208:
The resilience engineering perspective posits that a significant number of failure modes are literally inconceivable in advance of them happening, because the environment that systems operate in are very dynamic and the perspectives of the people within the system are always inherently limited. These
271:
The first type of resilience engineering work is determining how to best take advantage of the resilience that is already present in the system. Cook uses the example of setting a broken bone as this type of work: the resilience is already present in the physiology of bone, and setting the bone uses
225:
The resilience engineering perspective holds that human performance variability has positive effects as well as negative ones, and that safety is increased by amplifying the positive effects of human variability as well as adding controls to mitigate the negative effects. For example, the ability of
195:
The resilience engineering perspective assumes that the nature of work which people do within a system that contributes to an accident is fundamentally the same as the work that people do that contributes to successful outcomes. As a consequence, if work practices are only examined after an accident
439:
In 2012 the growing interest for resilience engineering gave rise the to the sub-field of
Resilient Health Care. This led to a series of annual conferences on the topic that are still ongoing as well as a series of books, on Resilient Health Care, and in 2022 to the establishment of the Resilient
127:
happen, they are understood as being due to the system temporarily being unable to cope with complexity. Hence, resilience engineering is related to other perspectives in safety that have reassessed the nature of human error, such as the "new look", the "new view", "safety differently", and
110:
In particular, resilience engineering researchers study how people are able to cope effectively with complexity to ensure safe system operation, especially when they are experiencing time pressure. Under the resilience engineering paradigm,
275:
Cook notes that this first type of resilience work does not require a deep understanding of the underlying mechanisms of resilience: humans have been setting bones long before the mechanism by which bone heals was understood.
37:
in this context refers to the capabilities that a system must possess in order to deal effectively with unanticipated events. Resilience engineering examines how systems build, sustain, degrade, and lose these capabilities.
299:
Cook notes that this second type of resilience work requires a much deeper understanding of the underlying existing resilience mechanisms in order to create interventions that can effectively increase resilience.
246:
Under the resilience engineering perspective, the operators are always required to trade-off risks. As a consequence, in order to create safety, it is sometimes necessary for a system to take on some risk.
65:, health care, and emergency response to both natural and industrial disasters. Resilience engineering researchers have also studied the non-safety-critical domain of software operations.
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The second type of resilience engineering work involves altering mechanisms in the system in order to increase the amount of the resilience. Cook uses the example of new drugs such as
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Expert operators are an important source of resilience inside of systems. These operators become experts through previous experience at dealing with failures.
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the ability of a system to develop new capabilities when faced with a surprise that cannot be dealt with effectively with a system's existing capabilities
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Because incidents often involve unforeseen challenges, resilience engineering researchers often use incident analysis as a research method.
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This section discusses aspects of the resilience engineering perspective that are different from traditional approaches to safety.
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safety. As a consequence, adding controls to mitigate the effects of human variability can reduce safety in certain circumstances
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401:(bone is constantly adapting through a dynamic balance between creation and destruction that is directed by mechanical strain).
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Dekker, Sidney W. A. (2002-10-01). "Reconstructing human contributions to accidents: the new view on error and performance".
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How do organizations adapt their structure and behavior to cope effectively when faced with an unforeseen challenge?
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378:, which is the ability of a system to deal effectively with potential challenges that were anticipated in advance.
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430:: relying on strategies that were previously adaptive but are no longer so due to changes in the environment
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1072:. Erik Hollnagel, Christopher P. Nemeth, Sidney Dekker. Aldershot, Hampshire, England: Ashgate. 2008–2009.
