Erik Hollnagel - Böcker

The book demonstrates how Resilient Health Care principles can enable those on the frontline to work more effectively towards interdisciplinary care by gaining a deeper understanding of the boundaries that exist in everyday clinical settings. This is done by presenting a set of case studies, theoretical chapters and applications that relate experiences, bring forth ideas and illustrate practical solutions. The chapters address many different issues such as resolving conflict, overcoming barriers to patient-flow management, and building connections through negotiation. They represent a range of approaches, rather than a single way of solving the practical problems, and have been written to serve both a scientific and an andragogical purpose. Working Across Boundaries is primarily aimed at people who are directly involved in the running and improvement of health care systems, providing them with practical guidance. It will also be of direct interest to health care professionals in clinical and managerial positions as well as researchers.Presents the latest work of the lauded Resilient Health Care Net group, developing applications of Resilience Engineering to health care, furthering safety thinking and generating applicable solutions that will benefit patient safety worldwideEnables health care professionals to become aware of the boundaries that affect their work so that they are able to use their strengths and overcome their weaknessesWritten from a Safety-II perspective, where the purpose is to make sure that as much as possible goes well and the focus therefore is on everyday work rather than on failures. There are at present no other books that adopt this perspective nor which go into the practical detailsProvides a concise presentation of the state of resilient health care as a science, in terms of major theoretical issues and practical methods and techniques on the overarching and important topics of boundary-crossing and integration of care settings

The book demonstrates how Resilient Health Care principles can enable those on the frontline to work more effectively towards interdisciplinary care by gaining a deeper understanding of the boundaries that exist in everyday clinical settings. This is done by presenting a set of case studies, theoretical chapters and applications that relate experiences, bring forth ideas and illustrate practical solutions. The chapters address many different issues such as resolving conflict, overcoming barriers to patient-flow management, and building connections through negotiation. They represent a range of approaches, rather than a single way of solving the practical problems, and have been written to serve both a scientific and an andragogical purpose. Working Across Boundaries is primarily aimed at people who are directly involved in the running and improvement of health care systems, providing them with practical guidance. It will also be of direct interest to health care professionals in clinical and managerial positions as well as researchers.Presents the latest work of the lauded Resilient Health Care Net group, developing applications of Resilience Engineering to health care, furthering safety thinking and generating applicable solutions that will benefit patient safety worldwideEnables health care professionals to become aware of the boundaries that affect their work so that they are able to use their strengths and overcome their weaknessesWritten from a Safety-II perspective, where the purpose is to make sure that as much as possible goes well and the focus therefore is on everyday work rather than on failures. There are at present no other books that adopt this perspective nor which go into the practical detailsProvides a concise presentation of the state of resilient health care as a science, in terms of major theoretical issues and practical methods and techniques on the overarching and important topics of boundary-crossing and integration of care settings

Preparation and Restoration is the second volume of Resilience Engineering Perspectives within the Ashgate Studies in Resilience Engineering series. In four sections, it broadens participation of the field to include policy and organization studies, and articulates aspects of resilience beyond initial definitions: - Policy and Organization explores public policy and organizational aspects of resilience and how they aid or inhibit preparation and restoration - Models and Measures addresses thoughts on ways to measure resilience and model systems to detect desirable, and undesirable, results - Elements and Traits examines features of systems and how they affect the ability to prepare for and recover from significant challenges - Applications and Implications examines how resilience plays out in the living laboratory of real-world operations. Preparation and Restoration addresses issues such as the nature of resilience; the similarities and differences between resilience and traditional ideas of system performance; how systems cope with varying demands and sometimes succeed and sometimes fail; how an organization's ways of preparing before critical events can enable or impede restoration; the trade-offs that are needed for systems to operate and survive; instances of brittle or resilient systems; how work practices affect resilience; the relationship between resilience and safety; and what improves or erodes resilience. This volume is valuable reading for those who create and operate systems that must not only survive, but thrive, in the face of challenge.

