The complexity of today's large organisations, businesses, and social institutions defeats management approaches based on monolithic thinking. Most industry and service organisations look at their performance either from a single perspective - productivity, quality, safety, etc. - or from different but separate perspectives that reside in organisational silos. Quality is treated separately from safety, which, again, is treated separately from productivity, and so on. While siloed thinking may be convenient in the short term, it fails to recognise that any specific perspective reveals only a part of what goes on. Yet it is essential to have a unified view of how an organisation functions effectively to manage changes and to ensure the organisation excels in what it does. Synesis represents the mutually dependent set of priorities, perspectives, and practices that an organisation needs to carry out its activities as intended. It shows how to overcome the fragmentation in foci, scope, and time that characterises the dominant change management paradigms. This book is consequently not about productivity or quality or safety or reliability but about all of these together. It is about why it is necessary to think of them as a whole. And it is about how this can be done in practice.

Our fascination with new technologies is based on the assumption that more powerful automation will overcome human limitations and make our systems 'faster, better, cheaper, ' resulting in simple, easy tasks for people. But how does new technology and more powerful automation change our work? Research in Cognitive Systems Engineering (CSE) looks at the intersection of people, technology, and work. What it has found is not stories of simplification through more automation, but stories of complexity and adaptation. When work changed through new technology, practitioners had to cope with new complexities and tighter constraints. They adapted their strategies and the artifacts to work around difficulties and accomplish their goals as responsible agents. The surprise was that new powers had transformed work, creating new roles, new decisions, and new vulnerabilities. Ironically, more autonomous machines have created the requirement for more sophisticated forms of coordination across people, and across people and machines, to adapt to new demands and pressures. This book synthesizes these emergent Patterns though stories about coordination and mis-coordination, resilience and brittleness, affordance and clumsiness in a variety of settings, from a hospital intensive care unit, to a nuclear power control room, to a space shuttle control center. The stories reveal how new demands make work difficult, how people at work adapt but get trapped by complexity, and how people at a distance from work oversimplify their perceptions of the complexities, squeezing practitioners. The authors explore how CSE observes at the intersection of people, technology, and work, how CSE abstracts patterns behind thesurface details and wide variations, and how CSE discovers promising new directions to help people cope with complexities. The stories of CSE show that one key to well-adapted work is the ability to be prepared to be surprised. Are you ready?

Nothing has been more prolific over the past century than human/machine interaction. Automobiles, telephones, computers, manufacturing machines, robots, office equipment, machines large and small; all affect the very essence of our daily lives. However, this interaction has not always been efficient or easy and has at times turned fairly hazardous. Cognitive Systems Engineering (CSE) seeks to improve this situation by the careful study of human/machine interaction as the meaningful behavior of a unified system. Written by pioneers in the development of CSE, Joint Cognitive Systems: Foundations of Cognitive Systems Engineering offers a principled approach to studying human work with complex technology. The authors use a top-down, functional approach and emphasize a proactive (coping) perspective on work that overcomes the limitations of the structural human information processing view. They describe a conceptual framework for analysis with concrete theories and methods for joint system modeling that can be applied across the spectrum of single human/machine systems, social/technical systems, and whole organizations. The book explores both current and potential applications of CSE illustrated by examples. Understanding the complexities and functions of the human/machine interaction is critical to designing safe, highly functional, and efficient technological systems. This is a critical reference for students, designers, and engineers in a wide variety of disciplines.

This "Handbook" serves as a single source for theories, models, and methods related to cognitive task design. It provides the scientific and theoretical basis required by industrial and academic researchers, as well as the practical and methodological guidance needed by practitioners who face problems of building safe and effective human-technology systems.
Fundamental across a wide range of disciplines, from military systems to consumer goods and process industries, cognitive task design covers the whole life-cycle of work from pre-analysis, specification, design, risk assessment, implementation, training, daily operation, fault finding, maintenance, and upgrading. It applies to people, sophisticated machines, and to human-machine ensembles. This comprehensive volume summarizes the extensive, worldwide experience with cognitive task design since the 1980s; it defines the state of the art and outlines the future of this ever-developing field.
Aimed at the graduate and postgraduate level, the "Handbook of Cognitive Task Design" is applicable to courses relating to the design of human-technology systems, interaction design, cognitive engineering, and applied industrial engineering.