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when individual agents in a system behave in a way that achieves local goals but goes against global goals
168:
A second symposium on resilience engineering was held in
November 2006 in Sophia Antipolis, France. The
73:
1215:
A Few
Observations on the Marvelous Resilience of Bone & Resilience Engineering - Dr. Richard Cook
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The safety anarchist: relying on human expertise and innovation, reducing bureaucracy and compliance
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IRGC resource guide on resilience (vol. 2): Domains of resilience for complex interconnected systems
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https://skybrary.aero/bookshelf/systemic-potentials-management-building-basis-resilient-performance
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and are only interpreted in the context of the accident, the result of this analysis is subject to
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Resilience
Engineering Perspectives, Volume 2: Remaining Sensitive to the Possibility of Failure
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Resilience
Engineering Perspectives, Volume 1: Remaining Sensitive to the Possibility of Failure
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for understanding what resilience is in the Woods perspective. Cook notes that bone has both
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the ability of a system to continue to keep adapting to surprises, over long periods of time
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This has been described in a White Paper from
Eurocontrol on Systemic Potentials Management
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What can organizations do in order to be better prepared to handle unforeseeable challenges?
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humans to adapt their behavior based on novel circumstances is a positive effect that
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distinguishes two separate kinds of work that tend to be conflated under the heading
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These symposia led to a series of books being published (see Books section below).
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Foundations of safety science: a century of understanding accidents and disasters
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Governance and
Control of Financial Systems: A Resilience Engineering Perspective
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Resilient Health Care, Volume 3: Reconciling Work-as-Imagined and Work-as-Done
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The first symposium on resilience engineering was held in
October 2004 in
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Resilient Health Care, Volume 2: The
Resilience of Everyday Clinical Work
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Resilience engineering researchers have studied multiple safety-critical
1010:
Erik
Hollnagel; Christopher P. Nemeth; Sidney Dekker, eds. (2008–2009).
694:
STELLA: Report from the SNAFUcatchers Workshop on Coping With Complexity
805:
Woods, David D.; Sidney Dekker; Richard Cook; Leila Johannesen (2017).
155:
124:
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considers the following two concepts in his definition of resilience:
104:
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Hollnagel, Erik; Christopher P. Nemeth; Sidney Dekker, eds. (2019).
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In Woods's view, there are three common patterns to the failure of
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views resilient performance as requiring four systemic potentials:
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Bringing existing resilience to bear vs generating new resilience
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Safety-I and safety-II: the past and future of safety management
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that were not previously known before they were encountered.
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looks at a more general capability of systems to deal with
608:. Lausanne, CH: EPFL International Risk Governance Center.
397:(has a soft boundary at which it can extend function) and
131:
Resilience engineering researchers ask questions such as:
92:), or on assuring that a particular system is safe (e.g.,
692:
662:. Vol. 2: Preparation and Restoration. CRC Press.
418:
exhaustion of capacity when encountering a disturbance
272:
this resilience to achieving better healing outcomes.
906:
Safety differently : human factors for a new era
604:. In Trump, B.D.; Florin, M.-V.; Linkov, I (eds.).
441:
1307:Woods, David D.; Branlat, Matthieu (2017-05-15),
472:Resilience Engineering in Practice: A Guidebook
1236:"Epilogue: RAG – The Resilience Analysis Grid"
154:, Sweden. It brought together fourteen safety
1309:"Basic Patterns in How Adaptive Systems Fail"
760:Resilience Engineering: Concepts and Precepts
454:Resilience Engineering: Concepts and Precepts
440:Health Care Society (registered in Sweden). (
367:These two concepts are elaborated in Woods's
217:which focuses on evaluate conceivable risks.
209:sorts of events are sometimes referred to as
191:Normal work leads to both success and failure
8:
790:: CS1 maint: multiple names: authors list (
80:) focus on designing controls to prevent or
33:cope when encountering a surprise. The term
1282:Reliability Engineering & System Safety
1171:: CS1 maint: location missing publisher (
1014:. Aldershot, Hampshire, England: Ashgate.
984:: CS1 maint: location missing publisher (
937:: CS1 maint: location missing publisher (
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234:The centrality of expertise and experience
1187:"Hindsight 31 | SKYbrary Aviation Safety"
221:Human performance variability as an asset
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296:and are used to treat osteoporosis.
