Resilience in everyday operations: A framework for analyzing adaptations in high-risk work

Journal of Cognitive Engineering and Decision Making

Volumn 8, Issue 1, 2014, Pages 78-97

  Rankin, Amy ^a   Lundberg, Jonas ^a   Woltjer, Rogier ^b   Rollenhagen, Carl ^c   Hollnagel, Erik ^d  

^a LINKÖPING UNIVERSITY   (Sweden)

^b SWEDISH DEFENCE RESEARCH AGENCY   (Sweden)

^c ROYAL INSTITUTE OF TECHNOLOGY   (Sweden)

^d UNIVERSITY OF SOUTHERN DENMARK   (Denmark)

Author keywords

adaptation; analysis methods; resilience engineering; topics

Indexed keywords

ADAPTATION; ADAPTIVE BEHAVIOR; ANALYSIS METHOD; RESILIENCE ENGINEERINGS; RESILIENT SYSTEMS; SOCIOTECHNICAL SYSTEMS; TOPICS; WORK PERFORMANCE;

SAFETY ENGINEERING;

OCCUPATIONAL RISKS;

EID: 84893856937     PISSN: 15553434     EISSN: 21695032     Source Type: Journal    
DOI: 10.1177/1555343413498753     Document Type: Article

References (64)

1. Ashby R. An introduction to cybernetics. London, UK: Chapman & Hall ; 1956:
2. Boddy C.. A rose by any other name may smell as sweet but "group discussion" is not another name for a "focus group" nor should it be. Qualitative Market Research: An International Journal. 2005 ; 8 (3). 248-255 (Pubitemid 41245170)
3. Brehmer B.. Dynamic decision making: Human control of complex systems. Acta Psychologica. 1992 ; 81 (3). 211-241
4. Cook R., Rasmussen J.. "Going solid": A model of system dynamics and consequences for patient safety. Quality & Safety in Health Care. 2005 ; 14: 130-134 (Pubitemid 40523858)
5. Cook R., Render M., Woods D. D.. Gaps in the continuity of care and progress on patient safety. BMJ (Clinical research ed.). 2000 ; 320: 791-794 (Pubitemid 30179436)
6. Cook R., Woods D. D.. Adapting to new technology in the operating room. Human Factors. 1996 ; 38: 593-613 (Pubitemid 26427582)
7. Dekker S.. Reconstructing human contributions to accidents: The new view on error and performance. Journal of Safety Research. 2002 ; 33: 371-385
8. Dekker S. Ten questions about human error: A new view of human factors and system safety. Mahwah, NJ: Lawrence Erlbaum ; 2004:
9. Dekker S. Drift into failure. Aldershot, UK: Ashgate ; 2011:
10. Dekker S., Cilliers P., Hofmeyr J.. The complexity of failure: Implications of complexity theory for safety investigations. Safety Science. 2011 ; 49: 939-945
11. Fischoff B.. Hindsight is not foresight: The effect of outcome knowledge on judgment under uncertainty. Journal of Experimental Psychology: Human Perception and Performance. 1975 ; 1: 288-299
12. Furniss D., Back J., Blandford A.. Unwritten rules for safety and performance in an oncology day care unit: Testing the resilience markers framework. Paper presented at the 4th Resilience Engineering Symposium ; 2011 Antibes Juan-Les Pins, France ; 2011..
13. Furniss D., Back J., Blandford A., Hildebrandt M., Broberg H.. A resilience markers framework for small teams. Reliability Engineering & System Safety. 2011 ; 96: 2-10
14. Guldenmund F.. The nature of safety culture: A review of theory and research. Safety Science. 2000 ; 34: 215-257 (Pubitemid 30331104)
15. Harms-Ringdahl L. Safety analysis. Boca Raton, FL: CRC Press ; 2001:
16. Hoffman R., Woods D.. Beyond Simon's slice: Five fundamental trade-offs that bound the performance of macrocognitive work systems. IEEE Intelligent Systems. 2011 ; 26 (6). 67-71
17. Hollnagel E. Intelligent decision support in process environments. Hollnagel E. Manicini G. Woods D. D., ed. Berlin, Germany: Springer-Verlag ; 1986: 211-226.
18. Hollnagel E. Barriers and accident prevention. Aldershot, UK: Ashgate ; 2004:
