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).
Cover -- Contents -- List of Figures -- List of Tables -- Prologue -- 1 The Need -- A State of (Relative) Ignorance -- Ignorance, Complexity and Intractability -- Systems Redefined -- From Probability to Variability -- Conclusions -- Comments on Chapter 1 -- 2 The Intellectual Background -- The Naturalness of Linear Thinking -- Simple Linear Thinking -- Complex Linear Thinking -- Dynamic Systems and Parallel Developments -- The Second Cybernetics -- Conclusions -- Comments on Chapter 2 -- 3 The Principles -- The Equivalence of Failures and Successes -- The Approximate Adjustments -- Emergence -- Resonance -- Conclusions -- Comments on Chapter 3 -- 4 The Method: Preliminaries -- Looking For What Should Go Right -- Step 0: Recognise the Purpose of the FRAM Analysis -- Comments on Chapter 4 -- 5 The Method: Identify and Describe the Functions (Step 1) -- How Can the Functions Be Identified? -- The Six Aspects -- Issues in the Description of Functions -- Comments on Chapter 5 -- 6 The Method: The Identification of Variability (Step 2) -- Variability of Different Types of Functions -- Manifestations (Phenotypes) of Performance Variability -- 7 The Method: The Aggregation of Variability (Step 3) -- Functional Upstream-Downstream Coupling -- Upstream-Downstream Coupling for Preconditions -- Upstream-Downstream Coupling for Resources or Execution Conditions -- Upstream-Downstream Coupling for Control -- Upstream-Downstream Coupling for Time -- Upstream-Downstream Coupling for Input -- Issues in Upstream-Downstream Coupling -- Comments on Chapter 7 -- 8 The Method: Consequences of the Analysis (Step 4) -- Elimination, Prevention, Protection and Facilitation -- Monitoring (Performance Indicators) -- Dampening -- What About Quantification? -- Comments on Chapter 8 -- 9 Three Cases -- 'Duk i buk' (The Sponge in the Abdomen).
The offshore exploration, drilling, and production, in O&G industry, are one of the most necessaryactivities of human Society. However, since its beginning in North America, the process variables- such as temperature, pressure and depth - have increased their operational parametersconsiderably, leaving the 21 meters deep, on land in 1859, extremely remote from the 6.500 metersin offshore area of Brazil Pre-Salt. To drill a subsea well and raise the crude oil to a platform, byitself, presents a series of risks that compromise the Process Safety of the entire plant. Avoiding aloss of containment, in addition to being inherent to safety itself, is also in the interest of theenvironment, production control and workers' health. In this sense, understand the safety barriers,as well as comprehend the Human Factors involved in Process Safety, not only brings operationalreliability to the plant, but also meets the requirements of the legislation and increases productivity.In this research, a FRAM was developed to analyze a loss of containment of an FPSO storage tank,showing the importance of a systemic understanding of Human Factors in Process Safety, actingas an effective barrier to the security of the entire process.
This volume describes how safety can change from being protective to being productive, thereby improving the resilience of the system. This is the fifth book published within the Ashgate Studies in Resilience Engineering series. The first introduced resilience engineering broadly. The second and third established the research foundation for the real-world applications that then were described in the fourth volume: Resilience Engineering in Practice. The current volume continues this development by focusing on the role of resilience in the development of solutions.
In accident investigation, the ideal is often to follow the principle "what-you-find-is-what-you-fix", an ideal reflecting that the investigation should be a rational process of first identifying causes, and then implement remedial actions to fix them. Previous research has however identified cognitive and political biases leading away from this ideal. Somewhat surprisingly, however, the same factors that often are highlighted in modern accident models are not perceived in a recursive manner to reflect how they influence the process of accident investigation in itself. Those factors are more extensive than the cognitive and political biases that are often highlighted in theory. Our purpose in this study was to reveal constraints affecting accident investigation practices that lead the investigation towards or away from the ideal of "what-you-find-is-what-you-fix". We conducted a qualitative interview study with 22 accident investigators from different domains in Sweden. We found a wide range of factors that led investigations away from the ideal, most which more resembled factors involved in organizational accidents, rather than reflecting flawed thinking. One particular limitation of investigation was that many investigations stop the analysis at the level of "preventable causes", the level where remedies that were currently practical to implement could be found. This could potentially limit the usefulness of using investigations to get a view on the "big picture" of causes of accidents as a basis for further remedial actions.