The complexity of today’s large organisations, businesses, and social institutions defeats management approaches based on monolithic thinking. Most industry and service organisations look at their performance either from a single perspective – productivity, quality, safety, etc. – or from different but separate perspectives that reside in organisational silos. Quality is treated separately from safety, which, again, is treated separately from productivity, and so on. While siloed thinking may be convenient in the short term, it fails to recognise that any specific perspective reveals only a part of what goes on. Yet it is essential to have a unified view of how an organisation functions effectively to manage changes and to ensure the organisation excels in what it does.Synesis represents the mutually dependent set of priorities, perspectives, and practices that an organisation needs to carry out its activities as intended. It shows how to overcome the fragmentation in foci, scope, and time that characterises the dominant change management paradigms. This book is consequently not about productivity or quality or safety or reliability but about all of these together. It is about why it is necessary to think of them as a whole. And it is about how this can be done in practice.

The complexity of today’s large organisations, businesses, and social institutions defeats management approaches based on monolithic thinking. Most industry and service organisations look at their performance either from a single perspective – productivity, quality, safety, etc. – or from different but separate perspectives that reside in organisational silos. Quality is treated separately from safety, which, again, is treated separately from productivity, and so on. While siloed thinking may be convenient in the short term, it fails to recognise that any specific perspective reveals only a part of what goes on. Yet it is essential to have a unified view of how an organisation functions effectively to manage changes and to ensure the organisation excels in what it does.Synesis represents the mutually dependent set of priorities, perspectives, and practices that an organisation needs to carry out its activities as intended. It shows how to overcome the fragmentation in foci, scope, and time that characterises the dominant change management paradigms. This book is consequently not about productivity or quality or safety or reliability but about all of these together. It is about why it is necessary to think of them as a whole. And it is about how this can be done in practice.

This book promotes an understanding of the purposeful muddling that health care workers rely on to be better able to function and operate in the multitude of complex ecosystems we call "health care."The book argues the case for the importance of recognising and understanding muddling behaviours, practices and activities in order to create resilient care. The book demonstrates how resilient health care principles can enable managers as well as those on the frontlines to work more effectively towards interdisciplinary care by gaining a deeper understanding of real-world practices that manifest in everyday clinical settings. This is done by presenting a set of case studies, theoretical chapters and applications that relate experiences, bring forth ideas and illustrate practical solutions.Primarily aimed at people who are directly involved in the running and improvement of health care systems, it provides practical guidance. It is also of direct interest to health care professionals in clinical and managerial positions as well as researchers.Jeffrey Braithwaite is Founding Director of the Australian Institute of Health Innovation, Professor of Health Systems Research and Director of the Centre for Healthcare Resilience and Implementation Science, Macquarie University (Australia). His research examines the changing nature of complex health systems and he has received over 50 different national and international awards for his teaching and research.Erik Hollnagel is Senior Professor of Patient Safety at Jönköping University (Sweden). He is a highly regarded international expert with significant contributions to a variety of fields ranging from nuclear power generation, aerospace and aviation to industry, transportation and, most notably, health care.Garthe Hunte is a Clinical Professor and Emergency Physician holding multiple academic and clinical leadership appointments across Canada. His research programme centres around how safety is created in complex socio-technical systems, and in the application of resilience engineering in health care.

This book promotes an understanding of the purposeful muddling that health care workers rely on to be better able to function and operate in the multitude of complex ecosystems we call "health care."The book argues the case for the importance of recognising and understanding muddling behaviours, practices and activities in order to create resilient care. The book demonstrates how resilient health care principles can enable managers as well as those on the frontlines to work more effectively towards interdisciplinary care by gaining a deeper understanding of real-world practices that manifest in everyday clinical settings. This is done by presenting a set of case studies, theoretical chapters and applications that relate experiences, bring forth ideas and illustrate practical solutions.Primarily aimed at people who are directly involved in the running and improvement of health care systems, it provides practical guidance. It is also of direct interest to health care professionals in clinical and managerial positions as well as researchers.Jeffrey Braithwaite is Founding Director of the Australian Institute of Health Innovation, Professor of Health Systems Research and Director of the Centre for Healthcare Resilience and Implementation Science, Macquarie University (Australia). His research examines the changing nature of complex health systems and he has received over 50 different national and international awards for his teaching and research.Erik Hollnagel is Senior Professor of Patient Safety at Jönköping University (Sweden). He is a highly regarded international expert with significant contributions to a variety of fields ranging from nuclear power generation, aerospace and aviation to industry, transportation and, most notably, health care.Garthe Hunte is a Clinical Professor and Emergency Physician holding multiple academic and clinical leadership appointments across Canada. His research programme centres around how safety is created in complex socio-technical systems, and in the application of resilience engineering in health care.