267:Bringing existing resilience to bear
1069:Resilience engineering perspectives
1012:Resilience engineering perspectives
909:(Second ed.). Boca Raton, FL.
660:Resilience engineering perspectives
428:getting stuck in outdated behaviors
294:Parathyroid hormone-related protein
16:Subfield of safety science research
1313:Resilience Engineering in Practice
1276:Woods, David D. (September 2015).
1240:Resilience Engineering in Practice
1120:Resilience Engineering Association
1048:Resilience Engineering Association
624:Resilience Engineering in Practice
174:Resilience Engineering Association
26:that focuses on understanding how
14:
524:, and Erik Hollnagel (eds), 2016.
374:Woods contrasts resilience with
369:theory of graceful extensibility
123:while under time pressure. When
1315:, CRC Press, pp. 127–143,
1242:, CRC Press, pp. 275–296,
482:Resilient Health Care, Volume 1
146:Resilience engineering symposia
1234:Hollnagel, Erik (2017-05-15),
1:
866:10.1016/S0022-4375(02)00032-4
215:probabilistic risk assessment
172:had eighty participants. The
78:probabilistic risk assessment
809:(2nd ed.). Boca Raton.
325:The potential to anticipate.
68:Whereas other approaches to
1044:"2006 Sophia Antipolis (F)"
758:(David), Woods, D. (2017).
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1294:10.1016/j.ress.2015.03.018
854:Journal of Safety Research
534:, Christopher Nemeth, and
422:working at cross purposes:
572:by Gunilla Sundström and
280:Generating new resilience
57:, space mission control,
1321:10.1201/9781317065265-10
1248:10.1201/9781317065265-19
952:Hollnagel, Erik (2014).
406:complex adaptive systems
319:The potential to monitor
316:The potential to respond
115:are not attributable to
1139:Dekker, Sidney (2018).
903:Dekker, Sidney (2015).
711:Dekker, Sidney (2019).
551:by Christopher Nemeth,
24:safety science research
1100:: CS1 maint: others (
599:"Resilience is a Verb"
399:sustained adaptability
395:graceful extensibility
381:The safety researcher
359:sustained adaptability
350:graceful extensibility
340:The safety researcher
322:The potential to learn
308:The safety researcher
261:resilience engineering
20:Resilience engineering
435:Resilient Health care
304:Hollnagel perspective
74:behavior-based safety
691:Woods, D.D. (2017).
597:Woods, D.D. (2018).
389:should serve as the
211:fundamental surprise
204:Fundamental surprise
161:with an interest in
518:Jeffrey Braithwaite
504:Jeffrey Braithwaite
502:by Erik Hollnagel,
490:Jeffrey Braithwaite
242:Risk is unavoidable
59:military operations
1356:Safety engineering
807:Behind human error
1330:978-1-315-60569-2
1257:978-1-315-60569-2
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816:978-1-317-17553-7
769:978-1-317-06528-9
722:978-1-351-05977-0
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633:978-1-317-06525-8
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559:(eds.), 2016.
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1116:"Symposium"
956:. Farnham.
458:David Woods
342:David Woods
159:researchers
152:Soderkoping
128:Safety-II.
117:human error
101:engineering
55:fire safety
1350:Categories
1336:2022-09-24
1263:2022-09-17
1221:2022-09-25
1196:2022-09-25
1159:1022761874
1143:. London.
1125:2022-09-25
1053:2022-09-25
825:1004974951
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731:1091899791
678:1105725342
642:1151009227
581:References
376:robustness
121:trade-offs
98:resilience
51:anesthesia
35:resilience
1167:cite book
1096:cite book
1088:192027611
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980:cite book
972:875819877
933:cite book
925:881430177
874:0022-4375
833:cite book
786:cite book
739:cite book
391:archetype
170:symposium
113:accidents
890:46350729
882:12404999
125:failures
82:mitigate
47:aviation
1288:: 5–9.
576:, 2018.
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