REA Symposium on Resilience Engineering Embracing Resilience
Diffusion of resilience as a concept and technology
Background: Healthcare is faced with challenges that cannot be managed by only increasing resources. Instead this paper argues for the need to reorganize healthcare around the concept of resilience. Objective: To analyze and discuss factors that influence the diffusion of both the concept of resilience and resilience technologies, such as simulation-based training in healthcare. Methods, material and theory: The paper applies innovation system theory to analyze the potential diffusion of the concept and technology of Resilience. It assumes that it is not sufficient for a concept to be accepted unless there are real effective examples of technologies and organizations that increase resilience in practice. Illustrative examples from simulation-based training in healthcare are used. Results: Based on the analysis of the Resilience concept and technology in terms of simulation-based training in healthcare critical factors for diffusion is identified. It is argued that strengthening the legitimacy of simulation will in turn strengthen the sub- processes: Influence on direction of search; Market formation and Resource mobilization that together supports sustained diffusion of simulation-based technology. Discussion: By analyzing the concept of resilience and the related technology of simulation-based training using an innovation system approach, critical factors for resilience to become accepted as an organizational concept for healthcare can better be identified. Conclusion: Innovation theory identifies the need to strengthen the legitimacy of simulation-based training to become more present in healthcare and in turn provide a tangible example of how healthcare resilience can be improved.
Copyright (c) 2019 Petra Appell https://creativecommons.org/licenses/by-nc/4.0
A joint approach to safety, security and resilience using the functional resonance analysis method
The protection of Offshore Wind Farms (OWF), a critical part of maritime infrastructure, faces new challenges due to the continually increasing share of renewable power generation (planned to reach 65% until 2030 in Germany). This is especially due to the large size of individual OWF (centralized generation units) and new threats such as climate change and their potential as targets for terrorism. It is no longer sufficient to simply optimize the performance of energy generation; the infrastructure also needs to be kept resilient when facing these new threats. To improve resilience, safety and security measures have to be taken into account and therefore safety, security and resilience (SSR) need to be addressed collectively. To this end, SSR goals are identified for a generic OWF by analyzing stakeholder needs and expectations. These goals include not only safe energy generation but also environmental protection, compliance with regulations, hazard defense and security. The SSR goals are classified and detailed in (i) who/what needs protection, (ii) hazards, and (iii) measures with available sensors. A common modeling tool in resilience research, the Functional Resonance Analysis Method (FRAM) is employed to visualize and model interrelations/interactions between SSR goals. The feasibility to model SSR goals as functions and the respective expected variabilities with FRAM are also studied. Further, the possibility to identify critical paths in the FRAM model which allows the introduction of cascade effects is assessed. Critical SSR goals are identified that need further measures to increase the level of fulfillment and to keep the infrastructure protected.
Infrastructure protection, Offshore Wind, FRAM
Copyright (c) 2019 Corinna Köpke, Jan Schäfer-Frey, Evelin Engler, Carl Philipp Wrede, Jennifer Mielniczek http://creativecommons.org/licenses/by-nc/4.0
Experimental study on the effect of a procedure under unexpected situations
Preparing procedures for a wide range of situations is considered important and has been confirmed to be effective for realizing reliable operations and a higher level of safety in complex socio-technical systems. However, once a situation drifts outside the scope of prepared situations, the effectiveness of using a pre-defined procedure may degrade, and operators have to make decisions without relying on procedures. In such cases, stronger operators are dependent on procedures, and the more unreliable operators' decision may come from the possible lack of a deeper understanding of the objective systems. The present study experimentally confirms that a strong dependence on the procedure may deteriorate the performance under unexpected situations outside the range of procedures. A Smart Grid Simulation environment, in which dynamic decision making is required to deal with the given situations to avoid blackout, is adopted as the experimental testbed. The scenarios for the expected situation presented herein are constructed on the basis of the events that have not been presented to the subjects in advance. The subjects are divided into two groups. The subjects in Group A are not given a written procedure that enables an effective operation for the predefined situations, whereas subjects in Group B are instructed to strictly follow the procedure. The results imply that the task performance evaluated on the basis of the number of causing a blackout degrades for the subjects following the procedure when facing unexpected situations.
