Resilience Engineering Perspectives: Remaining Sensitive to the Possibility of Failure

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Table of Contents

Preface Erik Hollnagel Hollnagel, Erik

1 Resilience and Restlessness Ron Westrum Westrum, Ron 1

2 Resilience Engineering: The Birth of a Notion Christopher P. Nemeth Nemeth, Christopher P. 3

3 The Need for "Translators" and for New Models of Safety Jean-Christophe Le Coze Le Coze, Jean-Christophe Michele Dupre Dupre, Michele 11

4 Measures of Resilient Performance David Mendonca Mendonca, David 29

5 Unexampled Events, Resilience, and PRA Steve Epstein Epstein, Steve 49

6 Safety Management - Looking Back or Looking Forward Erik Hollnagel Hollnagel, Erik 63

7 When Resilience Does Not Work Akinori Komatsubara Komatsubara, Akinori 79

8 Rules Management as Source for Loose Coupling in High-Risk Systems Gudela Grote Grote, Gudela 91

9 Work Practices and Prescription: A Key Issue for Organizational Resilience Dimitris Nathanael Nathanael, Dimitris Nicolas Marmaras Marmaras, Nicolas 101

10 Crew Resilience and Simulator Training in Aviation Sidney Dekker Dekker, Sidney Nicklas Dahlstrom Dahlstrom, Nicklas Roel van Winsen van Winsen, Roel James M. Nyce Nyce, James M. 119

11 Underlying Concepts in Robustness and Resilience and Their Use in Designing Socio-Technical Systems Bernard Pavard Pavard, Bernard Julie Dugdale Dugdale, Julie Narges Bellamine-Ben Saoud Saoud, Narges Bellamine-Ben Sandrine Darcy Darcy, Sandrine Pascal Salembier Salembier, Pascal 127

12 Stress-Strain Plots as a Basis for Assessing System Resilience David D. Woods Woods, David D. John Wreathall Wreathall, John 143

13 Designing Resilient Critical Infrastructure Systems Using Risk and Vulnerability Analysis Kurt E. Petersen Petersen, Kurt E. Henrik Johannson Johannson, Henrik 159

14 TowardsResilient Safety Assessment: Experiences from the Design of the Future Air Traffic Management System Oliver Strater Strater, Oliver 171

15 Resilience in the Emergency Department Robert L. Wears Wears, Robert L. Shawna J. Perry Perry, Shawna J. Shilo Anders Anders, Shilo David D. Woods Woods, David D. 193

16 The Beatson Event: A Resilience Engineering Perspective John Wreathall Wreathall, John 211

17 What Went Wrong at the Beatson Oncology Centre? Richard I. Cook Cook, Richard I. Christopher P. Nemeth Nemeth, Christopher P. Sidney Dekker Dekker, Sidney 225

18 Resilience, Safety, and Testing Steve Epstein Epstein, Steve 237

19 Detecting an Erroneous Plan: Does a System Allow for Effective Cross-Checking? Matthieu Branlat Branlat, Matthieu Shilo Anders Anders, Shilo David D. Woods Woods, David D. Emily S. Patterson Patterson, Emily S. 247

20 Investigation as an Impediment to Learning Erik Hollnagel Hollnagel, Erik 259

21 Analysis of the Scottish Case Pierre Le Bot Le Bot, Pierre 269

App List of Contributors 299

Bibliography 301

Author Index 325

Subject Index 331

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