Papers
Safety Differently
By Sidney Dekker
- Safety Differently ASSE Proceedings Paper
- The Learning Review: Adding to the accident investigation toolbox
- Is It Time To Purge Legal Constructs From Safety Investigations?
- Safety Visually
- Employees: a problem to control or solution to harness?
- The Bureaucratization of Safety
- Drifting into failure: theorising the dynamics of disaster incubation
- The complexity of failure: Implications of complexity theory for safety investigations
- Get To The Root Of Accidents: Systems thinking can provide insights on underlying issues not just their symptoms
- A just culture after Mid Staffordshire
- Book Review of Erik Hollnagel’s Safety-I and Safety-II
- What is rational about killing a patient with an overdose? Enlightenment, continental philosophy and the role of the human subject in system failure
- Just culture: “Evidence”, power and algorithms
- Reconstructing human contributions to accidents: the new view on error and performance
- The field guide to ‘human error’ investigations
- Behind Human Error
- Rule- and role retreat: An empirical study of procedures and resilience
- Anticipating the effects of technological change: A new era of dynamics for human factors
- Why do things go right?
- Six stages to the new view of human error
- Behind Human Error
- Employees: A Problem to Control or Solution to Harness?
- Team Coordination in Escalating Situations: An Empirical Study Using Mid-Fidelity Simulation
- Resilience Engineering: New directions for measuring and maintaining safety in complex systems
- Illusions of explanation: A critical essay on error classification
- Failure to adapt or adaptations that fail: contrasting models on procedures and safety
- Human factors and folk models
- Oil and Gas in a Post-Truth World
Safety II
By Erik Hollnagel
- Just Culture vs. Fair Culture
- The ETTO Principle: Efficiency-Thoroughness Trade-Off: Why Things That Go Right Sometimes Go Wrong
- From Safety-I to Safety-II: A White Paper
- Safety-II in Practice
- Safety-I and Safety-II: The past and future of safety management
- FRAM: The Functional Resonance Analysis Method: Modelling Complex Socio-technical System
- Joint Cognitive Systems: Patterns in Cognitive Systems Engineering
- Resilience Engineering: Concepts and Precepts
- I want to believe: some myths about the management of industrial safety
- Resilience engineering – Building a Culture of Resilience (slides)
- Anomaly Response
- Cognitive Systems Engineering: New wine in new bottles (TWRR)
- Epilogue: Resilience Engineering Precepts
- Resilience Engineering: New directions for measuring and maintaining safety in complex systems
- Resilience Engineering (web essay)
- RAG – Resilience Analysis Grid
- Resilience engineering in practice: a guidebook
- Mapping Cognitive Demands in Complex Problem-Solving Worlds
- Human factors and folk models
- A tale of two safeties
- The Arbitrariness of Accident Analysis
Resilience Engineering
By David Woods
- Resilience Engineering: Concepts and Precepts
- Resilience is a verb
- Four concepts for resilience and the implications for the future of resilience engineering
- Basic patterns in how adaptive systems fail (TWRR )* Resilience and the ability to anticipate
- Distancing through differencing: An obstacle to organizational learning following accidents
- Essential characteristics of resilience
- Essentials of resilience, revisited
- Learning from Automation Surprises and “Going Sour”
- Accidents: Progress on Human-Centered Automation
- Behind Human Error
- Joint Cognitive Systems: Patterns in Cognitive Systems Engineering
- Patterns in Cooperative Cognition
- Origins of cognitive systems engineering
- Incidents – markers of resilience or brittleness?