Our fascination with new technologies is based on the assumption that more powerful automation will overcome human limitations and make our systems 'faster, better, cheaper,' resulting in simple, easy tasks for people. But how does new technology and more powerful automation change our work?Research in Cognitive Systems Engineering (CSE) looks at the intersection of people, technology, and work. What it has found is not stories of simplification through more automation, but stories of complexity and adaptation. When work changed through new technology, practitioners had to cope with new complexities and tighter constraints. They adapted their strategies and the artifacts to work around difficulties and accomplish their goals as responsible agents. The surprise was that new powers had transformed work, creating new roles, new decisions, and new vulnerabilities. Ironically, more autonomous machines have created the requirement for more sophisticated forms of coordination across people, and across people and machines, to adapt to new demands and pressures.This book synthesizes these emergent Patterns though stories about coordination and mis-coordination, resilience and brittleness, affordance and clumsiness in a variety of settings, from a hospital intensive care unit, to a nuclear power control room, to a space shuttle control center. The stories reveal how new demands make work difficult, how people at work adapt but get trapped by complexity, and how people at a distance from work oversimplify their perceptions of the complexities, squeezing practitioners. The authors explore how CSE observes at the intersection of people, technology, and work, how CSE abstracts patterns behind the surface details and wide variations, and how CSE discovers promising new directions to help people cope with complexities. The stories of CSE show that one key to well-adapted work is the ability to be prepared to be surprised. Are you ready?

Nothing has been more prolific over the past century than human/machine interaction. Automobiles, telephones, computers, manufacturing machines, robots, office equipment, machines large and small; all affect the very essence of our daily lives. However, this interaction has not always been efficient or easy and has at times turned fairly hazardous. Cognitive Systems Engineering (CSE) seeks to improve this situation by the careful study of human/machine interaction as the meaningful behavior of a unified system.Written by pioneers in the development of CSE, Joint Cognitive Systems: Foundations of Cognitive Systems Engineering offers a principled approach to studying human work with complex technology. The authors use a top-down, functional approach and emphasize a proactive (coping) perspective on work that overcomes the limitations of the structural human information processing view. They describe a conceptual framework for analysis with concrete theories and methods for joint system modeling that can be applied across the spectrum of single human/machine systems, social/technical systems, and whole organizations. The book explores both current and potential applications of CSE illustrated by examples.Understanding the complexities and functions of the human/machine interaction is critical to designing safe, highly functional, and efficient technological systems. This is a critical reference for students, designers, and engineers in a wide variety of disciplines.

This book is the 3rd volume in the Resilient Health Care series. Resilient health care is a product of both the policy and managerial efforts to organize, fund and improve services, and the clinical care which is delivered directly to patients. This volume continues the lines of thought in the first two books. Where the first volume provided the rationale and basic concepts of RHC and the second teased out the everyday clinical activities which adjust and vary to create safe care, this book will look more closely at the connections between the sharp and blunt ends. Doing so will break new ground, since the systematic study in patient safety to date with few exceptions has been limited.

Accidents are preventable, but only if they are correctly described and understood. Since the mid-1980s accidents have come to be seen as the consequence of complex interactions rather than simple threads of causes and effects. Yet progress in accident models has not been matched by advances in methods. The author's work in several fields (aviation, power production, traffic safety, healthcare) made it clear that there is a practical need for constructive methods and this book presents the experiences and the state-of-the-art. The focus of the book is on accident prevention rather than accident analysis and unlike other books, has a proactive rather than reactive approach. The emphasis on design rather than analysis is a trend also found in other fields. Features of the book include: -A classification of barrier functions and barrier systems that will enable the reader to appreciate the diversity of barriers and to make informed decisions for system changes. -A perspective on how the understanding of accidents (the accident model) largely determines how the analysis is done and what can be achieved. The book critically assesses three types of accident models (sequential, epidemiological, systemic) and compares their strengths and weaknesses. -A specific accident model that captures the full complexity of systemic accidents. One consequence is that accidents can be prevented through a combination of performance monitoring and barrier functions, rather than through the elimination or encapsulation of causes. -A clearly described methodology for barrier analysis and accident prevention. Written in an accessible style, Barriers and Accident Prevention is designed to provide a stimulating and practical guide for industry professionals familiar with the general ideas of accidents and human error. The book is directed at those involved with accident analysis and system safety, such as managers of safety departments, risk and safety consultants, human factors professionals, and accident investigators. It is applicable to all major application areas such as aviation, ground transportation, maritime, process industries, healthcare and hospitals, communication systems, and service providers.

