Showing papers by "Erik Hollnagel published in 2010"

Resilience Engineering in Practice: A Guidebook

Abstract: Resilience engineering has since 2004 attracted widespread interest from industry as well as academia. Practitioners from various fields, such as aviation and air traffic management, patient safety, off-shore exploration and production, have quickly realised the potential of resilience engineering and have became early adopters. The continued development of resilience engineering has focused on four abilities that are essential for resilience. These are the ability a) to respond to what happens, b) to monitor critical developments, c) to anticipate future threats and opportunities, and d) to learn from past experience - successes as well as failures. Working with the four abilities provides a structured way of analysing problems and issues, as well as of proposing practical solutions (concepts, tools, and methods). This book is divided into four main sections which describe issues relating to each of the four abilities. The chapters in each section emphasise practical ways of engineering resilience and feature case studies and real applications. The text is written to be easily accessible for readers who are more interested in solutions than in research, but will also be of interest to the latter group.

How Resilient Is Your Organisation? An Introduction to the Resilience Analysis Grid (RAG)

Abstract: The Difference Between Safety and Resilience. Although there are several different definitions of safety, they all tend to emphasize the importance of avoiding unwanted outcomes (losses, harm, incidents, accidents). The common understanding is furthermore that a higher level of safety corresponds to fewer adverse outcomes - and vice versa.

The Changing Nature Of Risks

Abstract: Introduction Human life has always been fraught with risks. But until the first decades of the 19 century, risks were accepted as more or less natural in the sense that they were directly associated with human activity rather than with failures of systems or equipment. Accidents happened as a part of work (which often took place at home), during major building works, when travelling on land or at sea – and of course during wars. This perception changed dramatically after September 15, 1830, when William Huskisson became the first victim of a train accident. The occasion was the opening of the Liverpool and Manchester Railway and the train that hit the unfortunate Mr. Huskisson was George Stephenson’s Rocket. More accidents soon followed, involving exploding boilers, derailings, head-on collisions, collapsing bridges, and so on. (As an aside, the first recorded automobile death took place in Ireland on August 31, 1869, when a woman, Mary Ward, was thrown from and fell under the wheels of an experimental steam car built by her cousins. In 2002, road traffic accidents worldwide were estimated to kill 1.2 million people, with at least 20 million people being injured or disabled.) The crucial change that took place in the 19 century was that accidents became associated with the technological systems that people designed, built, and used as part of work, in the name of progress and civilisation. Suddenly, accidents happened not only because the people involved, today referred to as people at the sharp end, did something wrong or because of an act of nature, but also because a human-made system failed. Furthermore, the failures were no longer simple, such as a scaffolding falling down or a wheel axle breaking. The failures were complex, in the sense that they usually defied the immediate understanding of the people at the sharp end. In short, their knowledge and competence was about how to do their work, and not about how the technology worked or functioned. Before this change happened, people could take reasonable precautions against accidents at work because they understood the tools and artefacts they used sufficiently well. After this change had happened, that was no longer the case.

Att förstå olyckor : lätt att bli syndabock i "effektiv" organisation

Abstract: The evolutionary conserved protein Sem1/Dss1 is a bona fide subunit of the regulatory particle (RP) of the proteasome and in mammalian cells stabilizes the tumor suppressor protein BRCA2. A recent study from our laboratory has revealed an unexpected non- proteasomal role of Sem1 in mRNA export. We found that Sem1, independent of the RP, is a functional component of the nuclear pore associated TREX-2 complex that is directly involved in the dynamic relocalization of a subset of DNA loci to the nuclear periphery. Like other components of TREX-2, Sem1 is required for proper nuclear export of mRNAs, transcription elongation and preventing transcription-associated genomic instability. Strikingly, Sem1 associates with a third multi-subunit protein complex namely the COP9 signalosome, which is involved in de-neddylation. We propose that Sem1 is a versatile protein that regulates the functional integrity of multiple protein complexes involved in diverse biological pathways.

Essays on socio-technical vulnerabilities and strategies of control in Integrated Operations

Abstract: The essay discusses the scientific basis for the RIO project (Interdisciplinary Risk Assessment of Integrated Operations addressing Human and Organisational Factors – RIO) by looking at some of the presumptions and positions in the project description in terms of epistemological approaches to risk and the distinction between discipline-based academic risk research and applied, problem oriented risk research.. Arguments, reasons and elaborations for major hazard prevention in an IO context based on an interdisciplinary framework for risk governance is presented. Introduction and background1 Why asking this question in the title of the paper? Different perspectives and interdisciplinary approaches is a presumption for the RIO project (Interdisciplinary Risk Assessment of Integrated Operations addressing Human and Organisational Factors – RIO). The aims are therefore to give some arguments, reasons and elaborations for what is already decided. The scope given by the RIO project proposal is major hazard prevention in an IO context based on an interdisciplinary framework for risk governance (Renn, 2008). A core challenge for studying safety performance in a context of Integrated Operations is distributed, collaborative decision-making in control of hazardous processes and the adaptive response of decisionmakers to internal and external stressors and variability. Compared to the stable conditions of the past, the present dynamic oil and gas industry brings with it some dramatic changes of the conditions of industrial risk governance: The very fast pace of development of technology, especially information technology, leads to a high degree of integration and coupling of systems and effects of a single decision can have dramatic effects that propagate rapidly. It is thus becoming increasingly difficult to explain accident causation by analysing local factors within a work system. Safety and risk management increasingly become system problems. Furthermore, companies today live in a very aggressive and competitive environment. The German sociologist Ulrich Beck (1992) summarizes these challenges for risk management by the phrases: “produced uncertainties and organized irresponsibility” and “strategic uncertainty and structural vulnerability” as key words for risk research. The socio-technical system involved in risk management is normally de¬composed according to organizational levels and specific hazard phenomena, which are the subjects for studies within different disciplines, see the “vertical” risk management model of J. Rasmussen (1997). This raises the problem of the constraints of specialized academic risk research. 1 The paper is to a large extent based on a report for SRV (Hovden & Rasmussen, 1998) and a report for the Research Council of Norway (Hovden, 1999), and inspired by discussions and confrontations at meetings within the RIO group of researchers.

Simulator Studies: The Next Best Thing?

Abstract: The chapter describes the history of simulator studies in Human Factors research, and the roots in structural psychology and Scientific Management. Following that, the establishment and development of HAMMLAB is considered relative to the events and concerns of the early 1980s. After a short discussion of the use of simulated worlds, the changing conditions for human factors research are identified. These are the change from human–computer interaction to distributed cognition, the change from first to second generation HRA leading to the gradual irrelevance of HRA, the change human–machine systems to joint cognitive systems, the change from normal accidents to intractable systems, and the change from system safety to resilience engineering. The conclusion is that when the nature of work and the practical problems change, the methods and models should also change.