- The alarm problem and directed attention in dynamic fault management
- Can We Trust Best Practices? Six Cognitive Challenges of Evidence-Based Approaches
- Operating at the Sharp End: The Complexity of Human Error
- The theory of graceful extensibility: basic rules that govern adaptive systems
- Simon’s Slice: Five Fundamental Tradeoffs that Bound the Performance of Human Work Systems
- Beyond Simon’s Slice: Five Fundamental Trade-Offs that
- Bound the Performance of Macrocognitive Work Systems
- Anticipating the effects of technological change: A new era of dynamics for human factors
- Common Ground and Coordination in Joint Activity
- Resilience as Graceful Extensibility to Overcome Brittleness
- Resilience Engineering: Redefining the Culture of Safety and Risk Management
- Problem detection
- Cognitive consequences of clumsy automation on high workload, high consequence human performance
- Implications of automation surprises in aviation for the future of total intravenous anesthesia (TIVA)
- Ten challenges for making automation a team player
- The Messy Details: Insights From the Study of Technical Work in Healthcare
- Nosocomial automation: technology-induced complexity and human performance
- Human-centered software agents: Lessons from clumsy automation
- STELLA: Report from the SNAFUcatchers Workshop on Coping with Complexity
- The New Look at Error, Safety, and Failure: A Primer for Health Care
- Grounding explanations in evolving, diagnostic situations
- Resilience Engineering: Concepts and Precepts
- A Tale of Two Stories: Contrasting Views of Patient Safety
- Voice Loops as Coordination Aids in Space Shuttle Mission Control
- The Critical Incident Technique: 40 Years Later
- Functionally distributed coordination during anomaly response in space shuttle mission control
- Cooperative Advocacy: An Approach for Integrating
- Diverse Perspectives in Anomaly Response
- Visual momentum: A concept to improve the cognitive coupling of person and computer
- Cognitive demands and activities in dynamic fault management: abductive reasoning and disturbance management
- Coping with complexity: the psychology of human behaviour in complex systems
- Process Tracing Methods for The Study of Cognition
- Outside of the Experimental Laboratory. In Klein GA, Orasanu J, Calderwood R, Zsambok CE, eds. Decision making in action: Models
- Towards a theoretical base for representation design in the computer medium: ecological perception and aiding human cognition
- Perspectives on Human Error: Hindsight Biases and Local Rationality
- Anomaly Response
- The Risks of Autonomy: Doyles Catch
- Mistaking Error
- Adapting to new technology in the operating room
- The Strategic Agility Gap: How organizations are slow and stale to adapt in turbulent worlds
- Resiliency Trade Space Study: The Interaction of
- Degraded C2 Link and Detect and Avoid Autonomy on Unmanned Aircraft
- Cognitive Technologies: The Design of Joint Human-Machine Cognitive Systems
- Cognitive Systems Engineering: New wine in new bottles (TWRR)
- The Seven Deadly Myths of “Autonomous Systems”
- Resilience and the ability to anticipate
- Patterns in Cooperative Cognition
- Collaborative Cross-Checking to Enhance Resilience=
- Resilience Engineering: New directions for measuring and maintaining safety in complex systems
- A rose by any other name…would probably be given an acronym
- How do systems manage their adaptive capacity to successfully handle disruptions? A resilience engineering perspective
- How Unexpected Events Produce An Escalation Of
- Cognitive And Coordinative Demands
- How to Make Automated Systems Team Players
- Toward a Theory of Complex and Cognitive Systems
- Multiple systemic contributors versus root cause: learning from a NASA Near Miss
- Bootstrapping multiple converging cognitive task analysis techniques for system design
- New Arctic Air Crash Aftermath Role-Play Simulation Orchestrating a Fundamental Surprise
- How Unexpected Events Produce An Escalation Of Cognitive And Coordinative Demands
- Mapping Cognitive Demands in Complex Problem-Solving Worlds
- Fixation Errors: Failures to Revise Situation Assessment in Dynamic and Risky Systems
- Nine Steps to Move Forward From Error
- Handoff strategies in settings with high consequences for failure: lessons for health care operations (TWRR)
Theories
Resilience Engineering
By Richard Cook
- How complex systems fail
- Where complex systems fail
- Distancing through differencing: An obstacle to organizational learning following accidents
- Being bumpable (TWRR)
- Behind Human Error
- Incidents – markers of resilience or brittleness?
- “Going solid”: a model of system dynamics and consequences for patient safety
- Operating at the Sharp End: The Complexity of Human Error
- Patient boarding in the emergency department as a symptom of complexity-induced risks
- Sensemaking, Safety, and Cooperative Work in the Intensive Care Unit
- Medication Reconciliation Is a Window into “Ordinary” Work
- Cognitive consequences of clumsy automation on high workload, high consequence human performance
- Implications of automation surprises in aviation for the future of total intravenous anesthesia (TIVA)
- The Messy Details: Insights From the Study of Technical Work in Healthcare
- Nosocomial automation: technology-induced complexity and human performance
- The New Look at Error, Safety, and Failure: A Primer for Health Care
- Grounding explanations in evolving, diagnostic situations
- A Tale of Two Stories: Contrasting Views of Patient Safety
- “Those found responsible have been sacked”: some observations on the usefulness of error
- Sensemaking, Safety, and Cooperative Work in the Intensive Care Unit
- Perspectives on Human Error: Hindsight Biases and
- Local Rationality
- Mistaking Error
- Adapting to new technology in the operating room
- Verite, Abstraction, and Ordinateur Systems in the
- Evolution of Complex Process Control
- Collaborative Cross-Checking to Enhance Resilience
- Resilience Engineering: New directions for measuring and maintaining safety in complex systems
- The Role of Automation in Complex System Failures
- Thinking about accidents and systems
- The Stockholm blizzard of 2012
- New Arctic Air Crash Aftermath Role-Play Simulation Orchestrating a Fundamental Surprise
- Dissenting Statement: Health IT Is a Class III Medical Device
- Nine Steps to Move Forward From Error
Human Factors
By Steven Shorrock