Derailed decisions: The evolution of vulnerability on a Norwegian railway line

Risky Work Environments: Reappraising Human Work Within Fallible Systems

Volumn , Issue , 2009, Pages 53-80

  Rosness, Ragnar ^a  

^a SINTEF   (Norway)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 84900186346     PISSN: None     EISSN: None     Source Type: Book    
DOI: None     Document Type: Chapter

References (27)

1. Bergh, T. (2004), Jernbanen i Norge 1854-2004 (Bergen: Vigmostad Bjørke).
2. Brehmer, B. (1991), 'Distributed Decision Making: Some Notes on the Literature', in Rasmussen, J. et al. (eds.) (1991), Distributed Decision Making: Cognitive Models for Cooperative Work (Chichester: John Wiley & Sons).
3. Brunsson, N. (1985), The Irrational Organization (Chichester: Wiley).
4. Brunsson, N. (1989), The Organization of Hypocrisy: Talk, Decisions and Actions in Organisations (Chichester: Wiley).
5. Dekker, S. (2006), 'Resilience Engineering: Chronicling the Emergence of Confused Consensus', in Hollnagel, E. et al (eds.) (2006), Resilience Engineering: Concepts and Precepts (Aldershot: Ashgate).
6. Gulowsen, J. and Ryggvik, H. (2004), Jernbanen i Norge 1854-2004. Nye tider og gamle spor 1940-2004 (Bergen: Vigmostad & Bjørke).
7. Guttormsen, G. et al. (2003), Utforming av Regelverk for Togframføring. Report STF38 A03408 (Trondheim: SINTEF).
8. Hollnagel, E. (2004), Barriers and Accident Prevention (Aldershot: Ashgate).
9. Jernbaneverket (2000), Togsammenstøt ved Åsta på Rørosbanen 04.01.2000. Systematisk Gransking ved Hjelp av STEP-metoden. Rapport nr. 01/2000 (Oslo:(oslo: Jernbaneverket, Uhellskommisjonen). [Report from the accidentAccident investigation Investigation Commission of the National Railway Administration.]
10. Lindblom, C.E. (1959), 'The Science of "Muddling Through"', Public Administration Review 19: 79-88.
11. NOU 2000:30: Åsta-ulykken, 4. Januar 2000. Hovedrapport. Justis-og politidepartementet. Statens forvaltningstjeneste, 2001. [The Åsta accident,Accident, 4 January 2000. Main Report of the Public Commission of Inquiry.]
12. Perrow, C. (1984), Normal Accidents (New York: Basic Books).
13. Pidgeon, N. and O'Leary, M. (2000), 'Man-made Disasters: Why Technology and Organizations (Sometimes) Fail', Safety Science 34: 15-30.
14. Presidential Commission on the Space Shuttle Challenger Accident (1986), Report to the President by the Presidential Commission on the Space Shuttle Challenger Accident. 5 vols. (Washington, DC: U.S. Government Printing Office).
15. Rasmussen, J. (1994), 'Risk Management, Adaptation, and Design for Safety', in Brehmer, B. and Sahlin, N. E. (eds.) (1994), Future Risks and Risk Management (Dordrecht: Kluwer Academic Publishers).
16. Rasmussen, J. (1997), 'Risk Management in a Dynamic Society: A Modelling Problem', Safety Science 27(2-3): 183-213.
17. Rasmussen, J. and Svedung, I. (2000), Proactive Risk Management in a Dynamic Society (Karlstad, Sweden: Swedish Rescue Services Agency).
18. Reason, J. (1997), Managing the Risks of Organizational Accidents (Aldershot: Ashgate).
19. Schein, E.H. (1997), Organizational Culture and Leadership, 2nd edition (San Francisco: Jossey-Bass).
20. Skjerve, A.B. et al. (2004), 'Human and organizationalOrganizational Contributions to safetySafety Defences in Offshore Oil Production', in Spitzer, C. et al. (eds.) (2004), Probabilistic Safety Assessment and Management, vol 4 (London: SpringerVerlag).
21. Snook, S.A. (2000), Friendly Fire: The Accidental Shootdown of U.S. Black Hawks over Northern Iraq (Princeton, NJ: Princeton University Press).
22. Turner, B.A. (1978), Man-made Disasters (London: Wykeham Science Press).
23. Turner, B.A. and Pidgeon, N.F. (1997), Man-made Disasters, 2nd edition (London: Butterworth-Heinemann).
24. Vaughan, D. (1996), The Challenger Launch Decision: Risky Technology, Culture, and Deviance and NASA (Chicago: University of Chicago Press).
25. Vaughan, D. (2005), 'System Effects: On Slippery Slopes, Repeating Negative Patterns, and Learning from Mistakes', in Starbuck, W. and Farjoun, M. (eds.) (2005), Organization at the Limit: NASA and the Columbia Disaster (Malden, MA: Blackwell).
26. Weick, K.E. (1990), 'The Vulnerable System: An Analysis of the Tenerife Air Disaster', Journal of Management 16(3): 571-593.
27. Woods, D.D. and Cook, R.I. (2006), 'Incidents-Markers of Resilience of Brittleness?', in Hollnagel, E. et al. (eds.) (2006), Resilience Engineering: Concepts and Precepts (Aldershot: Ashgate).