Professor Erik Hollnagel

This book analyses and explains the principles behind Safety-I and Safety-II and approaches and considers the past and future of safety management practices. The analysis makes use of common examples and cases from domains such as aviation, nuclear power production, process management and health care. The final chapters explain the theoretical and practical consequences of the new, Safety-II perspective on day-to-day operations as well as on strategic management (safety culture).

The Past and Future of Safety Management

Safety-I and Safety–II

Ms Gunilla Sundström

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?

A Resilience Engineering Perspective

Governance and Control of Financial Systems

Accident investigation and risk assessment have for decades focused on the human factor, particularly ‘human error’. This bias towards performance failures leads to a neglect of normal performance. It assumes that failures and successes have different origins so 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 alternative is to understand why things go right and to amplify that. The ETTO Principle looks at the common trait of people at work to adjust what they do to match the conditions. It proposes that this efficiency-thoroughness trade-off (ETTO) is normal. While in some cases the adjustments may lead to adverse outcomes, these are due to the same processes that produce successes.

Why Things That Go Right Sometimes Go Wrong

The ETTO Principle: Efficiency-Thoroughness Trade-Off

Professor David D Woods

Professor Nancy Leveson

For Resilience Engineering, 'failure' is the result of the adaptations necessary to cope with the complexity of the real world, rather than a malfunction. Human performance must continually adjust to current conditions and, because resources and time are finite, such adjustments are always approximate. Featuring contributions from leading international figures in 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.

Concepts and Precepts

Resilience Engineering

Professor Robert L Wears

Professor Jeffrey Braithwaite

Properly performing health care systems require concepts and methods that match their complexity. Resilience engineering provides that capability. It focuses on a system’s overall ability to sustain required operations under both expected and unexpected conditions rather than on individual features or qualities. This book contains contributions from international experts in health care, organisational studies and patient safety, as well as resilience engineering. Whereas current safety approaches primarily aim to reduce the number of things that go wrong, Resilient Health Care aims to increase the number of things that go right.

Resilient Health Care

Safety has traditionally been defined as a condition where the number of adverse outcomes was as low as possible (Safety-I). From a Safety-I perspective, the purpose of safety management is to make sure that the number of accidents and incidents is kept as low as possible, or as low as is reasonably practicable. This means that safety management must start from the manifestations of the absence of safety and that - paradoxically - safety is measured by counting the number of cases where it fails rather than by the number of cases where it succeeds. This unavoidably leads to a reactive approach based on responding to what goes wrong or what is identified as a risk - as something that could go wrong. Focusing on what goes right, rather than on what goes wrong, changes the definition of safety from ‘avoiding that something goes wrong’ to ‘ensuring that everything goes right’. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. From a Safety-II perspective, the purpose of safety management is to ensure that as much as possible goes right, in the sense that everyday work achieves its objectives. This means that safety is managed by what it achieves (successes, things that go right), and that likewise it is measured by counting the number of cases where things go right. In order to do this, safety management cannot only be reactive, it must also be proactive. But it must be proactive with regard to how actions succeed, to everyday acceptable performance, rather than with regard to how they can fail, as traditional risk analysis does. This book analyses and explains the principles behind both approaches and uses this to consider the past and future of safety management practices. The analysis makes use of common examples and cases from domains such as aviation, nuclear power production, process management and health care. The final chapters explain the theoretical and practical consequences of the new perspective on the level of day-to-day operations as well as on the level of strategic management (safety culture). Safety-I and Safety-II is written for all professionals responsible for their organisation's safety, from strategic planning on the executive level to day-to-day operations in the field. It presents the detailed and tested arguments for a transformation from protective to productive safety management.

Professor Erik Hollnagel

About

Books

Join the club