Resilience Engineering (RE) studies have successfully identified and described many instances of resilient performance in high hazard sectors as well as in the far more frequent cases where people and organisations cope with the uncertainties of daily operations. Since RE was first described in 2006, a steady accumulation of insights and efforts have provided the basis for practical tools and methods. This development has been documented by a series of texts in the Resilience Engineering Perspectives series as well as by a growing number of papers and reports. This book encapsulates the essential practical lessons learned from the use of Resilience Engineering (RE) for over ten years. The main contents are a series of chapters written by those who have been instrumental in these applications. To increase the value for the reader, each chapter will include: rationale for the overall approach; data sought and reason(s) for choosing; data sources used, data analyses performed, and how recommendations were made and turned into practice. Serving as a reference for practitioners who want to analyse, support, and manage resilient performance, this book also advances research into RE by inquiring why work goes well in unpredictable environments, to improve work performance, or compensate for deficiencies.

Resilience engineering has since 2004 attracted widespread interest from industry as well as academia. Practitioners from various fields, such as aviation and air traffic management, patient safety, off-shore exploration and production, have quickly realised the potential of resilience engineering and have became early adopters. The continued development of resilience engineering has focused on four abilities that are essential for resilience. These are the ability a) to respond to what happens, b) to monitor critical developments, c) to anticipate future threats and opportunities, and d) to learn from past experience - successes as well as failures. Working with the four abilities provides a structured way of analysing problems and issues, as well as of proposing practical solutions (concepts, tools, and methods). This book is divided into four main sections which describe issues relating to each of the four abilities. The chapters in each section emphasise practical ways of engineering resilience and feature case studies and real applications. The text is written to be easily accessible for readers who are more interested in solutions than in research, but will also be of interest to the latter group.

The complexity of today's large organisations, businesses, and social institutions defeats management approaches based on monolithic thinking. Most industry and service organisations look at their performance either from a single perspective - productivity, quality, safety, etc. - or from different but separate perspectives that reside in organisational silos. Quality is treated separately from safety, which, again, is treated separately from productivity, and so on. While siloed thinking may be convenient in the short term, it fails to recognise that any specific perspective reveals only a part of what goes on. Yet it is essential to have a unified view of how an organisation functions effectively to manage changes and to ensure the organisation excels in what it does. Synesis represents the mutually dependent set of priorities, perspectives, and practices that an organisation needs to carry out its activities as intended. It shows how to overcome the fragmentation in foci, scope, and time that characterises the dominant change management paradigms. This book is consequently not about productivity or quality or safety or reliability but about all of these together. It is about why it is necessary to think of them as a whole. And it is about how this can be done in practice.

This book promotes an understanding of the purposeful muddling that health care workers rely on to be better able to function and operate in the multitude of complex ecosystems we call "health care." The book argues the case for the importance of recognising and understanding muddling behaviours, practices and activities in order to create resilient care. The book demonstrates how resilient health care principles can enable managers as well as those on the frontlines to work more effectively towards interdisciplinary care by gaining a deeper understanding of real-world practices that manifest in everyday clinical settings. This is done by presenting a set of case studies, theoretical chapters and applications that relate experiences, bring forth ideas and illustrate practical solutions. Primarily aimed at people who are directly involved in the running and improvement of health care systems, it provides practical guidance. It is also of direct interest to health care professionals in clinical and managerial positions as well as researchers. Jeffrey Braithwaite is Founding Director of the Australian Institute of Health Innovation, Professor of Health Systems Research and Director of the Centre for Healthcare Resilience and Implementation Science, Macquarie University (Australia). His research examines the changing nature of complex health systems and he has received over 50 different national and international awards for his teaching and research. Erik Hollnagel is Senior Professor of Patient Safety at Joenkoeping University (Sweden). He is a highly regarded international expert with significant contributions to a variety of fields ranging from nuclear power generation, aerospace and aviation to industry, transportation and, most notably, health care. Garthe Hunte is a Clinical Professor and Emergency Physician holding multiple academic and clinical leadership appointments across Canada. His research programme centres around how safety is created in complex socio-technical systems, and in the application of resilience engineering in health care.

