Safety-II in Practice

Table of contents

1. Cover
2. Half Title
3. Title Page
4. Copyright Page
5. Dedication
6. Table of Contents
7. List of figures and tables
8. Preface
9. 1 Safety management anno
   1. Managing what is not there
   2. Safety management: a focus on details
   3. Managing safety by snapshots
   4. Managing safety by everyday work
   5. Safety-I and Safety-II
   6. Safety as an antidote
      1. Antidote #1: prevention and elimination
      2. Antidote #2: improved defences
      3. Antidote #3: coping with complexity
10. 2 What does ‘resilience’ mean?
    1. The origin of resilience as a concept
       1. Other uses of resilience
    2. Negative connotations
       1. Accentuate the positive
    3. How resilient is my organisation?
11. 3 The basis for resilient performance
    1. Work-as-Imagined and Work-as-Done
    2. Individual or organisational ‘mechanisms’?
    3. From individual performance to culture
       1. Culture as a suffix
    4. The resilience potentials
    5. Interlude: on monolithic explanations
12. 4 The resilience potentials
    1. The potential to respond
       1. The Ebola crisis in 2015
       2. Target porn
    2. Characterisation of the potential to respond
    3. The potential to monitor
       1. The Prudhoe Bay oil spill
       2. Consumer Price Index to measure inflation
    4. Characterisation of the potential to monitor
       1. Indicators
    5. The potential to learn
       1. Saddleback fatality learning review
       2. A failure to detect patterns
    6. Characterisation of the potential to learn
       1. Prerequisites for learning
       2. Failing to learn
    7. The potential to anticipate
       1. Anticipation and models of the future
       2. Cheap travel (SNCF)
       3. Cloned meat (US)
    8. Characterisation of the potential to anticipate
    9. Issues in the potential to anticipate
    10. Other potentials?
13. 5 RAG – the resilience assessment grid
    1. Fundamental requirements to process management
       1. British Petroleum and the Baker report
    2. Measurement or assessment?
       1. ‘Six honest serving-men’
    3. Assessing the four potentials
    4. The potential to respond
       1. Example: Competence assessment of air traffic controllers
       2. Questions addressing the potential to respond
    5. The potential to monitor
       1. Example: hospital standardised mortality ratio (HSMR)
       2. Questions addressing the potential to monitor
    6. The potential to learn
       1. Example: Alan Greenspan and the financial crisis
       2. Questions addressing the potential to learn
    7. The potential to anticipate
       1. Example: Turing Pharmaceuticals
       2. Questions addressing the potential to anticipate
    8. Proxy measures
       1. Formulating the diagnostic questions
    9. How to present the results of an assessment
       1. Developing the potential to respond
    10. Diagnostic and formative questions
        1. The potential to respond
        2. The potential to monitor
        3. The potential to learn
        4. The potential to anticipate
    11. How to use the RAG to manage the potentials for resilient performance
14. 6 RAG – towards a model of resilient performance
    1. Structural models of organisations
    2. Functional models of how an organisation works
       1. The four potentials as functions
    3. The detailed model
    4. The complete model
    5. A generic model of resilience potentials
15. 7 Developing resilience potentials
    1. Changing organisational culture
    2. Changing practice
    3. The third way
    4. ‘Dysfunctional’ and ‘resilient’ organisations
    5. Developing the potential to monitor
       1. Reactive and proactive adjustments
       2. Alternative route: learning before monitoring
       3. Alternative route: anticipation before monitoring
    6. Developing the potential to learn
       1. Alternative route: anticipation before learning
    7. Developing the potential to anticipate
    8. Choosing how to develop the resilience potentials
    9. Managing the resilience potentials
    10. Using the RAG
16. 8 The changing face of safety
    1.  
       1. Safety as a privative
       2. Synesis
    2. The changing face of measurements
       1. Product and process measures
    3. The changing face of safety culture
17. Appendix: A FRAM primer
    1. First principle: the equivalence of successes and failures
    2. Second principle: approximate adjustments
    3. Third principle: emergent outcomes
    4. Fourth principle: functional resonance
    5. Basic concepts in developing a FRAM model
       1. The meaning of functions in the FRAM
       2. The meaning of aspects in the FRAM
       3. Couplings
       4. Foreground and background functions
    6. Upstream and downstream functions
    7. Graphical representation of a FRAM model
18. References
19. Glossary
20. Index