Resilience Engineering in Practice: a Guidebook
Gespeichert in:
Format: | Elektronisch E-Book |
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Sprache: | English |
Veröffentlicht: |
Farnham
Ashgate Gower
2011
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Schlagworte: | |
Online-Zugang: | FAW01 FAW02 Inhaltsverzeichnis |
Beschreibung: | Cover -- Contents -- List of Figures -- List of Tables -- List of Contributors -- Prologue: The Scope of Resilience Engineering by Erik Hollnagel -- PART I Dealing with the Actual -- Chapter 1 Resilience and the Ability to Respond -- Resilience in 8216;Real Time8217; -- Readiness and Anticipation -- Being Prepared to Be Unprepared -- Adapted or Adaptive? -- 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 8216;Satisficing8217; to 8216;Sacrificing8217; 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 -- Introduction -- Generic Competencies in Management of Unexpected and Escalating Situations -- Scenario Design -- Training Generic Competencies -- Discussion -- PART II Dealing with the Critical -- Chapter 5 Monitoring 8211; A Critical Ability in Resilience Engineering -- The Role of Indicators in Measurement -- Selection and Basis for Indicators -- Nature of Indicators -- Leading and Lagging Indicators -- Chapter 6 From Flight Time Limitations to Fatigue Risk Management Systems 8211; A Way Toward Resilience -- Introduction -- Fatigue and Safety -- The Development of Fatigue Risk Management System -- - Safety Policy and Objectives -- Fatigue Risk Management -- Safety Assurance -- Monitoring Process -- Safety Promotion -- Conclusion -- Acknowledgements -- Disclaimer -- Chapter 7 Practices for Noticing and Dealing with the Critical. A Case Study from Maintenance -- Introduction -- Business Background -- Loss Control Philosophy -- Highly Resilient Organizations -- Anticipate -- Notice -- Planning -- Adapting -- Conclusion -- Chapter 8 Cognitive Strategies in Emergency and Abnormal Situations Training -- Introduction -- Method -- T2EAM Model -- Results -- T2EAM Model and Cognitive Task Analysis -- Conclusion -- PART III Dealing with the Potential -- Chapter 9 Resilience and the Ability to Anticipate -- Patterns of Anticipation -- 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 The book brings together a strong field of anthropologists offering in-depth ethnographic studies of urban settings in the Mediterranean region, ranging from Portugal, to Albania and to Israel. Their aim is to initiate a comparative discussion of the relationship between established moralities, politics, law and civil society from a region with a strong tradition of cultural integration |
Beschreibung: | 362 |
ISBN: | 9781409486534 1409486532 |
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500 | |a Cover -- Contents -- List of Figures -- List of Tables -- List of Contributors -- Prologue: The Scope of Resilience Engineering by Erik Hollnagel -- PART I Dealing with the Actual -- Chapter 1 Resilience and the Ability to Respond -- Resilience in 8216;Real Time8217; -- Readiness and Anticipation -- Being Prepared to Be Unprepared -- Adapted or Adaptive? -- 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 8216;Satisficing8217; to 8216;Sacrificing8217; 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 -- | ||
500 | |a - 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 -- Introduction -- Generic Competencies in Management of Unexpected and Escalating Situations -- Scenario Design -- Training Generic Competencies -- Discussion -- PART II Dealing with the Critical -- Chapter 5 Monitoring 8211; A Critical Ability in Resilience Engineering -- The Role of Indicators in Measurement -- Selection and Basis for Indicators -- Nature of Indicators -- Leading and Lagging Indicators -- Chapter 6 From Flight Time Limitations to Fatigue Risk Management Systems 8211; A Way Toward Resilience -- Introduction -- Fatigue and Safety -- The Development of Fatigue Risk Management System -- | ||