Our fascination with new technologies is based on the assumption that more powerful automation will overcome human limitations and make our systems 'faster, better, cheaper,' resulting in simple, easy tasks for people. But how does new technology and more powerful automation change our work? Research in Cognitive Systems Engineering (CSE) looks at the intersection of people, technology, and work. What it has found is not stories of simplification through more automation, but stories of complexity and adaptation. When work changed through new technology, practitioners had to cope with new complexities and tighter constraints. They adapted their strategies and the artifacts to work around difficulties and accomplish their goals as responsible agents. The surprise was that new powers had transformed work, creating new roles, new decisions, and new vulnerabilities. Ironically, more autonomous machines have created the requirement for more sophisticated forms of coordination across people, and across people and machines, to adapt to new demands and pressures. This book synthesizes these emergent Patterns though stories about coordination and mis-coordination, resilience and brittleness, affordance and clumsiness in a variety of settings, from a hospital intensive care unit, to a nuclear power control room, to a space shuttle control center. The stories reveal how new demands make work difficult, how people at work adapt but get trapped by complexity, and how people at a distance from work oversimplify their perceptions of the complexities, squeezing practitioners. The authors explore how CSE observes at the intersection of people, technology, and work, how CSE abstracts patterns behind the surface details and wide variations, and how CSE discovers promising new directions to help people cope with complexities. The stories of CSE show that one key to well-adapted work is the ability to be prepared to be surprised. Are you ready?

Nothing has been more prolific over the past century than human/machine interaction. Automobiles, telephones, computers, manufacturing machines, robots, office equipment, machines large and small; all affect the very essence of our daily lives. However, this interaction has not always been efficient or easy and has at times turned fairly hazardous. Cognitive Systems Engineering (CSE) seeks to improve this situation by the careful study of human/machine interaction as the meaningful behavior of a unified system. Written by pioneers in the development of CSE, Joint Cognitive Systems: Foundations of Cognitive Systems Engineering offers a principled approach to studying human work with complex technology. The authors use a top-down, functional approach and emphasize a proactive (coping) perspective on work that overcomes the limitations of the structural human information processing view. They describe a conceptual framework for analysis with concrete theories and methods for joint system modeling that can be applied across the spectrum of single human/machine systems, social/technical systems, and whole organizations. The book explores both current and potential applications of CSE illustrated by examples. Understanding the complexities and functions of the human/machine interaction is critical to designing safe, highly functional, and efficient technological systems. This is a critical reference for students, designers, and engineers in a wide variety of disciplines.

Preparation and Restoration is the second volume of Resilience Engineering Perspectives within the Ashgate Studies in Resilience Engineering series. In four sections, it broadens participation of the field to include policy and organization studies, and articulates aspects of resilience beyond initial definitions: - Policy and Organization explores public policy and organizational aspects of resilience and how they aid or inhibit preparation and restoration - Models and Measures addresses thoughts on ways to measure resilience and model systems to detect desirable, and undesirable, results - Elements and Traits examines features of systems and how they affect the ability to prepare for and recover from significant challenges - Applications and Implications examines how resilience plays out in the living laboratory of real-world operations. Preparation and Restoration addresses issues such as the nature of resilience; the similarities and differences between resilience and traditional ideas of system performance; how systems cope with varying demands and sometimes succeed and sometimes fail; how an organization's ways of preparing before critical events can enable or impede restoration; the trade-offs that are needed for systems to operate and survive; instances of brittle or resilient systems; how work practices affect resilience; the relationship between resilience and safety; and what improves or erodes resilience. This volume is valuable reading for those who create and operate systems that must not only survive, but thrive, in the face of challenge.