19. Hollnagel E. The ETTO principle: Efficiency-thoroughness trade-off. Why things that go right sometimes go wrong. Farnham, UK: Ashgate ; 2009a:
20. Hollnagel E. Resilience engineering perspectives: Vol. 2. Preparation and restoration. Hollnagel E. Dekker S., ed. Farnham, UK: Ashgate ; 2009b: 117-133.
21. Hollnagel E. Resilience engineering in practice. Hollnagel E. Paries J. Woods D. Wreathall J., ed. Farnham, UK: Ashgate ; 2011: 275-296.
22. Hollnagel E. FRAM: The functional resonance analysis method. Modeling complex socio-technical systems. Aldershot, UK: Ashgate ; 2012a:
23. Hollnagel E. Bericht zum 58. Kongress der Gesellschaft für Arbeitswissenschaft vom 22 bis 24 Februar 2012. Dortmund, Germany: Gfa-Press ; 2012b: 19-24.
24. Resilience engineering in practice: A guidebook. Hollnagel E. Paries J. Woods D. Wreathall J., ed. Farnham, UK: Ashgate ; 2011:
25. HollnagelE.PedersenO. M.RasmussenJ. (1981). Notes on human performance analysis. Roskilde, Denmark: Risø National Laboratory. Retrieved from http://www.ida.liu.se/∼eriho
26. Hollnagel E., Woods D. D. Joint cognitive systems: Foundations of cognitive systems engineering. Boca Raton: CRC Press/Taylor & Francis Group ; 2005:
27. Hollnagel E., Woods D. D., Leveson N. Resilience engineering: Concepts and precepts. Aldershot, UK: Ashgate ; 2006:
28. Jagacinski R. J., Flach J. M. Control theory for humans: Quantitative approaches to modeling and performance. Mahwah, NJ: Lawrence Erlbaum ; 2002:
29. Jungk R., Mullert N. Future focus groups: How to create desirable futures. London, UK: Institute of Social Inventions ; 1987:
30. Klein G., Moon B., Hoffman R.. Making sense of sensemaking. IEEE Intelligent Systems. 2006 ; 21 (4). 70-73
31. Kontogiannis T.. User strategies in recovering from errors in man-machine systems. Safety Science. 1999 ; 32: 49-68 (Pubitemid 29142449)
32. Kontogiannis T.. A contemporary view of organizational safety: variability and interactions of organizational processes. Cognition, Technology & Work. 2009 ; 12: 231-249
33. Koopman P., Hoffman R. R.. "Work-arounds," "make- work" and "kludges.". IEEE Intelligent Systems. 2003 ; 18 (6). 70-75
34. Lundberg J., Rollenhagen C., Hollnagel E.. What-you-look-for-is-what-you- find: The consequences of underlying accident models in eight accident investigation manuals. Safety Science. 2009 ; 47: 1297-1311
35. Lundberg J., Rollenhagen C., Hollnagel E., Rankin A.. Strategies for dealing with resistance to recommendations from accident investigations. Accident Analysis & Prevention. 2012 ; 45: 455-467
36. Miles M., Huberman M. Qualitative data analysis: An expanded sourcebook. Thousand Oaks, CA: Sage ; 1994:
37. Morgan D. L. Focus groups as qualitative research. Thousand Oaks, CA: Sage ; 1997:
38. Mumaw R., Roth E., Vicente K., Burns C.. There is more to monitoring a nuclear power plant than meets the eye. Human Factors. 2000 ; 42: 36-55 (Pubitemid 30456527)
39. Mumaw R., Sarter N., Wickens C.. Analysis of pilots monitoring and performance on an automated flight deck. Paper presented at the 11th International Symposium on Aviation Psychology ; 2001 Columbus, OH ; 2001..
40. Resilience engineering perspectives: Vol 2. Preparation and restoration. Nemeth C. Hollnagel E. Dekker S., ed. Aldershot, UK: Ashgate ; 2009:
41. Nemeth C. P., Nunnally M., O'Connor M. F., Brandwijk M., Kowalsky J., Cook R. I.. Regularly irregular: How groups reconcile cross-cutting agendas and demand in healthcare. Cognition, Technology & Work. 2007 ; 9: 139-148