In accident investigation, the ideal is often to follow the principle "what-you-find-is-what-you-fix", an ideal reflecting that the investigation should be a rational process of first identifying causes, and then implement remedial actions to fix them. Previous research has however identified cognitive and political biases leading away from this ideal. Somewhat surprisingly, however, the same factors that often are highlighted in modern accident models are not perceived in a recursive manner to reflect how they influence the process of accident investigation in itself. Those factors are more extensive than the cognitive and political biases that are often highlighted in theory. Our purpose in this study was to reveal constraints affecting accident investigation practices that lead the investigation towards or away from the ideal of "what-you-find-is-what-you-fix". We conducted a qualitative interview study with 22 accident investigators from different domains in Sweden. We found a wide range of factors that led investigations away from the ideal, most which more resembled factors involved in organizational accidents, rather than reflecting flawed thinking. One particular limitation of investigation was that many investigations stop the analysis at the level of "preventable causes", the level where remedies that were currently practical to implement could be found. This could potentially limit the usefulness of using investigations to get a view on the "big picture" of causes of accidents as a basis for further remedial actions.
Coming of age -- The need of a guide to deliver resilient health care -- Procuring evidence for resilient health care -- Resilience engineering for quality improvement : case study in a unit for the care of older people -- Using workarounds to examine characteristics of resilience in action -- Simulation as a tool to study systems and enhance resilience -- Exploring resilience strategies in anaesthetists' work : a case study using interviews and the resilience markers framework (RMF) -- Promoting resilience in the maternity services -- Team resilience : implementing resilient healthcare at Middlemore ICU -- Understanding normal work to improve quality of care and patient safety in a spine center -- Engineering resilience in an urban emergency department -- Patterns of adaptive behaviour and adjustments in performance in response to authoritative safety pressure regarding the handling of KCl concentrate solutions -- A case study of resilience in inpatient diabetes care -- Where process improvement meets resilience : a study of the preparation and administration of drugs in a surgical inpatient unit -- The safety-II case : reconciling the gap between WAI and WAD through structured dialogue and reasoning about safety -- When disaster strikes : sustained resilience performance in an acute clinical setting -- Making it happen : from research to practice
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Part I: Openings. Introduction: The Journey to Here and What Happens Next. Bon Voyage: Navigating the Boundaries of Resilient Health Care. Part II: Negotiating Across Boundaries. Working Across Boundaries: Creating Value and Producing Safety in Health Care Using Empathetic Negotiation Skills. Untangling Conflict in Health Care. Part III: Theorising About Boundaries. 'Practical' Resilience: Misapplication of Theory?. Creating Resilience in Health Care Organisations through Various Forms of Shared Leadership. Simulation: A Tool to Detect and Traverse Boundaries. Part IV: Empiricising Boundaries. Looking Back Over the Boundaries of our Systems and Knowledge. Understanding Medication Dispensing as Done in Real World Settings -- Combining Conceptual Models and an Empirical Approach. Resilient Frontline Management of the Operating Room Floor: The Role of Boundaries and Coordination. Patient Flow Management: Codified and Opportunistic Escalation Actions. Trust and Psychological Safety as Facilitators of Resilient Health Care. Collaborative Use of Slack Resources as a Support to Resilience: Study of a Maternity Ward. Resilient Performance in Acute Health Care: Implementation of an Intervention Across Care Boundaries. Part V: Closure. Discussion, Integration and Concluding Remarks