The book demonstrates how Resilient Health Care principles can enable those on the frontline to work more effectively towards interdisciplinary care by gaining a deeper understanding of the boundaries that exist in everyday clinical settings. This is done by presenting a set of case studies, theoretical chapters and applications that relate experiences, bring forth ideas and illustrate practical solutions. The chapters address many different issues such as resolving conflict, overcoming barriers to patient-flow management, and building connections through negotiation. They represent a range of approaches, rather than a single way of solving the practical problems, and have been written to serve both a scientific and an andragogical purpose. Working Across Boundaries is primarily aimed at people who are directly involved in the running and improvement of health care systems, providing them with practical guidance. It will also be of direct interest to health care professionals in clinical and managerial positions as well as researchers. Presents the latest work of the lauded Resilient Health Care Net group, developing applications of Resilience Engineering to health care, furthering safety thinking and generating applicable solutions that will benefit patient safety worldwide Enables health care professionals to become aware of the boundaries that affect their work so that they are able to use their strengths and overcome their weaknesses Written from a Safety-II perspective, where the purpose is to make sure that as much as possible goes well and the focus therefore is on everyday work rather than on failures. There are at present no other books that adopt this perspective nor which go into the practical details Provides a concise presentation of the state of resilient health care as a science, in terms of major theoretical issues and practical methods and techniques on the overarching and important topics of boundary-crossing and integration of care settings

The book demonstrates how Resilient Health Care principles can enable those on the frontline to work more effectively towards interdisciplinary care by gaining a deeper understanding of the boundaries that exist in everyday clinical settings. This is done by presenting a set of case studies, theoretical chapters and applications that relate experiences, bring forth ideas and illustrate practical solutions. The chapters address many different issues such as resolving conflict, overcoming barriers to patient-flow management, and building connections through negotiation. They represent a range of approaches, rather than a single way of solving the practical problems, and have been written to serve both a scientific and an andragogical purpose. Working Across Boundaries is primarily aimed at people who are directly involved in the running and improvement of health care systems, providing them with practical guidance. It will also be of direct interest to health care professionals in clinical and managerial positions as well as researchers. Presents the latest work of the lauded Resilient Health Care Net group, developing applications of Resilience Engineering to health care, furthering safety thinking and generating applicable solutions that will benefit patient safety worldwide Enables health care professionals to become aware of the boundaries that affect their work so that they are able to use their strengths and overcome their weaknesses Written from a Safety-II perspective, where the purpose is to make sure that as much as possible goes well and the focus therefore is on everyday work rather than on failures. There are at present no other books that adopt this perspective nor which go into the practical details Provides a concise presentation of the state of resilient health care as a science, in terms of major theoretical issues and practical methods and techniques on the overarching and important topics of boundary-crossing and integration of care settings

Health care is under tremendous pressure regarding efficiency, safety, and economic viability. It has responded by adopting techniques that have been useful in other industries, such as quality management, lean production, and high reliability - although with limited, and all-too-often disappointing, results. The Resilient Health Care Network (RHCN) has worked since 2011 to facilitate the interaction and collaboration among practitioners and researchers interested in applying concepts from resilience engineering to health care and patient safety. This has met with considerable success, not least because the focus from the start was on developing concrete ways to complement a Safety-I perspective with a Safety-II perspective. Building on previous volumes, Delivering Resilient Health Care presents documented experiences and practical guidance on how to bring Resilient Health Care into practice. It provides concrete advice on how to prepare a study, how to choose the right data, how to collect it, how to analyse the data, and how to interpret the results. This fourth book in the Resilient Healthcare series contains contributions from international experts in health care, organisational studies and patient safety, as well as resilience engineering. This book provides a practical guide for delivering resilient healthcare, particularly for clinicians on the frontline of care unsure how to incorporate resilience into their everyday work, managers coordinating care, and for policymakers hoping to steer the system in the right direction. Other groups - patients, the media, and researchers - will also find much of interest here.

