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Proceedings of the fourth Resilience Engineering Symposium

Erik Hollnagel
Éric Rigaud
Denis Besnard

Resilience Management System And Development Of Resilience Capability On Site Workers

Akinori Komatsubara


When we consider the safety of socio-technical or safety critical systems, discussions from three layers are required; safety strategy, safety management and safety activity. In this study, development of resilience safety from the three layers is discussed. For the safety management layer, this study proposes resilience management system (RMS) as the style of safety management system (SMS) for resilience safety approach. Two cases at Japanese companies to enhance attitude and non-technical skills as resilience capability are also introduced.

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1 Introduction

1When we consider the safety of socio-technical or safety critical systems, discussions from three layers are required; safety strategy, safety management and safety activity.

2As to the safety strategy, three kinds of approaches are feasible (Komatsubara, 2010). One is the approach that depends on individual responsibility. This approach takes the idea that accidents would not occur when each worker will work carefully. This becomes Bad Apple theory (Dekker, 2006). Of course, though individual awareness of responsibility is important, however it is impossible to achieve reliable safety at safety critical systems only with the awareness and carefulness.

3The second one is the approach that does not rely on people. If automation, improvement of work environment and standardization of task procedure are possible -in other words, change of work condition is very small or can be diminished -this approach is effective. Assembly lines of automobiles seem to take this approach.

4The third one is resilience approach that relies on flexible behavior of workers. This is good where work situation changes. People are required to act to prevent the situation from getting worse.

5Whether which strategy -not rely or rely on people -should be taken depends on the characteristic of the task; e.g. automobile assembly lines will not need resilience approach, but they may be managed well with traditional ergonomics, industrial engineering and quality control.

6Resilience approach has range from normal operation in which the change is small to sudden emergency activity in which the change is so large. When the change is larger than those which individual can catch up with, resilience safety shall fail. Therefore, to obtain the success of resilience safety, some organizational management that enlarges the width of resilience activity as well as diminishing the change through improvement of work condition and standardization of the task is needed. Unless management shall be made, safety backs into the individual responsibility.

2 RMS: Resilience Safety Management System

2.1 Disaster of Fukushima Nuclear Power Plants (2011)

7Strong earthquakes of magnitude 9.0 and followed tsunami caused serious disaster on March 11, 2011 in Japan. About thirty thousand people were killed or missing. The earthquake and tsunami also attacked Fukushima nuclear power plants and caused the catastrophic accident of INES (international nuclear event scale) 7. This accident has not been settled yet and the details of this accident have also not been clear, but it is certain that the power plants stopped safely just when the earthquake happened. However after that, so strong and high tsunami surge that was beyond prior prediction and preparation destroyed every outside power supply. It was the start of the disaster.

8The safety standards of Japanese government and countermeasures by the power company were the premise that every power supply would not fail at the same time. Therefore, such emergency resources as mobile emergency vehicles had not been prepared. Also, emergency training when losing every power supply had not been conducted. At this premise, site-workers had to perform resilience activity. Therefore, they did not perform well, and the situation was gradually but rapidly getting worse. Though their morale was high, their fatigue due to radiological protective clothing that limits smooth movement, poor feeding and poor beddings etc. invited simple but somewhat critical human errors, too. Though the company and government agency recognized the seriousness of the situation, the command structure was not clearly formed. At some aspects it was robust and at the other aspects it was random. Therefore, countermeasures at the site might not be well-organized but confused.

2.2 Management for Resilience

9Considering the above mentioned regrettable Fukushima NPP case, it is obvious that some kinds of organizational management must be prepared and executed when we take resilience safety approach at safety critical systems, so as to achieve success. In this study, the management process shown in Figure 1 is proposed as safety management system, with the idea of PDCA (plan, do, check, act) cycle. This study calls Resilience Management System, RMS.

10Plan; At first, aspects or situation of which the organization expects resilience approach must be identified. This should include the aspect that the situation exceeds prior expectation, too. Next, both resource and capability needed for the resilience activity to be executed must be identified. Moreover, organizational structure - probably peach saving (Komatsubara, 2008a) which allows smooth resilience activity -must be identified.

11Do; These identified items should be technically developed, established and promoted. Check and Act; The effects of Do must be checked and evaluated regularly and continually. Based on the Check, supplements and correction as Act will be conducted if any unsatisfied matters may be observed.

Figure 1 Process of RMS; Resilience Management System

2.3 Resilience Capability which should be developed

12From the standpoint of human factors, we have much interest in individual resilience capability that is the basic element of organizational resilience. Komatsubara, (2008a, 2008b) points out that organizations should develop three elements as individual resilience capability; technical skill, non-technical skill and attitude. In addition, as being in the case of Fukushima NPP, mental and physical health including fatigue should be managed by organizations.

2.4 Structure of Organizational Resilience

13Based on the series of above discussion, the structure of organizational resilience is summarized as the model shown in Figure 2. The organization should progress RMS to enrich this structure.

Figure 2: Organizational Resilience Structure

3.1 Enhancement of positive attitude; A case of Japan Airlines Plan

14In Japan, fortunately, fatal accidents at commercial airlines have not occurred since JAL B747 crashed resulting in a total of 520 deaths in 1985.

