Table des matières
Erik Hollnagel et Éric Rigaud
PrefaceC. Alexandru, Siri Andersen, B. McKinstry et al.
Resilient Peer CommunitiesSiri Andersen et Eirik Albrechtsen
Resilience Abilities In Recent Blowouts In The Petroleum IndustrySiri Andersen, P. Fairbrother, M. Felici et al.
From Hazards To Resilience In Socio-Technical Healthcare SystemsGordon Baxter et Ian Sommerville
Responsibility Modelling For ResiliencePer Becker, Marcus Abrahamsson et Henrik Tehler
An Emergent Means To Assurgent Ends: Community Resilience For Societal Safety And SustainabilityJohan Bergström, Eder Henriqson et Nicklas Dahlström
From Crew Resource Management To Operational Resilience- 1 Introduction
- 2 Traditional CRM-principles
- 3 An Alternative Approach
- 4 Implementing Operational Resilience
- 4.1 The role of the observer
- 4.2 Control
- 4.3 Coordination
- 4.4 The emergent interactions in the system
- 4.5 Production of meaning
- 4.6 Focus on bridging gaps instead of categorizing and counting errors.
- 5 Concluding Remarks
Fabrizio Bracco, Andreina Bruno et Dimitri Sossai
Improving Resilience Through Practitioners’ Well-being: An Experience In Italian Health-careCaroline Catalan et Benoît Robert
Evaluation Of Organizational Resilience: Application In QuebecAlexander Cedergren
Challenges in Designing Resilient Socio-technical Systems: A Case Study of Railway Tunnel Projects- 1 Introduction
- 2 Decision-making In Railway Tunnel Projects
- 3 Results And Analysis
- 3.1 An Organisation Takes Past Success as a Reason for Confidence
- 3.2 Failure to Revise Assessments as New Evidence Accumulates
- 3.3 Drift Toward Failure as Defences Erode in the Face of Production Pressure
- 3.4 Fragmented Problem Solving Process that Clouds the Big Picture
- 3.5 Breakdowns at the Boundaries of Organisational Units
- 4 Conclusions
Capt. Antonio Chialastri
Resilience and Ergonomics in aviationLucie Cuvelier et Pierre Falzon
Resilience As Resource-based Design Of Anticipated Situations- 1 Safety And Resilience In Anesthesia
- 1.1 From safety to resilience
- 1.2 Disturbances in anesthesia: “potential situations” and “unthought situations”
- 2 A Study of Anticipation Processes In Anesthesia
- 3 Results
- 3.1 Several possible solutions and a diversity of anaesthetists’ practices
- 3.2 Analysis of decision criteria
- 4 Conclusion
- Acknowledgement
Paulo Victor Rodrigues de Carvalho, Rafael G. Costa et Antonio C. A. Mol
A Neuro-Fuzzy System to Improve the Resilience in Nuclear Power Plant OperationGiovanni Dolif, Andre Engelbrecht, Alessandro Jatobá et al.
Critical Decision Method To Access Resilience And Brittleness In Heavy Rainfall ForecastDominic Furniss, Jonathan Back et Ann Blandford
Unwritten Rules For Safety And Performance In An Oncology Day Care Unit: Testing The Resilience Markers Framework- 1 Introduction
- 2 Background
- 3 Resilience markers framework
- 4 Method
- 5 Results
- Resilience Episode 1: The trolley as a unit of work
- Resilience Episode 2: Monitoring community practice
- Resilience Episode 3: Reducing error when using two infusion pumps in parallel
- Resilience Episode 4: Workload management
- Resilience Episode 5: Swapping pumps when battery power is low
- Resilience Episode 6: Preparing for a power outage
- 6 Discussion
- 7 Acknowledgements
Tor Olav Grøtan
The Stratified And Dialectical Anatomy Of Organizational Resilience- 1 Introduction
- 1.1 Key challenges of organizational resilience (OR)
- 1.2 Looking behind the organizational facades of rationality
- 1.3 Can resilient action(s) be distinguished from other actions?
- 1.4 Scope of this paper
- 2 Episodic Adaptations
- 2.1 Basic inventory of episodic adaptations
- 2.2 The REL model: An instantiation of CSF formations
- 3. Stratification of Episodic Adaptations
- 4 Dialectical Functioning of OR
- 5 Conclusion
Mark Hartswood, Stuart Anderson, Lilian Blot et al.