The recent financial crisis has made it paramount for the financial services industry to find new perspectives to look at their industry and, most importantly, to gain a better understanding of how the global financial system can be made less vulnerable and more resilient. The primary objective of this book is to illustrate how the safety science of Resilience Engineering can help to gain a better understanding of what the financial services system is and how to improve governance and control of financial services systems by leveraging some of its key concepts. Resilience is the intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions. This definition is focused on the ability to function, rather than just to be impervious to failure, and thereby bridges the traditional conflict between productivity and safety. The core concept of the book is that the behaviour of the financial services system is the result of the tight couplings among the humans, organizations and technologies that are necessary to provide complex financial functions such as the transfer of economic resources. It is a consequence of this perspective that the risks associated with these systems cannot be understood without considering the nature of these tight couplings. Adopting this perspective, the book is designed to provide some answers to the following key questions about the financial crisis: - What actually happened? - Why and how did it happen? - Could something similar happen again? How can we see that in time and how can we control it? - How can sustainable recovery of the global financial system be established? How can its resilience be improved?

This book is the 3rd volume in the Resilient Health Care series. Resilient health care is a product of both the policy and managerial efforts to organize, fund and improve services, and the clinical care which is delivered directly to patients. This volume continues the lines of thought in the first two books. Where the first volume provided the rationale and basic concepts of RHC and the second teased out the everyday clinical activities which adjust and vary to create safe care, this book will look more closely at the connections between the sharp and blunt ends. Doing so will break new ground, since the systematic study in patient safety to date with few exceptions has been limited.

Health systems everywhere are expected to meet increasing public and political demands for accessible, high-quality care. Policy-makers, managers, and clinicians use their best efforts to improve efficiency, safety, quality, and economic viability. One solution has been to mimic approaches that have been shown to work in other domains, such as quality management, lean production, and high reliability. In the enthusiasm for such solutions, scant attention has been paid to the fact that health care as a multifaceted system differs significantly from most traditional industries. Solutions based on linear thinking in engineered systems do not work well in complicated, multi-stakeholder non-engineered systems, of which health care is a leading example. A prerequisite for improving health care and making it more resilient is that the nature of everyday clinical work be well understood. Yet the focus of the majority of policy or management solutions, as well as that of accreditation and regulation, is work as it ought to be (also known as 'work-as-imagined'). The aim of policy-makers and managers, whether the priority is safety, quality, or efficiency, is therefore to make everyday clinical work - or work-as-done - comply with work-as-imagined. This fails to recognise that this normative conception of work is often oversimplified, incomplete, and outdated. There is therefore an urgent need to better understand everyday clinical work as it is done. Despite the common focus on deviations and failures, it is undeniable that clinical work goes right far more often than it goes wrong, and that we only can make it better if we understand how this happens. This second volume of Resilient Health Care continues the line of thinking of the first book, but takes it further through a range of chapters from leading international thinkers on resilience and health care. Where the first book provided the rationale and basic concepts of RHC, the Resilience of Everyday Clinical Work b

This is the fifth book published within the Ashgate Studies in Resilience Engineering series. The first volume introduced resilience engineering broadly. The second and third volumes 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. Since its inception, the development of resilience engineering as a concept and a field of practice has insisted on expanding the scope from a preoccupation with failure to include also the acceptable everyday functioning of a system or an organisation. The preoccupation with failures and adverse outcomes focuses on situations where something goes wrong and the tries to keep the number of such events and their (adverse) outcomes as low as possible. The aim of resilience engineering and of this volume is to describe how safety can change from being protective to become productive and increase the number of things that go right by improving the resilience of the system.