15However, because the majority of staffs in Japanese aviation industry have become those who have not experienced the seriousness of aviation accidents now, it is worried that the idea that “safety originally exists, and safety can be obtained without specific efforts” come into workers. It is dangerous because they may tend to work with the attitude of efficiency rather than thoroughness, in the sense of ETTO (Hollnagel, 2009). In aviation industry, the positive attitude with safety first is strongly required. For example, they must not just obey operational manuals when they feel some anxiety. They must assert it and behave from the safety view. This attitude turns into resilience behavior. Japan Airlines had some anxiety in this respect, and has been making efforts to encourage the employee's safety attitude.


16JAL has various programs. The below are the examples.

17Safety Promotion Center; They established a exhibition-room named Safety Promotion Center that primarily helps to encourage the awareness of aviation safety among employees. In the center, items from a JAL B747-accident in 1985 are displayed; FDR, severely crashed seats, the rear pressure bulkhead from the aircraft, the testaments of the passenger on board, and so on. The mission of this center is focused on improving the mind of safety. Most of the employees who gaze at the exhibition shed tears, and they are reminded of their mission of aviation safety.

18Education for the new employee of mechanic staffs; Unlike cabin or cockpit crew, mechanics seldom meet the passengers directly. Therefore, it is worried that the consciousness to maintain aircraft on which the passengers actually board may be weakened. JAL holds pretty events at boarding gates that the young mechanics make a brief presentation about the knowledge learned at initial trainings. Through this event, they notice the meanings of aviation safety at maintenance jobs, and can grow the boast as professional mechanics. Figure 3 shows this event.

Figure 3 Presentation by young mechanics at Narita International Airport (photo by author)

Check and Act

19These programs are appreciated as the means of increasing the safety motivation of aviation. Though it is very difficult to measure the effects subjectively, intersubjectivity benefit has been obtained for enhancing safety positive attitude.

3.2 Development of non-technical skills; A case of Hitachi Plant Technologies Plan

20Hitachi Plant Technologies, Ltd. is a construction company of heavy-power facilities at power stations and factories. At their work-sites, the situation always changes. To keep safety and quality in such sites, supervisor's supervising skill as resilience capability is strongly requested. Even if the supervisor's level of technical skills is actually equal, the quality and safety often results differently. It is thought that maturity of some kinds of non-technical skills brings this difference. Especially in Japan, due to the generation change, occasions that younger supervisors must manage the construction sites without the support of veteran supervisors are increasing. Identifying and training of non-technical skill is therefore indispensable especially on younger supervisors.


21Depth-interviews were conducted to the veteran supervisors to clarify the know-how of achieving high safety and quality at sites. About 300 know-how items were gathered.

22These items were paired and semantically compared, with the score from 1 to 4 (completely same meaning – completely different meaning). The diagonal matrix of the score was processed with cluster analysis. The analysis showed four categories that consist of several elements with a few behavioral markers of non-technical skills. Table 1 shows the elements. Based on the results, they made a textbook named SMART Book (technique for Site Resource Management BOOK) which shows the non-technical skills required of their supervisors.

Table 1 Contents of SRM - site resource management at Hitachi Plant Technologies

Table 1 Contents of SRM - site resource management at Hitachi Plant Technologies

Check and Act

23Because the company is now developing the training program with using this textbook, the effect has not been evaluated yet, but as traditionally, non-technical skills of construction site supervisors have been usually grown by the informal OJT (on the job trainings), this case will be one good example for the companies which need management of their own non-technical skills for resilience safety.

4 Conclusion

24To keep the unstable systems stable, resilience countermeasures that exceed the width of the change of the unstableness are needed. To ensure this, RMS -resilience management system-must be needed. Moreover, the organization must promote the RMS actually. Otherwise, the resilience safety approach will become pie in the sky. We must build up RMS, but that is maybe not robust but resilient one.


25The author expresses the sincere thanks to Japan Airlines to which the author serves as a safety advisor. The author expresses the sincere thanks to Hitachi Plant Technologies, Ltd. with which the author conducted the research together.



Dekker, S., (2006), The Field Guide to Understanding Human Error, Ashgate, 1-14 Hitachi Plant Technologies.(2011), SMART Book (in-company textbook)

Hollnagel.E., (2009), The ETTO Principle: Efficiency-Thoroughness Trade-off, Why Things That Go Right Sometimes Go Wrong, Ashgate

Japan Airlines; JAL Safety Promotion Center,

Komatsubara.A., (2008a), Encouraging People to do Resilience, Proceedings of the Third Resilience Engineering Symposium 2008, 141-147

Komatsubara.A.,(2008b), When Resilience does not work, in Remaining Sensitive to the Possibility of Failure, ed. by E.Hollnagel, C.P.Nemeth, S.Dekker, Ashgate, 79-90

Komatsubara.A., (2010), Safety Secured by People, JR East Technical Review No.15, 37-40, (


1 Department of Industrial and Management Systems Engineering School of Creative Science and Engineering, Waseda University Tokyo 169-8555, Japan

Table des illustrations

Légende Figure 1 Process of RMS; Resilience Management System
Fichier image/jpeg, 260k
Légende Figure 2: Organizational Resilience Structure
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Légende Figure 3 Presentation by young mechanics at Narita International Airport (photo by author)
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Titre Table 1 Contents of SRM - site resource management at Hitachi Plant Technologies
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