Appendix

Symposium Participants

René Amalberti is doctor in Medicine (Marseille, 77), Professor of Physiology and Ergonomics (Paris, 95), and a PhD in Cognitive Psychology (Paris 92). He joined the French Air Force in 1977, graduated in aerospace medicine, and is presently head of the cognitive science department at IMASSA (Airforce Aerospace Medical Research Institute).

From 1980 to 1992, he was involved in four major research programs as: (i) developer of the French Electronic co-pilot for fighter aircraft, (ii) developer of an Intelligent-Training support system at Airbus, (iii) team member of the EC Research project Model of Human Activity at Work (MOHAWC), and (iv) co-developer of the first Air-France Crew Resource Management course.

In late 1992 he was detached half-time from the military to the French ministry of transportation, to lead the human factors for Civil Aviation in France, and in 1993 became the first chairman of JAA human factors steering committee, a position he held until late 1999. He has continued as a resource person for civil aviation authorities (HF certification A380, A400M), and manages safety research in various areas such as patient safety (co-writer of the accreditation reference document at the High Agency for Healthcare), road safety (chairman national research program), and the chemical industry (vice chairman of the new National Foundation for Industrial Risk).

René Amalberti has published and co-edited over 100 papers, chapters, and books, most of them on the safety and the emerging theory of Ecological safety.

Lars Axelsson is a Human Factors Specialist at the Swedish Nuclear Power Inspectorate (SKI) in Stockholm, Sweden. He is a specialist in organization and management issues and also works as a consultant for the aviation industry, mostly with pilot assessment and selection, and flight crew training.

Richard I. Cook (MD) is Associate Professor in the Department of Anesthesia and Critical Care at the University of Chicago. His current research interests include the study of human error, the role of technology in human expert performance, and patient safety. Dr. Cook is a founding member of the National Patient Safety Foundation and sits on the Foundation’s Board. He is internationally recognized as a leading expert on medical accidents, complex system failures, and human performance at the sharp end of these systems. He has investigated a variety of problems in such diverse areas as urban mass transportation, semiconductor manufacturing, and military software systems. He is often a consultant for not-for-profit organizations, government agencies, and academic groups. Dr. Cook’s most often cited publications are ‘Gaps in the Continuity of Patient Care and Progress in Patient Safety,’ ‘Operating at the Sharp End: The Complexity of Human Error,’ ‘Adapting to New Technology in the Operating Room,’ and the report ‘A Tale of Two Stories: Contrasting Views of Patient Safety.’

Vinh N. Dang has a PhD in Nuclear Engineering from the Massachusetts Institute of Technology (MIT). In 1994, he joined the Paul Scherrer Institute (PSI) in Switzerland, where he leads research and regulatory support activities related to Human Reliability Analysis (HRA). His research interests include the analysis and quantification of personnel decision-making in accident scenarios, in the frame of Probabilistic Safety Assessments (PSAs); the modeling of crew performance in joint human-system simulations, aimed at developing a dynamic risk assessment methodology to complement PSA; and the development of PSA for applications outside the domain of nuclear power plants. In this area, an on-going PSA study for PSI’s Proton Therapy Facility is a notable case combining elements of (medical) physics and the healthcare sector. Currently, he leads a task force on the collection and exchange of data for HRA research and applications, in the Working Group on Risk Assessment of the OECD Nuclear Energy Agency. Recently, he contributed HRA expertise and drew conclusions and recommendations for an IAEA Co-Ordinated Research Project (2001-2003) dealing with exploratory applications of PSA for radiation sources. He also served as Scientific Secretary for the 7th Probabilistic Safety Assessment and Management Conference (PSAM7/ESREL04, Berlin, June 2004).

Sidney Dekker is Professor of Human Factors and Aviation Safety, and Director of Research at Lund University, School of Aviation, Sweden. He received an M.A. in organizational psychology from the University of Nijmegen and an M.A. in experimental psychology from Leiden University, both in the Netherlands. He gained his Ph.D. in Cognitive Systems Engineering from The Ohio State University, USA. He has previously worked for the Public Transport Cooperation in Melbourne, Australia; the Massey University School of Aviation, New Zealand, British Aerospace, UK, and has been a Senior Fellow at Nanyang Technological University in Singapore. His specialties and research interests are system safety, human error, reactions to failure and criminalization, and organizational resilience. He has some experience as a pilot, type trained on the DC-9 and Airbus A340. His books include ‘The Field Guide to Human Error Investigations’ (2002) and ‘Ten Questions About Human Error: A New View of Human Factors and System Safety’ (2005).