500 | |a - Safety Policy and Objectives -- Fatigue Risk Management -- Safety Assurance -- Monitoring Process -- Safety Promotion -- Conclusion -- Acknowledgements -- Disclaimer -- Chapter 7 Practices for Noticing and Dealing with the Critical. A Case Study from Maintenance -- Introduction -- Business Background -- Loss Control Philosophy -- Highly Resilient Organizations -- Anticipate -- Notice -- Planning -- Adapting -- Conclusion -- Chapter 8 Cognitive Strategies in Emergency and Abnormal Situations Training -- Introduction -- Method -- T2EAM Model -- Results -- T2EAM Model and Cognitive Task Analysis -- Conclusion -- PART III Dealing with the Potential -- Chapter 9 Resilience and the Ability to Anticipate -- Patterns of Anticipation -- 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 -- | ||
500 | |a - 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 | ||
500 | |a The book brings together a strong field of anthropologists offering in-depth ethnographic studies of urban settings in the Mediterranean region, ranging from Portugal, to Albania and to Israel. Their aim is to initiate a comparative discussion of the relationship between established moralities, politics, law and civil society from a region with a strong tradition of cultural integration | ||
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Datensatz im Suchindex
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adam_text | Contents
List of Figures xiii
List of Tables xv
List of Contributors xvii
Prologue: The Scope of Resilience Engineering by Erik Hollnagel xxix
PART I DEALING WITH THE ACTUAL
Chapter 1 Resilience and the Ability to Respond 3
Jean Paries
Resilience in Real Time 3
Readiness and Anticipation 4
Being Prepared to Be Unprepared 6
Adapted or Adaptive? 8
Chapter 2 Lessons from the Hudson 9
Jean Paries
Miracle on the Hudson River? 10
The Bird Hazard 10
Bird Strike Protection Strategy 11
From Anticipated Emergency to Real Time Response 14
From Satisficing to Sacrificing Decisions 17
From Safety Strategies to Resilience Engineering
at the System Level 19
When Systemic Resilience Efforts Undermine
Resilience at the Sharp End 22
In Conclusion: Two Lessons and a Wish 26
Chapter 3 Coping with Uncertainty Resilient Decisions
in Anaesthesia 29
Lucie Cuvelier and Pierre Falzon
States of Resilience and Uncertain Events 30
Describing How Anaesthesiologists Manage
Uncertainty 31
Unforeseen Situations: Potential Variability and
Unthought-of Variability 34
vi
Resilience Engineering in Practice
Resilience as the Ability to Define an Envelope of
Potential Variability 36
Resilience as the Ability to Diagnose that the
System Leaves the Envelope of Potential Variability 40
Enhancing Resilience: Paths for Progress 42
Acknowledgements 43
Chapter 4 Training Organisational Resilience in
Escalating Situations 45
Johan Bergström, Nicklas Dahlström,
Sidney Dekker and Kurt Petersen
Introduction 45
Generic Competencies in Management of
Unexpected and Escalating Situations 46
Scenario Design 48
Training Generic Competencies 50
Discussion 56
PART II DEALING WITH THE CRITICAL
Chapter 5 Monitoring - A Critical Ability in Resilience
Engineering 61
John Wreathall
The Role of Indicators in Measurement 62
Selection and Basis for Indicators 65
Nature of Indicators 66
Leading and Lagging Indicators 67
Chapter 6 From Flight Time Limitations to Fatigue Risk
Management Systems - A Way Toward Resilience 69
P Cabon, S Deharvengt, I Berechet, J Y Grau,
N Maille and R Mollard
Introduction 70
Fatigue and Safety 71
The Development of Fatigue Risk Management
System 73
Safety Policy and Objectives 74
Fatigue Risk Management 74
Safety Assurance 79
Monitoring Process 83
Safety Promotion 84
Conclusion 85
Acknowledgements 86
Disclaimer 86
Contents
vü
Chapter 7 Practices for Noticing and Dealing with the
Critical A Case Study from Maintenance of
Power Plants 87
Elizabeth Lay
Introduction 88
Business Background 88
Loss Control Philosophy 88
Highly Resilient Organizations 90
Anticipate 92
Notice 93
Planning 96
Adapting 97
Conclusion 99
Chapter 8 Cognitive Strategies in Emergency and
Abnormal Situations Training - Implications
for Resilience in Air Traffic Control 101
