Showing papers by "Erik Hollnagel published in 2009"
Book•
28 May 2009
TL;DR: The ETTO principle as mentioned in this paper proposes that 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 -is normal.
Abstract: 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.
374 citations
Book•
20 Jan 2009
TL;DR: This work summarizes the extensive, worldwide experience with cognitive task design since the 1980s and defines the state of mind in the 21st Century.
Abstract: Offers the theories, models, and methods related to cognitive task design. This work summarizes the extensive, worldwide experience with cognitive task design since the 1980s. It defines the state ...
291 citations
TL;DR: In this article, the authors examined three aspects of accident investigation as described in a number of investigation manuals and found that the factors considered were in general (hu)man, technology, organization, and information.
291 citations
01 Jan 2009
TL;DR: The purpose of the rather roundabout definition given above is to avoid statements such as ‘a system is resilient if ...’, since this narrows resilience to a specific quality.
Abstract: Introduction A system1 cannot be resilient, but a system can have a potential for resilient performance. A system is said to perform in a manner that is resilient when it sustains required operations under both expected and unexpected conditions by adjusting its functioning prior to, during, or following events (changes, disturbances, and opportunities). Whereas current safety management (Safety-I) focuses on reducing the number of adverse outcomes by preventing adverse events, Resilience Engineering (RE) looks for ways to enhance the ability of systems to succeed under varying conditions (Safety-II). It is therefore necessary to understand what this ability really means, since it clearly is not satisfactory just to call it ‘resilience’. The purpose of the rather roundabout definition given above is to avoid statements such as ‘a system is resilient if ...’, since this narrows resilience to a specific quality. (Or even worse, that ‘a system has resilience if ...’.) RE has from the very beginning maintained that resilience is a characteristic of how a system performs, not a quality that the system as such has or possesses. Resilience is functional and not structural. If we want to use a short description, we should therefore refer to a system’s resilient performance rather than a system’s resilience.
46 citations
20 Oct 2009
TL;DR: In this article, the authors present a contemporary view on human factors in complex industrial systems and compare 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 system would be impossible.
Abstract: 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.
44 citations
Book•
01 Jan 2009
TL;DR: Nemeth et al. as discussed by the authors presented a comparison of selected models of system resilience and compared them with the infusion device as a source of healthcare resilience, and showed that infusion devices can be used to improve healthcare resilience.
Abstract: Contents: The ability to adapt, Christopher P. Nemeth Part I Policy and Organization: The politics and policy challenges of disaster resilience, Thomas A. Birkland and Sarah Waterman Resilience capacity and strategic agility: prerequisites for thriving in a dynamic environment, Cynthia Lengnick-Hall and Tammy E. Beck. Part II Models and Measures: An initial comparison of selected models of system resilience, David D. Woods, Jason Schenk and Theodore T. Allen Measuring resilience, John Wreathall. Part III Elements and Traits: The 4 cornerstones of resilience engineering, Erik Hollnagel Ready for trouble: 2 faces of resilience, Ron Westrum Layered resilience, Philip J. Smith, Amy L. Spencer and Charles E. Billings. Part IV Applications and Implications: Notes from underground: latent resiliency in healthcare, Shawna J. Perry and Robert L. Wears Cognitive underpinnings of resilience: a case study of group decision in emergency response, David MendonA a and Yao Hu Restoration through preparation: is it possible? Analysis of a low-probability/high-consequence event, Martin Nijhof and Sidney Dekker Understanding and contributing to resilient work systems, Emilie M. Roth, Jordan Multer and Ronald Scott The infusion device as a source of healthcare resilience, Christopher P. Nemeth, Michael O'Connor and Richard I. Cook Bibliography Index.
21 citations
Journal Article•
TL;DR: This thesis has shown that the concept of constraint management is instrumental in understanding the domains of command and control and aviation safety and functional modeling as a means to address constraint management provides a basis for analyzing the performance of socio-technical systems.
3 citations
01 Jan 2009
TL;DR: Hindsight as discussed by the authors describes the changing view of human error and the changing views on safety culture and organizational culture in the context of safety and security in the field of software engineering.
Abstract: Hindsight : The changing view of human error. Changing views on safety culture and organizational culture. Foresight.
3 citations