Copyright (c) 2019 Makoto Takahashi, Daisuke Karikawa, Genta Sawasato, Yoshitaka Hoshii http://creativecommons.org/licenses/by-nc/4.0
Non-resilient behavior of offshore wind farms due to cyber-physical attacks
The share of wind power generation is steadily increasing and it reached 20.4% of Germany’s power supply in 2018. Thus wind power is becoming a critical infrastructure with major contributions to power supply and power system grid stability. Consequently a resilient operation of offshore wind farms (OWFs) is required under normal and disturbed conditions. Resilience stands for the ability of a complex system to proactively and reactively maintain its functionality and performance despite failures or manipulations. A functional model describes the technical behavior of engineered, cyber-physical systems in relation to the intended task or results of the system. It is a representation of the operation, functionality and performance of the system, e.g. in the form of a block diagram. The block diagram consists of components performing, according to their technical characteristics, specified functions on the inputs. Applied to the OWF the components can be grouped into several layers representing the main functional processes. Within this paper we consider the threat of system failures triggered through cyber-physical attacks, based on the vulnerability of the OWFs to such attacks as documented in the literature. Most of the main functional processes can be manipulated maliciously. The functional model is used to discuss the impacts of different scenarios of cyber-physical attacks and their resulting cascade effects, which may cause a non-resilient behavior of the OFW. Crucial parameters and signals can be manipulated maliciously. Limit thresholds can be exceeded by far even under normal environmental and power grid conditions. Excessive mechanical stresses, electrical and thermal loads can be realized, leading to extreme damage or even destruction of components/subsystems without the possibility of reactive intervention or timely recovery. We propose measures on component and functional level for closing the mentioned security gaps to ensure the resilience of the OWF.
Offshore Windfarm, Resilience, Safety and Security, Cyber-physical Attacks
Copyright (c) 2019 Nikolai Kulev, Albrecht Reuter, Oliver Eichhorn, Evelin Engler, Carl Wrede http://creativecommons.org/licenses/by-nc/4.0
Resource-centric business continuity and resiliency planning
This paper presents a new framework for simple design and evaluation of business continuity and resilience plan (BCP) for medical institutions based on the categories of resources required for business continuity and the three phases of emergency response: preparedness, response, and recovery. Considering home-visit nursing stations as a use case study, this work also presents the manner in which the proposed framework can be used for the design and evaluation of BCPs.
Business continuity and resilience plan (BCP), Resource-centric framework, Medical institutions
Copyright (c) 2019 Taro Kanno, Chie Ishida, Takayuki Kanesaka, Risa Okada, Takashi Kawazoe, Kazuaki Tae, Jun Sato http://creativecommons.org/licenses/by-nc/4.0
Positioning the study of first line managers’ resilient action strategies
This paper introduces a study on the action strategies of first line managers (FLMs) using a resilience perspective and the aim is to position the study in the theoretical field of resilience management and engineering. One important key to an organization's long-term competitiveness are the first line managers’ ability to handle the role as a leader in daily work. In the role of a FLM, there are a lot of conflicting objectives to manage, for example, regarding available resources, subordinates’ views versus superiors’, centralized and/or local control, optimization of cost and capability (quality and delivery). Moreover, at the operational level of detail, FLMs have to balance daily deliveries in relation to development activities, i.e. technical development, product development, implementation of new system and management concepts. Regardless of the complexity in work and organisational change over time, a FLM’s most important task is to contribute to a high and stable production output out of an input that is characterized by variability and disturbances. To do so in a sustainable way, the FLMs must develop action strategies about ways of working and problem solving that systematically facilitate coping with the situation and managing their own workload. We consider this as developing resilient actions strategies that allow the FLMs to handle the upcoming problems without getting problems on their own. In this paper we describe and develop the theoretical underpinnings of the study as well as how we position our own research in relation to the different theoretical strands of resilience management. We further suggest some methodological ideas on how to capture the work and nature of first line managers’ resilient action strategies. The focus in our work will thus be on how FLMs handle and can improve the more or less chaotic mix of activities in daily work in a resilient way.
First line managers, resilience, manufacturing industry
Copyright (c) 2019 Johan Karltun, Anette Karltun, Karin Havemose, Sofia Kjellström http://creativecommons.org/licenses/by-nc/4.0
The next step towards operationalizing resilience: the measurement of self-synchronization
The concept of resilience is becoming widely used by many industries where safety and security is crucial for success. At the last REA we’ve presented a definition of resilience that can be used in CD&E experiments regarding socio-technical systems. Self-synchronization was identified to play an important role. Methods: The approach chosen towards diagnosing self-synchronization was inspired by the methods used in psychiatry to diagnose psychiatric diseases as utilized in the “Diagnostic and Statistical Manual of Mental Disorders” (DSM 5) and the International Classification of Diseases (ICD 10). This approach was chosen because it allows to diagnose certain conditions based solely on the presence or absence of easily observable and assessable conditions and observations. We introduced two categories of indicators. The first category constitutes of five factors (mandate, autonomy, communication, coordination, cooperation) and was named “threshold conditions”. These conditions are necessary for self-synchronization to occur but are not sufficient to determine if self-synchronization occurred. The second category was named “value added observations” and consists of seven factors (situational awareness, self-awareness, negotiation, dependability, motivation, sub-networks, distributed decision making). These observations are used to quantify the level of self-synchronization reached. Results: The model was applied in two different settings of war games, performed during the Multinational Capability Development Campaign (MCDC) “Info-age C2” campaign. It was possible to diagnose the level of self-synchronization reached in the exercises. Based on these results, the model was further simplified and transferred into a checklist-format that allows for real-time self-synchronization diagnosis during exercises and real-live missions. Conclusion: In this paper, we will present our experience with a newly developed diagnostic model of self-synchronization. A high-fidelity research-version will be presented together with an operational version that can be applied for the assessment of self-synchronization during real world missions.