For Resilience Engineering, 'failure' is the result of the adaptations necessary to cope with the complexity of the real world, rather than a breakdown or malfunction. The performance of individuals and organizations must continually adjust to current conditions and, because resources and time are finite, such adjustments are always approximate. This definitive new book explores this groundbreaking new development in safety and risk management, where 'success' is based on the ability of organizations, groups and individuals to anticipate the changing shape of risk before failures and harm occur. Featuring contributions from many of the worlds leading figures in the fields of human factors and safety, Resilience Engineering provides thought-provoking insights into system safety as an aggregate of its various components, subsystems, software, organizations, human behaviours, and the way in which they interact. The book provides an introduction to Resilience Engineering of systems, covering both the theoretical and practical aspects. It is written for those responsible for system safety on managerial or operational levels alike, including safety managers and engineers (line and maintenance), security experts, risk and safety consultants, human factors professionals and accident investigators.

For Resilience Engineering, 'failure' is the result of the adaptations necessary to cope with the complexity of the real world, rather than a breakdown or malfunction. The performance of individuals and organizations must continually adjust to current conditions and, because resources and time are finite, such adjustments are always approximate. This definitive new book explores this groundbreaking new development in safety and risk management, where 'success' is based on the ability of organizations, groups and individuals to anticipate the changing shape of risk before failures and harm occur. Featuring contributions from many of the worlds leading figures in the fields of human factors and safety, Resilience Engineering provides thought-provoking insights into system safety as an aggregate of its various components, subsystems, software, organizations, human behaviours, and the way in which they interact. The book provides an introduction to Resilience Engineering of systems, covering both the theoretical and practical aspects. It is written for those responsible for system safety on managerial or operational levels alike, including safety managers and engineers (line and maintenance), security experts, risk and safety consultants, human factors professionals and accident investigators.

In the resilience engineering approach to safety, failures and successes are seen as two different outcomes of the same underlying process, namely how people and organizations cope with complex, underspecified and therefore partly unpredictable work environments. Therefore safety can no longer be ensured by constraining performance and eliminating risks. Instead, it is necessary to actively manage how people and organizations adjust what they do to meet the current conditions of the workplace, by trading off efficiency and thoroughness and by making sacrificing decisions. The Ashgate Studies in Resilience Engineering series promulgates new methods, principles and experiences that can complement established safety management approaches, providing invaluable insights and guidance for practitioners and researchers alike in all safety-critical domains. While the Studies pertain to all complex systems they are of particular interest to high hazard sectors such as aviation, ground transportation, the military, energy production and distribution, and healthcare. Published periodically within this series will be edited volumes titled Resilience Engineering Perspectives. The first volume, Remaining Sensitive to the Possibility of Failure, presents a collection of 20 chapters from international experts. This collection deals with important issues such as measurements and models, the use of procedures to ensure safety, the relation between resilience and robustness, safety management, and the use of risk analysis. The final six chapters utilise the report from a serious medical accident to illustrate more concretely how resilience engineering can make a difference, both to the understanding of how accidents happen and to what an organisation can do to become more resilient.

Preparation and Restoration is the second volume of Resilience Engineering Perspectives within the Ashgate Studies in Resilience Engineering series. In four sections, it broadens participation of the field to include policy and organization studies, and articulates aspects of resilience beyond initial definitions: - Policy and Organization explores public policy and organizational aspects of resilience and how they aid or inhibit preparation and restoration - Models and Measures addresses thoughts on ways to measure resilience and model systems to detect desirable, and undesirable, results - Elements and Traits examines features of systems and how they affect the ability to prepare for and recover from significant challenges - Applications and Implications examines how resilience plays out in the living laboratory of real-world operations. Preparation and Restoration addresses issues such as the nature of resilience; the similarities and differences between resilience and traditional ideas of system performance; how systems cope with varying demands and sometimes succeed and sometimes fail; how an organization's ways of preparing before critical events can enable or impede restoration; the trade-offs that are needed for systems to operate and survive; instances of brittle or resilient systems; how work practices affect resilience; the relationship between resilience and safety; and what improves or erodes resilience. This volume is valuable reading for those who create and operate systems that must not only survive, but thrive, in the face of challenge.