Safety has traditionally been defined as a condition where the number of adverse outcomes was as low as possible (Safety-I). From a Safety-I perspective, the purpose of safety management is to make sure that the number of accidents and incidents is kept as low as possible, or as low as is reasonably practicable. This means that safety management must start from the manifestations of the absence of safety and that - paradoxically - safety is measured by counting the number of cases where it fails rather than by the number of cases where it succeeds. This unavoidably leads to a reactive approach based on responding to what goes wrong or what is identified as a risk - as something that could go wrong. Focusing on what goes right, rather than on what goes wrong, changes the definition of safety from 'avoiding that something goes wrong' to 'ensuring that everything goes right'. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. From a Safety-II perspective, the purpose of safety management is to ensure that as much as possible goes right, in the sense that everyday work achieves its objectives. This means that safety is managed by what it achieves (successes, things that go right), and that likewise it is measured by counting the number of cases where things go right. In order to do this, safety management cannot only be reactive, it must also be proactive. But it must be proactive with regard to how actions succeed, to everyday acceptable performance, rather than with regard to how they can fail, as traditional risk analysis does. This book analyses and explains the principles behind both approaches and uses this to consider 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 theoret

Health care is everywhere under tremendous pressure with regard to efficiency, safety, and economic viability - to say nothing of having to meet various political agendas - and has responded by eagerly adopting techniques that have been useful in other industries, such as quality management, lean production, and high reliability. This has on the whole been met with limited success because health care as a non-trivial and multifaceted system differs significantly from most traditional industries. In order to allow health care systems to perform as expected and required, it is necessary to have concepts and methods that are able to cope with this complexity. Resilience engineering provides that capacity because its focus is on a system's overall ability to sustain required operations under both expected and unexpected conditions rather than on individual features or qualities. Resilience engineering's unique approach emphasises the usefulness of performance variability, and that successes and failures have the same aetiology. This book contains contributions from acknowledged international experts in health care, organisational studies and patient safety, as well as resilience engineering. Whereas current safety approaches primarily aim to reduce or eliminate the number of things that go wrong, Resilient Health Care aims to increase and improve the number of things that go right. Just as the WHO argues that health is more than the absence of illness, so does Resilient Health Care argue that safety is more than the absence of risk and accidents. This can be achieved by making use of the concrete experiences of resilience engineering, both conceptually (ways of thinking) and practically (ways of acting).

Resilience engineering has consistently argued that safety is more than the absence of failures. Since the first book was published in 2006, several book chapters and papers have demonstrated the advantage in going behind 'human error' and beyond the failure concept, just as a number of serious accidents have accentuated the need for it. But there has not yet been a comprehensive method for doing so; the Functional Resonance Analysis Method (FRAM) fulfils that need. Whereas commonly used methods explain events by interpreting them in terms of an already existing model, the FRAM is used to model the functions that are needed for everyday performance to succeed. This model can then be used to explain specific events, by showing how functions can be coupled and how the variability of everyday performance sometimes may lead to unexpected and out-of-scale outcomes - either good or bad. The FRAM is based on four principles: equivalence of failures and successes, approximate adjustments, emergence, and functional resonance. As the FRAM is a method rather than a model, it makes no assumptions about how the system under investigation is structured or organised, nor about possible causes and cause-effect relations. Instead of looking for failures and malfunctions, the FRAM explains outcomes in terms of how functions become coupled and how everyday performance variability may resonate. This book presents a detailed and tested method that can be used to model how complex and dynamic socio-technical systems work, to understand why things sometimes go wrong but also why they normally succeed.