42. Patterson E. S., Roth E. M., Woods D. D., Chow R., Gomes J. O.. Handoff strategies in settings with high consequences for failure: Lessons for health care operations. International Journal for Quality in Health Care. 2004 ; 16: 125-132 (Pubitemid 38489473)
43. Patterson E. S., Woods D. D., Cook R. I., Render M. L.. Collaborative cross-checking to enhance resilience. Cognition, Technology & Work. 2006 ; 9: 155-162
44. Perrow C. Normal accidents: Living with high-risk technologies. Princeton, NJ: Princeton University Press ; 1984:
45. Rankin A., Lundberg J., Woltjer R.. Resilience strategies for managing everyday risks. Paper presented at the 4th Resilience Engineering Symposium ; 2011 Sophia Antipolis, France ; 2011..
46. Rasmussen J. Information processing and human-machine interaction: An approach to cognitive engineering. New York, NY: North-Holland ; 1986:
47. Reason J. Managing the risks of organizational accidents. Burlington, VT: Ashgate ; 1997:
48. Rollenhagen C.. Event investigation at nuclear power plant in Sweden: Reflection about a method and some practices. Safety Science. 2011 ; 49: 21-26
49. Simon H. The sciences of the artificial. Cambridge, MA: MIT Press ; 1969:
50. Sklet S.. Comparison of some selected methods for accident investigation. Journal of Hazardous Materials. 2004 ; 111: 29-37 (Pubitemid 38844536)
51. Stephens R. J., Woods D. D., Branlat M., Wears R. L.. Colliding dilemmas: Interactions of locally adaptive strategies in a hospital setting. Paper presented at the Fourth International Symposium on Resilience Engineering ; 2011 Sophia Antipolis, France ; 2011..
52. Wears R. L. Exploring the dynamics of resilient performance. Paris, France: L'Ecole nationale supérieure des mines de Paris ; 2011:
53. Weick K. Sensemaking in organisations. Thousand Oaks, CA: Sage ; 1995:
54. Weick K., Sutcliffe K. M., Obstfeld D.. Organizing and the process of sensemaking. Organization Science. 2005 ; 16: 409-421 (Pubitemid 43057590)
55. Westrum R. Resilience engineering: Concepts and precepts. Hollnagel E. Woods D. D. Leveson N., ed. Farnham, UK: Ashgate ; 2006: 55-65.
56. Wibeck V. Fokusgrupper: Om fokuserande gruppintervjuer som undersökningsmetod. Linköping, Sweden: Studentlitteratur AB ; 2000:
57. Woods D. D.. The price of flexibility. Knowledge-Based Systems. 1993 ; 6: 1-8
58. Woods D. D.. Steering the reverberations of technology change on fields of practice: Laws that govern cognitive work. Paper presented at the annual meeting of the Cognitive Science Society ; 2002 Columbus, OH ; 2002..
59. Woods D. D., Branlat M.. Hollnagel's test: Being "in control" of highly interdependent multi-layered networked systems. Cognition, Technology & Work. 2010 ; 12: 95-101
60. Woods D. D., Dekker S. W. A.. Anticipating the effects of technological change: A new era of dynamics for human factors. Theoretical Issues in Ergonomic Science. 2000 ; 1: 272-282
61. Woods D. D., Dekker S., Cook R., Johannesen L., Sarter N. Behind human error. 2010 ). Behind human error (2nd ed.). Aldershot, UK: Ashgate. Aldershot, UK: Ashgate ; 2010:
62. Woods D. D., Hollnagel E. Joint cognitive systems engineering. Boca Raton, FL: CRC Press/Taylor & Francis Group ; 2006:
63. Woods D. D., Sarter N. B. Cognitive engineering in the aviation domain. Sarter N. Amalberti R., ed. Hillsdale, NJ: Lawrence Erlbaum ; 2000: 327-354.
64. Woods D. D., Wreathall J. Resilience engineering perspectives: 1. Remaining sensitive to the possibility of failure. Hollnagel E. Nemeth C. P. Dekker S. W. A., ed. Aldershot, UK: Ashgate ; 2008: 145-161.