Accident investigation and risk assessment have for decades focused on the human factor, particularly 'human error'. Countless books and papers have been written about how to identify, classify, eliminate, prevent and compensate for it. This bias towards the study of performance failures, leads to a neglect of normal or 'error-free' performance and the assumption that as failures and successes have different origins there is little to be gained from studying them together. Erik Hollnagel believes this assumption is false and that safety cannot be attained only by eliminating risks and failures. The ETTO Principle looks at the common trait of people at work to adjust what they do to match the conditions - to what has happened, to what happens, and to what may happen. It proposes that this efficiency-thoroughness trade-off (ETTO) - usually sacrificing thoroughness for efficiency - is normal. While in some cases the adjustments may lead to adverse outcomes, these are due to the very same processes that produce successes, rather than to errors and malfunctions. The ETTO Principle removes the need for specialised theories and models of failure and 'human error' and offers a viable basis for effective and just approaches to both reactive and proactive safety management.

Accident investigation and risk assessment have for decades focused on the human factor, particularly 'human error'. Countless books and papers have been written about how to identify, classify, eliminate, prevent and compensate for it. This bias towards the study of performance failures, leads to a neglect of normal or 'error-free' performance and the assumption that as failures and successes have different origins there is little to be gained from studying them together. Erik Hollnagel believes this assumption is false and that safety cannot be attained only by eliminating risks and failures. The ETTO Principle looks at the common trait of people at work to adjust what they do to match the conditions - to what has happened, to what happens, and to what may happen. It proposes that this efficiency-thoroughness trade-off (ETTO) - usually sacrificing thoroughness for efficiency - is normal. While in some cases the adjustments may lead to adverse outcomes, these are due to the very same processes that produce successes, rather than to errors and malfunctions. The ETTO Principle removes the need for specialised theories and models of failure and 'human error' and offers a viable basis for effective and just approaches to both reactive and proactive safety management.

Technological development has changed the nature of industrial production so that it is no longer a question of humans working with a machine, but rather that a joint human machine system is performing the task. This development, which started in the 1940s, has become even more pronounced with the proliferation of computers and the invasion of digital technology in all wakes of working life. It may appear that the importance of human work has been reduced compared to what can be achieved by intelligent software systems, but in reality, the opposite is true: the more complex a system, the more vital the human operator's task. The conditions have changed, however, whereas people used to be in control of their own tasks, today they have become supervisors of tasks which are shared between humans and machines. A considerable effort has been devoted to the domain of administrative and clerical work and has led to the establishment of an internationally based human-computer interaction (HCI) community at research and application levels. The HCI community, however, has paid more attention to static environments where the human operator is in complete control of the situation, rather than to dynamic environments where changes may occur independent of human intervention and actions. This book's basic philosophy is the conviction that human operators remain the unchallenged experts even in the worst cases where their working conditions have been impoverished by senseless automation. They maintain this advantage due to their ability to learn and build up a high level of expertise -- a foundation of operational knowledge -- during their work. This expertise must be taken into account in the development of efficient human-machine systems, in the specification of training requirements, and in the identification of needs for specific computer support to human actions. Supporting this philosophy, this volume *deals with the main features of cognition in dynamic environments, combining issues coming from empirical approaches of human cognition and cognitive simulation, *addresses the question of the development of competence and expertise, and *proposes ways to take up the main challenge in this domain -- the design of an actual cooperation between human experts and computers of the next century.

This Handbook serves as a single source for theories, models, and methods related to cognitive task design. It provides the scientific and theoretical basis required by industrial and academic researchers, as well as the practical and methodological guidance needed by practitioners who face problems of building safe and effective human-technology systems.Fundamental across a wide range of disciplines, from military systems to consumer goods and process industries, cognitive task design covers the whole life-cycle of work from pre-analysis, specification, design, risk assessment, implementation, training, daily operation, fault finding, maintenance, and upgrading. It applies to people, sophisticated machines, and to human-machine ensembles. This comprehensive volume summarizes the extensive, worldwide experience with cognitive task design since the 1980s; it defines the state of the art and outlines the future of this ever-developing field.Aimed at the graduate and postgraduate level, the Handbook of Cognitive Task Design is applicable to courses relating to the design of human-technology systems, interaction design, cognitive engineering, and applied industrial engineering.