Arthur Dijkstra is a captain in KLM Royal Dutch Airlines on a Boeing 777 as well as a flight safety investigator. From 1982 to 1984 he completed the Dutch Civil Aviation flying school and started in 1985 as First Officer at the McDonnell Douglas DC 9, followed by Boeing B747-300 and B747-400. On this aircraft he started as a flight instructor. He later became captain on Airbus A310, followed by the Boeing B767 and Boeing B777. From 1998 he was also (Senior) Type Rating examiner, which includes pilot and instructor training and examination. In 2005 he started as flight safety investigator in the flight safety department of KLM. From 2003 to June 2005 Arthur Dijkstra completed a MSc study in Human Factors at Linköping University, Sweden. In 2005 he started a PhD study in the field of Resilience Engineering at the section of Safety Science at the University of Technology in Delft in the Netherlands sponsored by the KLM.

Rhona Flin (BSc, PhD Psychology) is Professor of Applied Psychology in the School of Psychology at the University of Aberdeen. She is a Chartered Psychologist, a Fellow of the British Psychological Society and a Fellow of the Royal Society of Edinburgh. Rhona Flin directs a team of psychologists working with high reliability industries (especially the energy sector) on research and consultancy projects concerned with the management of safety and emergency response. The group has worked on projects relating to aviation safety (funded by the EC and CAA), leadership and safety in offshore management (funded by HSE and the oil industry), health management and safety in the offshore oil industry (HSE), team skills and emergency management (funded by the nuclear industry). She is currently studying anaesthetists’ and surgeons’ non-technical skills (funded by NES/RCS, Edinburgh) and safety climate in hospitals (funded by GUHT). Her recent books include ‘Incident Command: Tales from the Hot Seat’ (Ed. & Arbuthnot, Ashgate, 2002); ‘Sitting in the Hot Seat: Leaders and Teams for Critical Incident Management’ (Wiley, 1996), ‘Managing the Offshore Installation Workforce’ (Ed. & Slaven, PennWell Books, 1996) and ‘Decision Making under Stress’ (Ed. & Salas, Strub & Martin, Ashgate, 1997). See also www.abdn.ac.uk/iprc.

Yushi Fujita is a Specialist in the field of human – machine interfaces, individual and organizational characteristics, human cognitive modelling and human reliability analysis, who has over twenty-five years of experience mainly in the nuclear industry. He is currently a managing director at Technova Inc., a research organization in Japan. He received a PhD from the University of Tokyo in 1992.

Andrew Hale has been Professor of Safety Science at the Delft University of Technology since 1984. He worked in London and at Aston University and pioneered the field of occupational accident research, particularly as an occupational psychologist specialising in human factors in safety, safety management and regulation. His early research was centred on individual behaviour and training in the face of danger. Since moving to the Netherlands he has focused more on the modelling and measurement of safety management and culture and on regulation of safety. He has conducted studies in the manufacturing, process and construction industries and more recently in air, road and rail transport.

He is chairman of the Scientific Advisory Board of the Dutch Traffic Safety Institute, member of the Safety Advisory Committee on Schiphol Airport, member of the Executive Board of the Dutch Association of Safety Engineers and editor of Safety Science.

The department at Delft has three main research lines: the incorporation of risk as a criterion in the design process of new technology, processes and products; the development, assessment and improvement of risk management systems; and the development and evaluation of tools for risk assessment and modelling and for learning from incidents and accidents.

Erik Hollnagel is since mid-2006 Industrial Safety Chair at Ecole des Mines de Paris, after having been Professor of Human – Machine Interaction at Linköping University (S) since 1999. He is an internationally recognised expert in the fields of system safety, accident analysis, cognitive systems engineering, cognitive ergonomics and intelligent human – machine systems. He has worked at universities, research institutes and private companies in several countries since 1971, and has experience from applications in nuclear power, aerospace, software engineering, healthcare, and road vehicles. He has published widely including ten books, the most recent titles being ‘Joint Cognitive Systems: Foundations of Cognitive Systems Engineering’ (Taylor & Francis, 2005; co-authored with D. D. Woods) and ‘Barriers and Accident Prevention’ (Ashgate, 2004), and is, together with Pietro C. Cacciabue, Editor-in-Chief of the international journal of Cognition, Technology & Work.

