Contents
PROLOGUE: RESILIENCE ENGINEERING CONCEPTS
David D. Woods & Erik Hollnagel
From Reactive to Proactive Safety
1 RESILIENCE: THE CHALLENGE OF THE UNSTABLE
Erik Hollnagel
Yushi Fujita
2 ESSENTIAL CHARACTERISTICS OF RESILIENCE
David D. Woods
Avoiding the Error of the Third Kind
Andrew Hale & Tom Heijer
How Do We Recognise Resilience When We See It?
Yushi Fujita
4 COMPLEXITY, EMERGENCE, RESILIENCE …
Jean Pariès
5 A TYPOLOGY OF RESILIENCE SITUATIONS
Ron Westrum
Situation I. The Regular Threat
Situation II. The Irregular Threat
Situation III. The Unexampled Event
Time: Foresight, Coping, and Recovery
Yushi Fujita
6 INCIDENTS – MARKERS OF RESILIENCE OR BRITTLENESS?
David D. Woods & Richard I. Cook
‘Decompensation:’ A Pattern in Adaptive Response
7 RESILIENCE ENGINEERING: CHRONICLING THE EMERGENCE OF CONFUSED CONSENSUS
Sidney Dekker
Resilience Engineering and Getting Smarter at Predicting the Next Accident
Modelling the Drift into Failure
Work as Imagined versus Work as Actually Done
Towards Broader Markers of Resilience
8 ENGINEERING RESILIENCE INTO SAFETY-CRITICAL SYSTEMS
Nancy Leveson, Nicolas Dulac, David Zipkin, Joel Cutcher-Gershenfeld, John Carroll & Betty Barrett
Principal Findings and Anticipated Outcomes/Benefits
Implications for Designing and Operating Resilient Systems
9 IS RESILIENCE REALLY NECESSARY? THE CASE OF RAILWAYS
Andrew Hale & Tom Heijer
Observations on Safety Management in Railway Track Maintenance
Yushi Fujita
10 STRUCTURE FOR MANAGEMENT OF WEAK AND DIFFUSE SIGNALS
Lars Axelsson
11 ORGANIZATIONAL RESILIENCE AND INDUSTRIAL RISK
Nick McDonald
What is the Nature of Resilience?
Planning and Flexibility in Operational Systems
The Role of Quality and Safety in Achieving Resilience
The Problem of Organizational Change
Conclusions – the Focus on Resilience
AN EVIL CHAIN MECHANISM LEADING TO FAILURES
Yushi Fujita
12 SAFETY MANAGEMENT IN AIRLINES
Arthur Dijkstra
Current Practices in Safety Management
What Next? From Safety to Resilience
13 TAKING THINGS IN ONE’S STRIDE: COGNITIVE FEATURES OF TWO RESILIENT PERFORMANCES
Richard I. Cook & Christopher Nemeth
Example 1: Handling a ‘Soft’ Emergency
Example 2: Response to a Bus Bombing
14 EROSION OF MANAGERIAL RESILIENCE: FROM VASA TO NASA
Rhona Flin
Safety Culture and Managerial Resilience
Measuring Managerial Resilience
Training Managerial Resilience
15 LEARNING HOW TO CREATE RESILIENCE IN BUSINESS SYSTEMS
Gunilla Sundström & Erik Hollnagel
The System View: Implications for Business Systems
What would have made Barings more Resilient?
16 OPTIMUM SYSTEM SAFETY AND OPTIMUM SYSTEM RESILIENCE: AGONISTIC OR ANTAGONISTIC CONCEPTS?
René Amalberti
Introduction: Why are Human Activities Sometimes Unsafe?
Mapping the Types of Resilience
Understanding the Transition from One Type of Resilience to Another
Conclusion: Adapt the Resilience – and Safety – to the Requirements and Age of Systems
PART III: CHALLENGES FOR A PRACTICE OF RESILIENCE ENGINEERING
17 PROPERTIES OF RESILIENT ORGANIZATIONS: AN INITIAL VIEW
John Wreathall
Approach of Resilience Engineering
Yushi Fujita
18 AUDITING RESILIENCE IN RISK CONTROL AND SAFETY MANAGEMENT SYSTEMS
Andrew Hale, Frank Guldenmund & Louis Goossens
Structure of the ARAMIS Audit Model
Does the Model Encompass Resilience?
Conclusions and General Issues
19 HOW TO DESIGN A SAFETY ORGANIZATION: TEST CASE FOR RESILIENCE ENGINEERING
David D. Woods
Dilemmas of Safety Organizations
The 4 ‘I’s of Safety Organizations: Independent, Involved, Informed, and Informative
Safety as Analogous to Polycentric Management of Common Pool Resources
Yushi Fujita
20 DISTANCING THROUGH DIFFERENCING: AN OBSTACLE TO ORGANIZATIONAL LEARNING FOLLOWING ACCIDENTS
Richard I. Cook & David D. Woods
Organizational Learning in this Case
Extending or Enhancing the Learning Opportunity
Erik Hollnagel & Gunilla Sundström
Resilience and State-space Transitions
EPILOGUE: RESILIENCE ENGINEERING PRECEPTS
Erik Hollnagel & David D. Woods
Safety is Not a System Property