Nothing has been more prolific over the past century than human/machine interaction. Automobiles, telephones, computers, manufacturing machines, robots, office equipment, machines large and small; all affect the very essence of our daily lives. However, this interaction has not always been efficient or easy and has at times turned fairly hazardous. Cognitive Systems Engineering (CSE) seeks to improve this situation by the careful study of human/machine interaction as the meaningful behavior of a unified system.Written by pioneers in the development of CSE, Joint Cognitive Systems: Foundations of Cognitive Systems Engineering offers a principled approach to studying human work with complex technology. The authors use a top-down, functional approach and emphasize a proactive (coping) perspective on work that overcomes the limitations of the structural human information processing view. They describe a conceptual framework for analysis with concrete theories and methods for joint system modeling that can be applied across the spectrum of single human/machine systems, social/technical systems, and whole organizations. The book explores both current and potential applications of CSE illustrated by examples.Understanding the complexities and functions of the human/machine interaction is critical to designing safe, highly functional, and efficient technological systems. This is a critical reference for students, designers, and engineers in a wide variety of disciplines.

Our fascination with new technologies is based on the assumption that more powerful automation will overcome human limitations and make our systems 'faster, better, cheaper,' resulting in simple, easy tasks for people. But how does new technology and more powerful automation change our work?Research in Cognitive Systems Engineering (CSE) looks at the intersection of people, technology, and work. What it has found is not stories of simplification through more automation, but stories of complexity and adaptation. When work changed through new technology, practitioners had to cope with new complexities and tighter constraints. They adapted their strategies and the artifacts to work around difficulties and accomplish their goals as responsible agents. The surprise was that new powers had transformed work, creating new roles, new decisions, and new vulnerabilities. Ironically, more autonomous machines have created the requirement for more sophisticated forms of coordination across people, and across people and machines, to adapt to new demands and pressures.This book synthesizes these emergent Patterns though stories about coordination and mis-coordination, resilience and brittleness, affordance and clumsiness in a variety of settings, from a hospital intensive care unit, to a nuclear power control room, to a space shuttle control center. The stories reveal how new demands make work difficult, how people at work adapt but get trapped by complexity, and how people at a distance from work oversimplify their perceptions of the complexities, squeezing practitioners. The authors explore how CSE observes at the intersection of people, technology, and work, how CSE abstracts patterns behind the surface details and wide variations, and how CSE discovers promising new directions to help people cope with complexities. The stories of CSE show that one key to well-adapted work is the ability to be prepared to be surprised. Are you ready?

The conventional interpretation of safety, known as Safety-I, denotes a condition where as little as possible goes wrong, and the focus of practical efforts in management or analysis is on the occurrence of unacceptable outcomes and on how to reduce their number to an acceptable level, ideally zero. The emphasis is therefore on how to manage safety as such, as seen in the ubiquitous safety management systems (SMS). As Professor James Reason astutely points out, this raises the interesting question of how it is possible to learn about something, let alone manage it, if it is studied only in situations in which it is absent. The solution proposed by and described in this book is to stop using safety as a noun and instead use it as an adverb: safely.Now often referred to as Safety-II, this solution is the logical consequence of resilience engineering and will require new methods, several of which already exist and have proved their worth in practice for years. The question ceases being what to manage and becomes how to manage. Managing safety is protective, hence a non-productive cost, which at best avoids a loss. Conversely, managing safely is productive and can generate revenue in addition to preventing or avoiding losses; aviation and mining are prime examples.From Safety to Safely provides a practical perspective on managing safely, illustrating a practical form of synesis. It offers a new understanding of safety, combining concerns for productivity and safety rather than juxtaposing them, and it shows how to manage complex industrial and social systems in the spirit of resilience engineering and synesis. It is the first book to completely dispense with the loaded term "safety" while offering a practical and viable alternative. Spoiler alert: this book does not mention or analyse any celebrated accidents.This book is for all middle and senior managers, board members, and independent consultants seeking to ensure safe, revenue-generating operations.