Stathis Malakis and Tom Kontogiannis
Introduction 102
Method 104
T2EAM Model 106
Results 111
T2EAM Model and Cognitive Task Analysis 112
Conclusion 115
PART III DEALING WITH THE POTENTIAL
Chapter 9 Resilience and the Ability to Anticipate 121
David D Woods
Patterns of Anticipation 121
Chapter 10 Basic Patterns in How Adaptive Systems Fail 127
David D Woods and Matthieu Branlat
The Optimist-Pessimist Divide on Complex
Adaptive Systems 127
Assessing Future Resilience from Studying the
History of Adaptation (and Maladaptation) 129
Patterns of Maladaptation 130
Illustration of the Basic Patterns 136
Urban Fire-fighting and the Dynamics of
Decompensation 138
Urban Fire-fighting and Coordination over
Multiple Groups and Goals 139
Urban Fire-fighting and the Risk of Getting Stuck
in Outdated Behaviours 140
Resilience Engineering in Practice
viii
Recognising what is Maladaptive Depends on
Perspective Contrasts 141
Chapter 11 Measuring Resilience in the Planning of Rail
Engineering Work 145
P Ferreira, J R Wilson, B Ryan and S Sharpies
Introduction 145
Measuring Resilience Factors 146
Questionnaire Design 147
Questionnaire Implementation 148
Principal Components Analysis 148
Interpretation of the Extracted Components 150
Extracted Factors and the Potential for Resilience 154
Acknowledgements 156
Chapter 12 The Art of Balance: Using Upward Resilience
Traits to Deal with Conflicting Goals 157
Berit Tjorhom and Karina Aase
Introduction 157
The Art of Balance 159
Downward and Upward Resilience 160
Traces of Balancing Within the Norwegian
Aviation Transport System 162
Conclusion 168
Chapter 13 The Importance of Functional
Interdependencies in Financial Services Systems 171
Gunilla A Sundström and Erik Hollnagel
Introduction 171
The Financial Services System 2007-2009 172
What is the Financial Services System? 176
What Creates the Dynamic Interactions? 179
The Modelling Steps 180
Identifying the Core Functions 181
Identifying Potential for Functional Resonance 183
Identifying How Performance Variance can be
Monitored and Controlled 186
Example: The Demise of Northern Rock 187
Concluding Remarks 189
Contents
ix
PART IV DEALING WITH THE FACTUAL
Chapter 14 To Learn or Not to Learn, that is the Question 193
Erik Hollnagel
The Conditions for Learning 193
The Impact of Learning 195
What Should Be Learned? 196
Chapter 15 No Facts, No Glory 199
John Stoop
Introduction 199
Case 1: Before, During and After the Event; the
Boeing 747 Case Study 201
The Reason for Building such Aircraft 202
The Bijlmermeer Crash 203
Case 2: ERTMS An Inquiry into the Safety
Architecture of High Speed Train Safety 209
Emergent Properties 211
Transparency 212
Towards a New Train Control Concept 213
Lessons Learned 214
Discussion 214
What Do We Need to Design Resilient Systems? 215
What has Created Opportunities for Resilience in
these two Cases? 216
Chapter 16 From Myopic Coordination to Resilience in
Socio-technical Systems A Case Study in a
Hospital 219
Anne Sophie Nyssen
Introduction 220
Coordination as a Component of Resilience in
Socio-Technical Systems like Hospitals 221
The Organisation s Approach to Coordination 223
Vertical Coordination Tools 225
Lateral Coordination Tools 226
Longitudinal Coordination Tools 226
A Catastrophic Experience 227
Case Analysis: An Emergence-through-use
Approach of Coordination 228
Discussion 231
Conclusions - Enhancing Projection outside the
Local Immediate 233
X
Resilience Engineering in Practice
Chapter 17 Requisites for Successful Incident Reporting
in Resilient Organisations 237
Alberto Pasquini, Simone Pozzi, Luca Save and
Mark-Alexander Sujan
Introduction 238
A Success and a Failure Story: Reporting Systems
in Aviation and Healthcare 239
Handle with Care: All Reporting System are
Different 246
The Pass Criterion 247
Degree of Standardisation 248
Visibility 249
Understand the Characteristics of your Community 250
Assess Safety Culture 251
What Happens When Key Structural Properties
are Missing? 252
Proactive Risk Monitoring 253
Conclusion 254
Chapter 18 Is the Aviation Industry Ready for Resilience?
