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PART I: EMERGENCE
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PART I: EMERGENCE
by David D. Woods, Erik Hollnagel
Resilience Engineering
Cover
Half Title
Title Page
Copyright Page
Table of Contents
PREFACE
PROLOGUE: RESILIENCE ENGINEERING CONCEPTS
Hindsight and Safety
From Reactive to Proactive Safety
Resilience
PART I: EMERGENCE
1 RESILIENCE: THE CHALLENGE OF THE UNSTABLE
Understanding Accidents
Anticipating Risks
SYSTEMS ARE EVER-CHANGING
2 ESSENTIAL CHARACTERISTICS OF RESILIENCE
Avoiding the Error of the Third Kind
Dynamic Balancing Acts
Acknowledgements
3 DEFINING RESILIENCE
Pictures of Resilience
How Do We Recognise Resilience When We See It?
Is Road Traffic Resilient?
Conclusion
NATURE OF CHANGES IN SYSTEMS
4 COMPLEXITY, EMERGENCE, RESILIENCE …
Introduction
Emergence and Systems
From Emergence to Resilience
Conclusion
5 A TYPOLOGY OF RESILIENCE SITUATIONS
Resilience against What?
Situation I. The Regular Threat
Situation II. The Irregular Threat
Situation III. The Unexampled Event
Time: Foresight, Coping, and Recovery
Foresee and Avoid
Coping with Ongoing Trouble
Repairing after Catastrophe
Conclusion
Acknowledgement
RESILIENT SYSTEMS
6 INCIDENTS – MARKERS OF RESILIENCE OR BRITTLENESS?
Incidents are Ambiguous
‘Decompensation:’ A Pattern in Adaptive Response
Acknowledgements
7 RESILIENCE ENGINEERING: CHRONICLING THE EMERGENCE OF CONFUSED CONSENSUS
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
PART II: CASES AND PROCESSES
8 ENGINEERING RESILIENCE INTO SAFETY-CRITICAL SYSTEMS
Resilience and Safety
STAMP
The Models
Principal Findings and Anticipated Outcomes/Benefits
Implications for Designing and Operating Resilient Systems
9 IS RESILIENCE REALLY NECESSARY? THE CASE OF RAILWAYS
Introduction
Observations on Safety Management in Railway Track Maintenance
Assessing Resilience
Discussion and Conclusions
SYSTEMS ARE NEVER PERFECT
10 STRUCTURE FOR MANAGEMENT OF WEAK AND DIFFUSE SIGNALS
Problem Awareness
Forum for Consultation
Strengthening the Forum
Other Fora
A Bundle of Arrows
11 ORGANIZATIONAL RESILIENCE AND INDUSTRIAL RISK
Introduction
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
Change in Technology
Conclusions – the Focus on Resilience
AN EVIL CHAIN MECHANISM LEADING TO FAILURES
12 SAFETY MANAGEMENT IN AIRLINES
Introduction
How Safe is Flying?
Current Practices in Safety Management
Models of Risk and Safety
What Next? From Safety to Resilience
13 TAKING THINGS IN ONE’S STRIDE: COGNITIVE FEATURES OF TWO RESILIENT PERFORMANCES
Introduction
Example 1: Handling a ‘Soft’ Emergency
Example 2: Response to a Bus Bombing
Analysis
Conclusion
14 EROSION OF MANAGERIAL RESILIENCE: FROM VASA TO NASA
Vasa to Columbia
Managerial Resilience
Safety Culture and Managerial Resilience
Measuring Managerial Resilience
Training Managerial Resilience
Conclusion
15 LEARNING HOW TO CREATE RESILIENCE IN BUSINESS SYSTEMS
The System View: Implications for Business Systems
The Barings plc Case
What would have made Barings more Resilient?
Concluding Remarks
16 OPTIMUM SYSTEM SAFETY AND OPTIMUM SYSTEM RESILIENCE: AGONISTIC OR ANTAGONISTIC CONCEPTS?
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
Concept of Resilience
Approach of Resilience Engineering
Summary
Example: Adaptation of Leading Indicators of Organizational Performance to Resilience Engineering Processes
Acknowledgments
REMEDIES
18 AUDITING RESILIENCE IN RISK CONTROL AND SAFETY MANAGEMENT SYSTEMS
Introduction
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
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
Summary
Acknowledgements
RULES AND PROCEDURES
20 DISTANCING THROUGH DIFFERENCING: AN OBSTACLE TO ORGANIZATIONAL LEARNING FOLLOWING ACCIDENTS
Introduction
Barriers to Learning
An Incident
Organizational Learning in this Case
Extending or Enhancing the Learning Opportunity
21 STATES OF RESILIENCE
Introduction
Resilience and State-space Transitions
Conclusions
EPILOGUE: RESILIENCE ENGINEERING PRECEPTS
Safety is Not a System Property
Resilience as a Form of Control
Readiness for Action
Why Things Go Wrong
A Constant Sense of Unease
Precepts
The Way Ahead
APPENDIX
Symposium Participants
Contributing Authors
BIBLIOGRAPHY
AUTHOR INDEX
SUBJECT INDEX
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PROLOGUE: RESILIENCE ENGINEERING CONCEPTS
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1 RESILIENCE: THE CHALLENGE OF THE UNSTABLE
Part I: Emergence
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