systems
Gunilla A Sundström and Erik Hollnagel
The Financial Services System 2007–2009
What is the Financial Services System?
What Creates the Dynamic Interactions?
Identifying the Core Functions
Identifying Potential for Functional Resonance
Identifying How Performance Variance can be Monitored and Controlled
Example: The Demise of Northern Rock
PART IV DEALING WITH THE FACTUAL
Chapter 14 To Learn or Not to Learn, that is the Question
Erik Hollnagel
John Stoop
Case 1: Before, During and After the Event; the Boeing 747 Case Study
The Reason for Building such Aircraft
Case 2: ERTMS. An Inquiry into the Safety Architecture of High Speed Train Safety
Towards a New Train Control Concept
What Do We Need to Design Resilient Systems?
What has Created Opportunities for Resilience in these two Cases?
Anne Sophie Nyssen
Coordination as a Component of Resilience in Socio-Technical Systems like Hospitals
The Organisation’s Approach to Coordination
Longitudinal Coordination Tools
Case Analysis: An Emergence-through-use Approach of Coordination
Conclusions – ‘Enhancing Projection outside the Local Immediate’
Chapter 17 Requisites for Successful Incident Reporting in Resilient Organisations
Alberto Pasquini, Simone Pozzi, Luca Save and Mark-Alexander Sujan
A Success and a Failure Story: Reporting Systems in Aviation and Healthcare
Handle with Care: All Reporting System are Different
Understand the Characteristics of your Community
What Happens When Key Structural Properties are Missing?
Kyla Zimmermann, Jean Pariès, René Amalberti and Daniel H. Hummerdal
Paradigms in Safety and Human Factors
The Safety Assumptions and Resilient Attitudes (SARA) Survey
The Business of (not) Measuring Resilience
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
Discussion: Integrating and Interpreting Ambiguity and Contradictions
The Limitations of Attitude Measurement
Two Explanations, One Conclusion
Is Resilience Ready for the Aviation Industry?
Epilogue: RAG – The Resilience Analysis Grid by Erik Hollnagel