Mapping Human Factors Assumptions across
the Aviation Sector 257
Kyla Zimmermann, Jean Paries, Rene Amalberti
and Daniel H Hummerdal
Paradigms in Safety and Human Factors 257
Diversity in Aviation 259
The Safety Assumptions and Resilient Attitudes
(SARA) Survey 260
The Business of (not) Measuring Resilience 260
Developing the SARA Survey 261
The Survey Respondents and Interview
Participants 261
Analysis of the SARA Survey Results 262
Differences between National and Occupational
Cultures 263
Discussion of Differences between National/
Societal Cultures 265
Discussion of the Differences between
Occupational Cultures 268
Cultural Bias in Culture Research 269
Ambiguity and Contradictions 270
Discussion: Integrating and Interpreting
Ambiguity and Contradictions 270
The Limitations of Attitude Measurement 271
Contents jd
Two Explanations, One Conclusion 272
Is Resilience Ready for the Aviation Industry? 273
Acknowledgements 274
Epilogue: RAG - The Resilience Analysis Grid by Erik Hollnagel 275
Bibliography 297
Author Index 317
|
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id | DE-604.BV043786472 |
illustrated | Not Illustrated |
indexdate | 2024-07-10T07:35:06Z |
institution | BVB |
isbn | 9781409486534 1409486532 |
language | English |
oai_aleph_id | oai:aleph.bib-bvb.de:BVB01-029197531 |
oclc_num | 728835664 |
open_access_boolean | |
owner | DE-1046 DE-1047 |
owner_facet | DE-1046 DE-1047 |
physical | 362 |
psigel | ZDB-4-EBA ZDB-4-ENC ZDB-4-EBA FAW_PDA_EBA |
publishDate | 2011 |
publishDateSearch | 2011 |
publishDateSort | 2011 |
publisher | Ashgate Gower |
record_format | marc |
spelling | Resilience Engineering in Practice a Guidebook Farnham Ashgate Gower 2011 362 txt rdacontent c rdamedia cr rdacarrier Cover -- Contents -- List of Figures -- List of Tables -- List of Contributors -- Prologue: The Scope of Resilience Engineering by Erik Hollnagel -- PART I Dealing with the Actual -- Chapter 1 Resilience and the Ability to Respond -- Resilience in 8216;Real Time8217; -- Readiness and Anticipation -- Being Prepared to Be Unprepared -- Adapted or Adaptive? -- 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 8216;Satisficing8217; to 8216;Sacrificing8217; 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 -- Introduction -- Generic Competencies in Management of Unexpected and Escalating Situations -- Scenario Design -- Training Generic Competencies -- Discussion -- PART II Dealing with the Critical -- Chapter 5 Monitoring 8211; A Critical Ability in Resilience Engineering -- The Role of Indicators in Measurement -- Selection and Basis for Indicators -- Nature of Indicators -- Leading and Lagging Indicators -- Chapter 6 From Flight Time Limitations to Fatigue Risk Management Systems 8211; A Way Toward Resilience -- Introduction -- Fatigue and Safety -- The Development of Fatigue Risk Management System -- - Safety Policy and Objectives -- Fatigue Risk Management -- Safety Assurance -- Monitoring Process -- Safety Promotion -- Conclusion -- Acknowledgements -- Disclaimer -- Chapter 7 Practices for Noticing and Dealing with the Critical. A Case Study from Maintenance -- Introduction -- Business Background -- Loss Control Philosophy -- Highly Resilient Organizations -- Anticipate -- Notice -- Planning -- Adapting -- Conclusion -- Chapter 8 Cognitive Strategies in Emergency and Abnormal Situations Training -- Introduction -- Method -- T2EAM Model -- Results -- T2EAM Model and Cognitive Task Analysis -- Conclusion -- PART III Dealing with the Potential -- Chapter 9 Resilience and the Ability to Anticipate -- Patterns of Anticipation -- 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 The book brings together a strong field of anthropologists offering in-depth ethnographic studies of urban settings in the Mediterranean region, ranging from Portugal, to Albania and to Israel. Their aim is to initiate a comparative discussion of the relationship between established moralities, politics, law and civil society from a region with a strong tradition of cultural integration TECHNOLOGY & ENGINEERING / Engineering (General) bisacsh TECHNOLOGY & ENGINEERING / Reference bisacsh Fault tolerance (Engineering) fast Reliability (Engineering) fast Reliability (Engineering) Fault tolerance (Engineering) Resilienz (DE-588)4817917-6 gnd rswk-swf Technisches System (DE-588)4126276-1 gnd rswk-swf Technisches System (DE-588)4126276-1 s Resilienz (DE-588)4817917-6 s DE-604 Hollnagel, Erik 1941- Sonstige (DE-588)103845378X oth Pariès, Jean Sonstige oth Wreathall, David D. Woods and John Sonstige oth HEBIS Datenaustausch application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=029197531&sequence=000001&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis |
spellingShingle | Resilience Engineering in Practice a Guidebook TECHNOLOGY & ENGINEERING / Engineering (General) bisacsh TECHNOLOGY & ENGINEERING / Reference bisacsh Fault tolerance (Engineering) fast Reliability (Engineering) fast Reliability (Engineering) Fault tolerance (Engineering) Resilienz (DE-588)4817917-6 gnd Technisches System (DE-588)4126276-1 gnd |
subject_GND | (DE-588)4817917-6 (DE-588)4126276-1 |
title | Resilience Engineering in Practice a Guidebook |
title_auth | Resilience Engineering in Practice a Guidebook |
title_exact_search | Resilience Engineering in Practice a Guidebook |
title_full | Resilience Engineering in Practice a Guidebook |
title_fullStr | Resilience Engineering in Practice a Guidebook |
title_full_unstemmed | Resilience Engineering in Practice a Guidebook |
title_short | Resilience Engineering in Practice |
title_sort | resilience engineering in practice a guidebook |
title_sub | a Guidebook |
topic | TECHNOLOGY & ENGINEERING / Engineering (General) bisacsh TECHNOLOGY & ENGINEERING / Reference bisacsh Fault tolerance (Engineering) fast Reliability (Engineering) fast Reliability (Engineering) Fault tolerance (Engineering) Resilienz (DE-588)4817917-6 gnd Technisches System (DE-588)4126276-1 gnd |
topic_facet | TECHNOLOGY & ENGINEERING / Engineering (General) TECHNOLOGY & ENGINEERING / Reference Fault tolerance (Engineering) Reliability (Engineering) Resilienz Technisches System |
url | http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=029197531&sequence=000001&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA |
work_keys_str_mv | AT hollnagelerik resilienceengineeringinpracticeaguidebook AT pariesjean resilienceengineeringinpracticeaguidebook AT wreathalldaviddwoodsandjohn resilienceengineeringinpracticeaguidebook |