Nancy G. Leveson is Professor of Aeronautics and Astronautics and of Engineering Systems at MIT and Director of the Complex Systems Research Lab. She has over 25 years experience working on system safety, including cross-disciplinary research encompassing engineering, cognitive psychology, and organizational sociology. She has published almost 200 papers on system safety, human – computer interaction, software engineering, and system engineering. She has also published a book entitled Safeware (Addison-Wesley, 1995). Dr. Leveson is a member of the National Academy of Engineering and has received numerous awards for her research including the 1999 ACM Allen Newell Award for outstanding computer science research, the 1995 AIAA Information Systems Award for ‘developing the field of software safety and for promoting responsible software and system engineering practices where life and property are at stake.’ In 2004 she received the ACM Sigsoft Outstanding Research Award. Her research results are currently being used by aerospace, automotive, nuclear power, and defense companies and government agencies. In 1995, Dr. Leveson and some of her former students started a company, Safeware Engineering Corporation, that creates specification and system safety engineering tools and consults on safety in a wide variety of industries.

Nick McDonald is Senior Lecturer in the Department of Psychology, Trinity College Dublin. He chairs the Aerospace Psychology Research Group, which has played a leading role in developing human factors research in aviation within the European Commission’s 4th, 5th & 6th Framework RTD Programmes, co-ordinating and participating in a series of projects that have addressed human factors in the aircraft maintenance industry, and in the wider aviation system. Other current research addresses safety in commercial road transport and in process industries. Through the European Transport Safety Council he has also contributed to various forums and reports on transport safety policy in Europe. His main research interests are in organisational aspects of safety and efficiency and with problems of implementation, change and innovation.

Jean Pariès is CEO of the Dédale SA company (Paris, France). Dédale’s activity focuses on the Human Factors dimensions of safety, across the domains of aviation, rail, nuclear power, shipping, road tunnels, and health care. Jean is also Associated Research Director with the Centre National de Recherche Scientifique (CNRS).

He graduated from ENAC, the French National School of Civil Aviation, as an aeronautical engineer in 1973. He joined the French civil aviation authority (DGAC), where he worked in a succession of roles including airworthiness regulation, operational regulation, and pilot licensing regulation. From 1988 he participated in the foundation of the ICAO Flight Safety and Human Factors Working Group chaired by Captain Daniel Maurino. In 1990, he joined the French air accident investigation body, the Bureau Enquêtes Accidents (BEA) as Deputy Head, and Head of Investigations. He led the investigation into the A320 aircraft accident at Mont Saint-Odile, France (1992). He contributed to the evolution of accident analysis methods and particularly to the introduction of an organisational perspective into the ICAO Annex 13 accident investigation guidelines. Jean left the BEA in 1994 and has, since that time, led the Dédale team on a wide variety of applied human factors, training development, operational research and organisational reliability consulting assignments. He has also taught Human Factors, Human Reliability and Organisational Reliability for more than 15 years at several schools and universities.

Gunilla A. Sundström is Senior Vice President with Wachovia Corporation leading Wachovia’s Outsourcing Governance & Program Office. In this role she is responsible for development of governance capabilities, processes and tools in support of outsourcing-related decisions at an enterprise level. For more than 18 years, she has been engaged in decision making research in complex systems in various domains including industrial process control, telecommunications and financial services. Her primary research interests include decision modeling, analysis and design of decision support for complex systems. She has authored more than 60 papers/book chapters and articles in refereed journals, technical journals and magazines. She currently serves on the editorial boards of the International Journal of Human – Computer Studies and the International Journal of Cognition Technology & Work. She has been awarded various leadership and teamwork commendations including the IEEE-Systems Man Cybernetics Society’s outstanding contributions award. Dr. Sundström holds a Dr. phil. degree from University of Mannheim, Germany.

Ron Westrum is Professor of Sociology and Interdisciplinary Technology at Eastern Michigan University. A specialist in the sociology of science and technology and in systems safety, he has lectured widely to the international community in aviation, medicine, and nuclear power. He has numerous publications, including three books, the last of which is ‘Sidewinder: Creative Missile Development at China Lake’ (1999). He is a management consultant through his firm Aeroconcept, LLC. A member of the Human Factors and Ergonomics Society, he is writing a book on information flow. He lives in Ann Arbor, Michigan, with his wife Deborah and two children, Max and Piper.

David D. Woods is Professor at Ohio State University and pastpresident of the Human Factors and Ergonomics Society. From his initial work following the Three Mile Island accident in nuclear power, to studies of coordination breakdowns between people and automation in aviation accidents, to his work on to his role in today’s national debates about patient safety, he has developed and advanced the foundations and practice of Cognitive Engineering. David Woods was President and is Fellow of the Human Factors and Ergonomic Society as well as Fellow of the American Psychological Society, and the American Psychological Association. He received the Kraft Innovators award from the Human Factors and Ergonomic Society for developing the foundations of Cognitive Engineering and shared the Ely Award for best paper in the journal Human Factors (1994), as well as a Laurels Award from Aviation Week and Space Technology (1995) for research on the human factors of highly automated cockpits.