Learning From Experience: Maintaining Flexibility In The Production Of Training Materials To Support Breast Cancer ScreeningStig O. Johnsen et Mona Veen
Risk Assessment of Critical Communication Infrastructure in Railways in NorwayFrédéric Juglaret, Jean-Marc Rallo, R. Textoris et al.
New Balanced Scorecard leading indicators to monitor performance variability in OHS management systems- 1 Background
- 1.1 Safety indicators
- 1.2 The limitations of traditional safety indicators
- 1.3 OHS safety management systems: sub-processes
- 1.4 A model of advanced indicators
- 2 The OHS Balanced Scorecard Model
- 2.1 Scorecard overview
- 2.2 Advanced indicators for regulatory compliance
- 3 Method and Results
- 3.1 Experimental context
- 3.2 Regulatory compliance indicators
- 4 Conclusion
Taro Kanno, Toshio Fujii, Ryosuke Watari et al.
Modeling And Simulation Of A Service System In A Disaster To Assess Its ResilienceDaisuke Karikawa, Makoto Takahashi, Hisae Aoyama et al.
A Simulation-based Analysis of “Resilience” in Enroute Air Traffic Control TasksMasaharu Kitamura
Extraction of Lessons from the Fukushima Daiichi Accident based on a Resilience Engineering PerspectiveAkinori Komatsubara
Resilience Management System And Development Of Resilience Capability On Site Workers- 1 Introduction
- 2 RMS: Resilience Safety Management System
- 2.1 Disaster of Fukushima Nuclear Power Plants (2011)
- 2.2 Management for Resilience
- 2.3 Resilience Capability which should be developed
- 2.4 Structure of Organizational Resilience
- 3.1 Enhancement of positive attitude; A case of Japan Airlines Plan
- Do
- Check and Act
- 3.2 Development of non-technical skills; A case of Hitachi Plant Technologies Plan
- Do
- Check and Act
- 4 Conclusion
- Acknowledgement
Elizabeth Lay, Joshua Hecht et Selena Shaefer
Generating Resilience: Handling Extraordinarily High Work Load in High Three (Intensity, Technology, Reliability) Maintenance WorkJean Christophe Le Coze, Romuald Périnet, Nicolas Herchin et al.
Observing Resilience Within A Large Technical System- 1. High Pressure Gas Transmission as a Large Technical System (LTS)
- 2. The Threat of ‘External Aggression’
- Ghislenghien’s disaster (2004)
- 3. Observing Resilience in LTS
- 3.1. Elements of methodology and theory
- 3.2. Main safety measures for preventing external aggressions
- 4. Some results
- 4.1. A task requiring constant adaptations
- 4.2. From a collective to an individual expertise
- 4.3. Towards a heuristic model of resilience in the domain of ‘external aggression’
- 5. ‘Engineering’ Resilience
- 6. Conclusion
Serge Lhomme, Marie Toubin, Damien Serre et al.
From technical resilience toward urban services resilience- 1 Introduction
- 2 The use of Safety methods to improve networks resilience
- 2.1 The methodology
- 2.2 Results
- 3 A necessary shift toward network managers
- 3.1 Collaborative approaches and their interest for networks resilience
- 3.2 Tools and methods to enable a shared diagnosis of networks resilience
- 4 Conclusion
Luigi Macchi, T. Reiman, E. Pietikäinen et al.
DISC model as a conceptual tool for engineering organisational resilience: Two case studies in nuclear and healthcare domainsChristopher Nemeth, Sterling Wiggins, Robert Strouse et al.
Engineering Naval Resilience: Expeditionary Command and Control- 1 Introduction
- 2 Naval Expeditionary combat command
- 2 Research Design
- 2.1 Preparation and Framing
- 2.2 Data Collection/Knowledge elicitation
- 2.3 Analysis and Representation
- 2.4 Concept Development
- 2.5 Evaluation
- 3 Findings
- 3.1 Sources of brittleness
- 3.2 C2 System Requirements
- 4 Discussion
- 4.1 Design for an Envisioned World
- 4.2 The Ability to Adapt
- 5 Conclusion
Pia Oedewald, N. Gotcheva, T. Reiman et al.
Managing Safety In Subcontractor Networks: The Case Of Olkiluoto3 Nuclear Power Plant Construction ProjectJean Pariès, Nicolas Lot, Fanny Rome et al.