The recent financial crisis has made it paramount for the financial services industry to find new perspectives to look at their industry and, most importantly, to gain a better understanding of how the global financial system can be made less vulnerable and more resilient. The primary objective of this book is to illustrate how the safety science of Resilience Engineering can help to gain a better understanding of what the financial services system is and how to improve governance and control of financial services systems by leveraging some of its key concepts. Resilience is the intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions. This definition is focused on the ability to function, rather than just to be impervious to failure, and thereby bridges the traditional conflict between productivity and safety. The core concept of the book is that the behaviour of the financial services system is the result of the tight couplings among the humans, organizations and technologies that are necessary to provide complex financial functions such as the transfer of economic resources. It is a consequence of this perspective that the risks associated with these systems cannot be understood without considering the nature of these tight couplings. Adopting this perspective, the book is designed to provide some answers to the following key questions about the financial crisis: - What actually happened? - Why and how did it happen? - Could something similar happen again? How can we see that in time and how can we control it? - How can sustainable recovery of the global financial system be established? How can its resilience be improved?

Resilience engineering has since 2004 attracted widespread interest from industry as well as academia. Practitioners from various fields, such as aviation and air traffic management, patient safety, off-shore exploration and production, have quickly realised the potential of resilience engineering and have became early adopters. The continued development of resilience engineering has focused on four abilities that are essential for resilience. These are the ability a) to respond to what happens, b) to monitor critical developments, c) to anticipate future threats and opportunities, and d) to learn from past experience - successes as well as failures. Working with the four abilities provides a structured way of analysing problems and issues, as well as of proposing practical solutions (concepts, tools, and methods). This book is divided into four main sections which describe issues relating to each of the four abilities. The chapters in each section emphasise practical ways of engineering resilience and feature case studies and real applications. The text is written to be easily accessible for readers who are more interested in solutions than in research, but will also be of interest to the latter group.

Preparation and Restoration is the second volume of Resilience Engineering Perspectives within the Ashgate Studies in Resilience Engineering series. In four sections, it broadens participation of the field to include policy and organization studies, and articulates aspects of resilience beyond initial definitions: - Policy and Organization explores public policy and organizational aspects of resilience and how they aid or inhibit preparation and restoration - Models and Measures addresses thoughts on ways to measure resilience and model systems to detect desirable, and undesirable, results - Elements and Traits examines features of systems and how they affect the ability to prepare for and recover from significant challenges - Applications and Implications examines how resilience plays out in the living laboratory of real-world operations. Preparation and Restoration addresses issues such as the nature of resilience; the similarities and differences between resilience and traditional ideas of system performance; how systems cope with varying demands and sometimes succeed and sometimes fail; how an organization's ways of preparing before critical events can enable or impede restoration; the trade-offs that are needed for systems to operate and survive; instances of brittle or resilient systems; how work practices affect resilience; the relationship between resilience and safety; and what improves or erodes resilience. This volume is valuable reading for those who create and operate systems that must not only survive, but thrive, in the face of challenge.

Accident investigation and risk assessment have for decades focused on the human factor, particularly 'human error'. Countless books and papers have been written about how to identify, classify, eliminate, prevent and compensate for it. This bias towards the study of performance failures, leads to a neglect of normal or 'error-free' performance and the assumption that as failures and successes have different origins there is little to be gained from studying them together. Erik Hollnagel believes this assumption is false and that safety cannot be attained only by eliminating risks and failures. The ETTO Principle looks at the common trait of people at work to adjust what they do to match the conditions - to what has happened, to what happens, and to what may happen. It proposes that this efficiency-thoroughness trade-off (ETTO) - usually sacrificing thoroughness for efficiency - is normal. While in some cases the adjustments may lead to adverse outcomes, these are due to the very same processes that produce successes, rather than to errors and malfunctions. The ETTO Principle removes the need for specialised theories and models of failure and 'human error' and offers a viable basis for effective and just approaches to both reactive and proactive safety management.