The conventional interpretation of safety, known as Safety-I, denotes a condition where as little as possible goes wrong, and the focus of practical efforts in management or analysis is on the occurrence of unacceptable outcomes and on how to reduce their number to an acceptable level, ideally zero. The emphasis is therefore on how to manage safety as such, as seen in the ubiquitous safety management systems (SMS). As Professor James Reason astutely points out, this raises the interesting question of how it is possible to learn about something, let alone manage it, if it is studied only in situations in which it is absent. The solution proposed by and described in this book is to stop using safety as a noun and instead use it as an adverb: safely.Now often referred to as Safety-II, this solution is the logical consequence of resilience engineering and will require new methods, several of which already exist and have proved their worth in practice for years. The question ceases being what to manage and becomes how to manage. Managing safety is protective, hence a non-productive cost, which at best avoids a loss. Conversely, managing safely is productive and can generate revenue in addition to preventing or avoiding losses; aviation and mining are prime examples.From Safety to Safely provides a practical perspective on managing safely, illustrating a practical form of synesis. It offers a new understanding of safety, combining concerns for productivity and safety rather than juxtaposing them, and it shows how to manage complex industrial and social systems in the spirit of resilience engineering and synesis. It is the first book to completely dispense with the loaded term "safety" while offering a practical and viable alternative. Spoiler alert: this book does not mention or analyse any celebrated accidents.This book is for all middle and senior managers, board members, and independent consultants seeking to ensure safe, revenue-generating operations.

Safety is a concept as complex as it is crucial. In this new book, Erik Hollnagel reimagines how we approach, understand, and manage safety in modern contexts. It challenges traditional perspectives while weaving together historical insights, cultural analysis, and practical guidance to offer a richer understanding of what it means to work and live safely.Decremental and Incremental Safety Cultures: Safety-I and Safety-II Revisited goes beyond identifying and analyzing safety issues to offer practicable strategies that balance protection and productivity. From the ambivalence of safety and the dialectics of outcomes to the seven stages of safety thinking, each chapter highlights a key aspect of safety practices. It introduces new frameworks including the deconstruction of everyday work and safety solutionism, offering readers the tools to critically assess their own safety measures and form better outcomes. Written in clear, jargon-free language, the book ensures that these insights are accessible to everyone, regardless of their background or experience and readers will develop a decremental and incremental safety.This book is an ideal read for professionals in the fields of occupational health and safety, human factors and risk management. If you have read Safety-I and Safety-II (CRC Press, 9781472423085) by the same author, this book is a must-have to understand the next phase of the Safety-I and Safety-II concepts.

Safety is a concept as complex as it is crucial. In this new book, Erik Hollnagel reimagines how we approach, understand, and manage safety in modern contexts. It challenges traditional perspectives while weaving together historical insights, cultural analysis, and practical guidance to offer a richer understanding of what it means to work and live safely.Decremental and Incremental Safety Cultures: Safety-I and Safety-II Revisited goes beyond identifying and analyzing safety issues to offer practicable strategies that balance protection and productivity. From the ambivalence of safety and the dialectics of outcomes to the seven stages of safety thinking, each chapter highlights a key aspect of safety practices. It introduces new frameworks including the deconstruction of everyday work and safety solutionism, offering readers the tools to critically assess their own safety measures and form better outcomes. Written in clear, jargon-free language, the book ensures that these insights are accessible to everyone, regardless of their background or experience and readers will develop a decremental and incremental safety.This book is an ideal read for professionals in the fields of occupational health and safety, human factors and risk management. If you have read Safety-I and Safety-II (CRC Press, 9781472423085) by the same author, this book is a must-have to understand the next phase of the Safety-I and Safety-II concepts.

The recent financial crisis has made it paramount for the financial services industry to find new perspectives to look at their industry and, most importantly, to gain a better understanding of how the global financial system can be made less vulnerable and more resilient. The primary objective of this book is to illustrate how the safety science of Resilience Engineering can help to gain a better understanding of what the financial services system is and how to improve governance and control of financial services systems by leveraging some of its key concepts. Resilience is the intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions. This definition is focused on the ability to function, rather than just to be impervious to failure, and thereby bridges the traditional conflict between productivity and safety. The core concept of the book is that the behaviour of the financial services system is the result of the tight couplings among the humans, organizations and technologies that are necessary to provide complex financial functions such as the transfer of economic resources. It is a consequence of this perspective that the risks associated with these systems cannot be understood without considering the nature of these tight couplings. Adopting this perspective, the book is designed to provide some answers to the following key questions about the financial crisis: - What actually happened? - Why and how did it happen? - Could something similar happen again? How can we see that in time and how can we control it? - How can sustainable recovery of the global financial system be established? How can its resilience be improved?

