Resilience has become an important topic on the safety research agenda and in organizational practice. In this chapter we give an introduction to the research area and some of the current challenges, before we present the aim of the book.
a b s t r a c tThis special issue presents papers from a workshop conducted by New Technologies and Work (NeTWork) to honor the memory of Bernhard Wilpert, the founder and organiser of NeTWork. The papers reflect the theme that undesirable incidents and events, serious and disturbing as they may be, are a ''gift of failure." In short, events offer an opportunity to learn about safe and unsafe operations, generate productive conversations across engaged stakeholders, and bring about beneficial changes to technology, organization, and mental models (understanding). Papers in the special issue are organised around three topics: the process of event analysis, the relationship between event analysis and organisational learning, and learning at multiple system levels. In this introduction we describe the workshop, summarize the contributions of Bernhard Wilpert, suggest three themes that emerged from the workshop, and offer our thoughts about the future of event analysis and learning from events.Ó 2010 Elsevier Ltd. All rights reserved. Background to the special issueThe same wondrous technologies that underlie our modern societies, such as air and sea transportation, nuclear power, and health care, also lead to challenges to safety: their innovativeness and complexity makes them difficult to predict and control (Beck, 1992;Perrow, 1984; Rollenhagen, this issue). As well, organizations ''push the limits" for greater productivity with more complex, software-intensive systems that require interdependent participation from multiple professionals. The public demands more safety at the same time as it demands more services at less cost, while corporate shareholders demand higher returns. These issues are of great importance in so-called ''high-hazard" industries where a rare and surprising event can place hundreds or thousands of people at risk, however, they are also of importance in settings such as health care and ordinary workplaces where undesired events occur more frequently but lives are disrupted one at a time.Organizations need appropriate structures, rules, and practices to avoid and respond appropriately to safety relevant events, in order to ensure their safety and reliability. These structures and rules are the safety management system that is based on both anticipatory feed-forward models of risk and strategies for feedback control (Rasmussen, 1990). Of course, we cannot completely specify all risks: even if risks are specified within the operating envelope, in real life organizations sometimes operate beyond their operating envelope (some scholars would say, all the time). Therefore, adequate feedback control relies on learning from operational experience. Organizational weaknesses and latent failures (e.g., Reason, 1997) are identified by continual monitoring and systematic analyses of problems, deviations, defects, events, near-misses and organizational surprises. Results of event analyses should lead to new knowledge, new structures, new rules, and new practices with the goal of higher reliability and saf...
The human factors approach relies on understanding the properties of human capability and limitations under various conditions and the application of that knowledge in designing and developing safe systems. Following the principles of the MTO (Man Technology Organisation) approach, emphasis should be given to the way people interact with technical as well as organisational systems. A model describing human factor influences in relation to the performance shaping factors and their effect on manual ultrasonic inspection performance had been built and a part of it empirically tested. The experimental task involved repeated inspection of 18 defects according to the standard procedure under no, middle and high time pressure. Stress coping strategies, the mental workload of the task, stress reaction and organisational factors have been measured. The results have shown that time pressure, mental workload and experience influence the quality of the inspection performance. Organisational factors and their influence on the inspection results were rated as important by the operators. However, further research is necessary into the effects of stress.
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