John Wreathall is a Specialist in the field of human and organizational performance, who has worked for over 35 years in the fields of nuclear power, medicine, aviation and aerospace, rail transport, chemical process and pharmaceutical manufacturing. He has led the development of two state-of-the-art human reliability analysis methods, and participated in nine probabilistic safety assessments, mostly applied to nuclear power, but most recently in the fields of transplant surgery and bio-terrorism. In addition, a major activity he has led has been the development of leading indicators of organizational behaviour as a management tool for use in the nuclear and aerospace industries.

Mr. Wreathall has degrees in nuclear engineering and systems engineering from Queen Mary College, The University of London. He is president of John Wreathall & co., Inc., based in Dublin, Ohio.

Contributing Authors

Dr. Betty Barrett, MIT Research Scientist based in the Center for Technology, Policy and Industrial Development (CTPID), expertise in the application of complexity principles in organizational settings, workplace dynamics, and the operation of geographically distributed teams.

John S. Carroll is Professor of Behavioral and Policy Sciences at the MIT Sloan School of Management and the MIT Engineering Systems Division and Co-Director of the MIT Lean Aerospace Initiative. He taught previously at Carnegie-Mellon University, Loyola University of Chicago, and the University of Chicago. He received a B.S. (Physics) from MIT and a Ph.D. (Social Psychology) from Harvard. His research has focused on decision-making and learning in organizational contexts. Current projects examine organizational safety issues in high-hazard industries such as nuclear power, aerospace, and health care, including self-analysis and organizational learning, safety culture, leadership, communication and systems thinking. He has published five books and over 70 journal articles and book chapters.

Dr. Joel Cutcher-Gershenfeld is a Senior Research Scientist in MIT’s Sloan School of Management. He has over 20 years experience in studying and leading large-scale systems change and institutional realignment initiatives. Dr. Cutcher-Gershenfeld is co-author of Valuable Disconnects in Organizational Learning Systems (Oxford University Press, 2005), Lean Enterprise Value (Palgrave/Macmillan, 2002), Knowledge-Driven Work (Oxford University Press, 1998), Strategic Negotiations (Harvard Business School Press, 1994) and three additional co-authored or co-edited books, as well as over 60 articles on large-scale systems change, new work systems, labor-management relations, negotiations, conflict resolution, organizational learning, public policy and economic development.

Nicolas Dulac is a Ph.D. student in the Aeronautics and Astronautics Department at MIT. His research interests are in safety and visualization. He is currently working on the design of advanced risk management tools.

Louis Goossens is a Chemical Engineer by training. Since 1980 he has been (senior) lecturer in Safety Science at Delft University of Technology. He specializes in methods of risk assessment and the modeling of risk, risk control and management. He has published widely on the use of expert judgment for risk assessment and managed a number of international projects, covering risks ranging from the nuclear and process industry to environmental and transport. He has also developed a number of inspection and audit systems. He is associate editor of the Journal of Risk Research.

Frank Guldenmund studied psychology at Leiden University and majored in cognitive psychology and methodology. Joining the Safety Science Group in 1992 primarily as a methodologist his involvement subsequently enlarged to include the modelling of safety management systems and the role of organisational culture in relation to (occupational) safety. He has been involved in projects regarding both the modelling and the measurement of these variables. Being quantitative by education his interest has gradually become more qualitative and holistic.

Tom Heijer graduated as Control Engineer from Delft University of Technology in 1975. He worked at the Dutch Institute for Road Safety Research on crash simulation and human biomechanics and later on long term safety research including the safety implications of telematics applications. Since 1989 he has worked part time at the Safety Science Group of the Delft University of Technology on a broad range of transport safety projects in the road, rail and air traffic sectors. His specialization is in system safety, risk modeling and feedback systems.

Dr. Christopher Nemeth is a Research Associate (Assistant Professor) in the Department of Anesthesia and Critical Care at the University of Chicago who studies human performance in complex high hazard environments. Recent research interests include technical work in high stakes settings, research methods in individual and distributed cognition, and understanding how information technology erodes or enhances system resilience. He has experience as a corporate manager, design and human factors consultant, university instructor, expert witness, and career active duty and reserve US Naval officer. His book on human factors research methods, Human Factors Methods for Design, is available from Taylor and Francis/CRC Press.

David Zipkin has a master’s degree in Technology and Policy from the Massachusetts Institute of Technology. Prior to MIT, he worked in the software industry.

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