While a quick response can save you in a time of crisis, avoiding a crisis remains the best defense. When dealing with complex industrial systems, it has become increasingly obvious that preparedness requires a sophisticated understanding of human factors as they relate to the functional characteristics of socio-technology systems. Edited by industrial safety expert Erik Hollnagel and featuring commentary from leaders in the field, Safer Complex Industrial Environments: A Human Factors Approach examines the latest research on the contemporary human factors approach and methods currently in practice. Drawing on examples mainly from the nuclear industry, the book presents a contemporary view on human factors in complex industrial systems. The contributors contrast the traditional view of human factors as a liability with the contemporary view that recognizes human factor as also an asset without which the safe and efficient performance of complex industrial systems would be impossible. It describes how this view has developed in parallel to the increasing complexity and intractability of socio-technical systems and partly as a consequence of that. The book also demonstrates how this duality of the human factor can be reconciled by recognizing that the human and organizational functions that can be the cause of adverse events are also the very foundation for safety.Building on this, the book introduces theories and methods that can be used to describe human and collective performance in a complex socio-technical environment. It explores how contemporary human factors can be used to go beyond failure analysis to actively make complex industrial environments safer.

Accidents are preventable, but only if they are correctly described and understood. Since the mid-1980s accidents have come to be seen as the consequence of complex interactions rather than simple threads of causes and effects. Yet progress in accident models has not been matched by advances in methods. The author's work in several fields (aviation, power production, traffic safety, healthcare) made it clear that there is a practical need for constructive methods and this book presents the experiences and the state-of-the-art. The focus of the book is on accident prevention rather than accident analysis and unlike other books, has a proactive rather than reactive approach. The emphasis on design rather than analysis is a trend also found in other fields. Features of the book include: -A classification of barrier functions and barrier systems that will enable the reader to appreciate the diversity of barriers and to make informed decisions for system changes. -A perspective on how the understanding of accidents (the accident model) largely determines how the analysis is done and what can be achieved. The book critically assesses three types of accident models (sequential, epidemiological, systemic) and compares their strengths and weaknesses. -A specific accident model that captures the full complexity of systemic accidents. One consequence is that accidents can be prevented through a combination of performance monitoring and barrier functions, rather than through the elimination or encapsulation of causes. -A clearly described methodology for barrier analysis and accident prevention. Written in an accessible style, Barriers and Accident Prevention is designed to provide a stimulating and practical guide for industry professionals familiar with the general ideas of accidents and human error. The book is directed at those involved with accident analysis and system safety, such as managers of safety departments, risk and safety consultants, human factors professionals, and accident investigators. It is applicable to all major application areas such as aviation, ground transportation, maritime, process industries, healthcare and hospitals, communication systems, and service providers.

Health care is under tremendous pressure regarding efficiency, safety, and economic viability. It has responded by adopting techniques that have been useful in other industries, such as quality management, lean production, and high reliability – although with limited, and all-too-often disappointing, results. The Resilient Health Care Network (RHCN) has worked since 2011 to facilitate the interaction and collaboration among practitioners and researchers interested in applying concepts from resilience engineering to health care and patient safety. This has met with considerable success, not least because the focus from the start was on developing concrete ways to complement a Safety-I perspective with a Safety-II perspective.Building on previous volumes, Delivering Resilient Health Care presents documented experiences and practical guidance on how to bring Resilient Health Care into practice. It provides concrete advice on how to prepare a study, how to choose the right data, how to collect it, how to analyse the data, and how to interpret the results. This fourth book in the Resilient Healthcare series contains contributions from international experts in health care, organisational studies and patient safety, as well as resilience engineering. This book provides a practical guide for delivering resilient healthcare, particularly for clinicians on the frontline of care unsure how to incorporate resilience into their everyday work, managers coordinating care, and for policymakers hoping to steer the system in the right direction. Other groups – patients, the media, and researchers – will also find much of interest here.