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Safety Differently
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Safety II
Safety Differently
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Human Factors
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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
Prologue: Resilience Engineering Concepts
Epilogue: Resilience Engineering 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
The theory of graceful extensibility: basic rules that govern adaptive systems
Summary of graceful extensibility theorems
How do systems manage their adaptive capacity to successfully handle disruptions? A resilience engineering perspective
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
HindSight Magazine