Resilience Engineering

Table of contents

1. Cover
2. Half Title
3. Title Page
4. Copyright Page
5. Table of Contents
6. PREFACE
7. PROLOGUE: RESILIENCE ENGINEERING CONCEPTS
   1. Hindsight and Safety
   2. From Reactive to Proactive Safety
   3. Resilience
8. PART I: EMERGENCE
   1. 1 RESILIENCE: THE CHALLENGE OF THE UNSTABLE
      1. Understanding Accidents
      2. Anticipating Risks
      3. SYSTEMS ARE EVER-CHANGING
   2. 2 ESSENTIAL CHARACTERISTICS OF RESILIENCE
      1. Avoiding the Error of the Third Kind
      2. Dynamic Balancing Acts
      3. Acknowledgements
   3. 3 DEFINING RESILIENCE
      1. Pictures of Resilience
      2. How Do We Recognise Resilience When We See It?
      3. Is Road Traffic Resilient?
      4. Conclusion
      5. NATURE OF CHANGES IN SYSTEMS
   4. 4 COMPLEXITY, EMERGENCE, RESILIENCE …
      1. Introduction
      2. Emergence and Systems
      3. From Emergence to Resilience
      4. Conclusion
   5. 5 A TYPOLOGY OF RESILIENCE SITUATIONS
      1. Resilience against What?
      2. Situation I. The Regular Threat
      3. Situation II. The Irregular Threat
      4. Situation III. The Unexampled Event
      5. Time: Foresight, Coping, and Recovery
      6. Foresee and Avoid
      7. Coping with Ongoing Trouble
      8. Repairing after Catastrophe
      9. Conclusion
      10. Acknowledgement
      11. RESILIENT SYSTEMS
   6. 6 INCIDENTS – MARKERS OF RESILIENCE OR BRITTLENESS?
      1. Incidents are Ambiguous
      2. ‘Decompensation:’ A Pattern in Adaptive Response
      3. Acknowledgements
   7. 7 RESILIENCE ENGINEERING: CHRONICLING THE EMERGENCE OF CONFUSED CONSENSUS
      1. Resilience Engineering and Getting Smarter at Predicting the Next Accident
      2. Modelling the Drift into Failure
      3. Work as Imagined versus Work as Actually Done
      4. Towards Broader Markers of Resilience
9. PART II: CASES AND PROCESSES
   1. 8 ENGINEERING RESILIENCE INTO SAFETY-CRITICAL SYSTEMS
      1. Resilience and Safety
      2. STAMP
      3. The Models
      4. Principal Findings and Anticipated Outcomes/Benefits
      5. Implications for Designing and Operating Resilient Systems
   2. 9 IS RESILIENCE REALLY NECESSARY? THE CASE OF RAILWAYS
      1. Introduction
      2. Observations on Safety Management in Railway Track Maintenance
      3. Assessing Resilience
      4. Discussion and Conclusions
      5. SYSTEMS ARE NEVER PERFECT
   3. 10 STRUCTURE FOR MANAGEMENT OF WEAK AND DIFFUSE SIGNALS
      1. Problem Awareness
      2. Forum for Consultation
      3. Strengthening the Forum
      4. Other Fora
      5. A Bundle of Arrows
   4. 11 ORGANIZATIONAL RESILIENCE AND INDUSTRIAL RISK
      1. Introduction
      2. What is the Nature of Resilience?
      3. Planning and Flexibility in Operational Systems
      4. The Role of Quality and Safety in Achieving Resilience
      5. The Problem of Organizational Change
      6. Change in Technology
      7. Conclusions – the Focus on Resilience
      8. AN EVIL CHAIN MECHANISM LEADING TO FAILURES
   5. 12 SAFETY MANAGEMENT IN AIRLINES
      1. Introduction
      2. How Safe is Flying?
      3. Current Practices in Safety Management
      4. Models of Risk and Safety
      5. What Next? From Safety to Resilience
   6. 13 TAKING THINGS IN ONE’S STRIDE: COGNITIVE FEATURES OF TWO RESILIENT PERFORMANCES
      1. Introduction
      2. Example 1: Handling a ‘Soft’ Emergency
      3. Example 2: Response to a Bus Bombing
      4. Analysis
      5. Conclusion
   7. 14 EROSION OF MANAGERIAL RESILIENCE: FROM VASA TO NASA
      1. Vasa to Columbia
      2. Managerial Resilience
      3. Safety Culture and Managerial Resilience
      4. Measuring Managerial Resilience
      5. Training Managerial Resilience
      6. Conclusion
   8. 15 LEARNING HOW TO CREATE RESILIENCE IN BUSINESS SYSTEMS
      1. The System View: Implications for Business Systems
      2. The Barings plc Case
      3. What would have made Barings more Resilient?
      4. Concluding Remarks
   9. 16 OPTIMUM SYSTEM SAFETY AND OPTIMUM SYSTEM RESILIENCE: AGONISTIC OR ANTAGONISTIC CONCEPTS?
      1. Introduction: Why are Human Activities Sometimes Unsafe?
      2. Mapping the Types of Resilience
      3. Understanding the Transition from One Type of Resilience to Another
      4. Conclusion: Adapt the Resilience – and Safety – to the Requirements and Age of Systems
10. PART III: CHALLENGES FOR A PRACTICE OF RESILIENCE ENGINEERING
    1. 17 PROPERTIES OF RESILIENT ORGANIZATIONS: AN INITIAL VIEW
       1. Concept of Resilience
       2. Approach of Resilience Engineering
       3. Summary
       4. Example: Adaptation of Leading Indicators of Organizational Performance to Resilience Engineering Processes
       5. Acknowledgments
       6. REMEDIES
    2. 18 AUDITING RESILIENCE IN RISK CONTROL AND SAFETY MANAGEMENT SYSTEMS
       1. Introduction
       2. Structure of the ARAMIS Audit Model
       3. Does the Model Encompass Resilience?
       4. Conclusions and General Issues
    3. 19 HOW TO DESIGN A SAFETY ORGANIZATION: TEST CASE FOR RESILIENCE ENGINEERING
       1. Dilemmas of Safety Organizations
       2. The 4 ‘I’s of Safety Organizations: Independent, Involved, Informed, and Informative
       3. Safety as Analogous to Polycentric Management of Common Pool Resources
       4. Summary
       5. Acknowledgements
       6. RULES AND PROCEDURES
    4. 20 DISTANCING THROUGH DIFFERENCING: AN OBSTACLE TO ORGANIZATIONAL LEARNING FOLLOWING ACCIDENTS
       1. Introduction
       2. Barriers to Learning
       3. An Incident
       4. Organizational Learning in this Case
       5. Extending or Enhancing the Learning Opportunity
    5. 21 STATES OF RESILIENCE
       1. Introduction
       2. Resilience and State-space Transitions
       3. Conclusions
11. EPILOGUE: RESILIENCE ENGINEERING PRECEPTS
    1. Safety is Not a System Property
    2. Resilience as a Form of Control
    3. Readiness for Action
    4. Why Things Go Wrong
    5. A Constant Sense of Unease
    6. Precepts
    7. The Way Ahead
12. APPENDIX
    1. Symposium Participants
    2. Contributing Authors
13. BIBLIOGRAPHY
14. AUTHOR INDEX
15. SUBJECT INDEX