Engineering Resilience Into Intensive Care UnitsManikam Pillay, David Borys et Dennis Else
Exploring Safe Work Method Statements In The Australian Construction Industry: A Prospective Study In Resilience EngineeringJodi Ploquin, Robert J. Brown et Brenda Clark
Bridging Professional Silos In Radiation Medicine: The Ottawa Hospital ExperienceSimone Pozzi, Carlo Valbonesi, Valentina Beato et al.
Mapping Resilience through Automatic Safety Data GatheringGesa Praetorius, Monica Lundh et Margareta Lützhöft
Learning From The Past For Pro-activity – A Re-analysis Of The Accident Of The MV Herald Of Free Enterprise- Introduction
- Methodology
- FRAM
- Step 1: Identify essential system functions
- Step 2: Determine the potential for variability of the functions
- Step 3: Define the functional resonance based on dependencies among functions
- Step 4: Formulate countermeasures
- Results and discussion
- Results from the accident investigation
- Results from the application of FRAM
- Step 1: Identifying The Essential Functions
- Step 2: Determining The Potential Variability For The Functions
- Step 3: Defining The Functional Resonance Based On Dependencies AmongThe Functions
- Step 4: Formulating Countermeasures
- Discussion
- Conclusion
- Acknowledgements
Amy Rankin, Joris Field, William Wong et al.
Scenario Design For Training Systems In Crisis Management: Training Resilience CapabilitiesTarcisio Abreu Saurin et Guido Carim Junior
A Framework For Identifying And Analyzing Sources Of Resilience And Brittleness: A Case Study Of An Air Taxi Carrier- 1 Introduction
- 2 The Proposed Framework
- 2.1 Identifying SRs and SBs
- 2.2 Analysis of the SBs and SRs
- 3. Research Method
- 4. Results
- 4.1 Main characteristics of the socio-technical system
- 4.2 Sources of brittleness
- 4.3 Sources of resilience
- 5. Discussions and conclusions
- 5.1 Overall assessment of the company investigated
- 5.2 Assessment of the framework
Tarcisio Abreu Saurin, Camila Campos Famá et Carlos Torres Formoso
Principles For Designing H&S Performance Measurement Systems: Insights From Resilience Engineering- 1 Introduction
- 2 Principles for the design of HSPMS from the RE perspective
- 3 Research Method
- 4 The HSPMS of the Company Investigated
- 5 Evaluation of the HSPMS Design Principles
- 5.1 The HSPMS should monitor the organization's strategies for adjusting to variability
- 5.2 The HSPMS should monitor vulnerabilities throughout the socio-technical system
- 5.3 Managing HS is inseparable from managing other dimensions of the organization
- 6 Conclusions
Samuel B Sheps, Karen Cardiff et Rob Robson
Patient Safety: A Wakeup Call And Resilient Response- Patient safety: A wake up call
- Public events vs private events
- Quality is not safety, and safety is not quality
- Normal accidents: Old view vs new view
- Oranizational/professional self image
- Communication between senior management and front line staff
- Risk management or learning from critical incidents
- Isolation and siloing of current efforts
- Conclusion
- Acknowledgement
Robert J. Stephens, David D. Woods, Matthieu Branlat et al.
Colliding Dilemmas: Interactions Of Locally Adaptive Strategies In A Hospital SettingJohan Van der Vorm, Dolf Van der Beek, Ellen Bos et al.
Images Of Resilience: The Resilience Analysis Grid Applicable At Several Organizational Levels?Robert L. Wears et L. Kendall Webb
Fundamental On Situational Surprise: A Case Study With Implications For ResilienceDavid D. Woods et Matthieu Branlat
How Human Adaptive Systems Balance Fundamental Trade-offs: Implications For Polycentric Governance Architectures- 1 Introduction
- 2 Five Bounds
- 2.1 Bounded Ecology – the optimality-fragility trade-off
- 2.2 Bounded Cognizance – the efficiency-thoroughness trade-off
- 2.3 Bounded Perspectivity -- the acute-chronic trade-off
- 2.4 Bounded Responsibility -- the specialist-generalist tradeoff
- 2.5 Bounded Effectivity -- the distributed-concentrated tradeoff
- 3 Unifying Fundamentals
- 4 Polycentric Control Architectures
Kyla Zimmermann (née Steele)
Safety In Numbers? Using Graphs Or Gut Feelings When It Comes To Safety