Self-synchronization, Model, Diagnose, Resilience, Questionnaire, Research, Practice
Copyright (c) 2019 Samuel W. Huber, Thomas Kuhn http://creativecommons.org/licenses/by-nc/4.0
Safety-I and safety-II: opportunities for an integrated approach in the construction industry
Construction projects are known for their complexity characteristics, such as a large number of stakeholders, uncertainty, and a dynamic work environment. These characteristics imply that different approaches for safety management can be useful under different circumstances. For example, low severity occupational accidents are fairly common in most construction sites, and therefore these events offer useful learning opportunities. In turn, resilience across managerial and operational levels is probably ubiquitous in construction sites, regardless of being taken for granted and neglected as a source of learning. Therefore, there is an opportunity for the joint use of how Safety-I and Safety-II in construction, giving rise to more effective safety management. This paper explores how Safety-I and Safety-II can be jointly adopted in construction. The discussion is based on two case studies, one from Brazil and another from Norway, in which two safety practices – safety planning and event reporting - were analysed from the perspectives of Safety-I and Safety-II. We conclude that these two perspectives can be integrated into established practices allowing organisation to learn from accidents, incidents as well as from everyday operations.
Safety-I, Safety-II, construction industry
Copyright (c) 2019 Guillermina Andrea Peñaloza, Kinga Wasilkiewicz, Tarcisio Abreu Saurin, Ivonne Andrade Herrera, Carlos Torres Formoso http://creativecommons.org/licenses/by-nc/4.0
Receipt and dispatch of an aircraft: a functional risk analysis
Receipt and dispatch operations in aviation require the contribution of a variety of tightly inter-connected agents (dispatchers, pilots, ground-handlers, air traffic controller, etc.). These agents have to deal with processes that are frequently affected by variable working conditions and limited resources. In this context, human actions acquire a crucial role to cope with situations underspecified by procedures, and to manage unanticipated circumstances. This paper proposes the application of the Functional Resonance Analysis Method (FRAM) for modelling receipt and dispatch process for Boeing-737 in a major airport (about 70 movements per day). The proposed FRAM has been enriched by the adoption of a multi-level representation aimed at deconstructing the complexity of work at different abstraction levels. The analysis focuses on agents and macro-meso-micro functions (i.e. functions aggregated into a single function at a higher abstraction level), combining qualitative and semi-quantitative analyses. This paper aims to detail the main project phases for the development of a FRAM model to be used as a basis for systemic risk analyses in large socio-technical systems.
system safety, socio-technical system, airport safety, aviation safety, airline safety
Copyright (c) 2019 Riccardo Patriarca, Arie Adriaensen, Mark Peters, Joel Putnam, Francesco Costantino, Guilio Di Gravio http://creativecommons.org/licenses/by-nc/4.0
Resilience of Air Traffic Controllers in control tower
The air traffic controllers in the control tower at an airport are responsible for the safe and efficient movements of aircraft on the taxiways and runways of the airport, and of aircraft in the airspace near the airport. In aerodrome Air Traffic Control (ATC), controllers always face inevitable disturbances, such as changing traffic situations, variability in the performance of pilots, variable wind conditions, and so on. However, controllers deal with these challenging situations to provide safe and efficient ATC services continuously. The aim of this study is to determine the resilience of controllers during their normal daily ATC operations. Multiple interviews with tower controllers and observations in the control tower at Chubu Centrair International Airport in Japan were conducted to investigate their working processes, including cognitive aspects. Their answers to the interview questions were analyzed from the perspective of Safety-II, that is, how they manage disturbances in their working environment to achieve successful ATC operations. The analysis results are described using the functional resonance analysis method (FRAM), modified for the description of three types of functions and situational factors: (1) basic functions for meeting the separation standards between aircraft, (2) threat factors, which could disturb the basic functions, and (3) response functions for managing possible negative effects caused by the threat factors. The FRAM model obtained visualizes the complex interactions among the functions and the situational factors in aerodrome ATC tasks, and it shows the essential role of performance adjustments of controllers for the proper functioning of ATC.
Copyright (c) 2019 Daisuke Karikawa, Hisae Aoyama, Tomoki Ohashi, Makoto Takahashi, Masaharu Kitamura http://creativecommons.org/licenses/by-nc/4.0
Connectivity and resilience of remote operations: insights from air traffic management
Greater connectivity is transforming critical infrastructures profoundly. One specific aspect enabled by connectivity are remote operations, which allow for the provision of services difficult to provide in a direct capacity, physically (e.g., due to cost or resource availability). Domains of applications are very diverse, e.g.: industry, public services, healthcare, culture. In the domain of Air Traffic Management (ATM), increased connectivity is seen as one of the main drivers of the improvement of operations and building of capacity to handle the expected traffic increase. The concept of Remote Tower operations provides the capacity to manage tower operations remotely from a virtual tower and remote centre. It increasingly appears as a valuable alternative to traditional control towers. However, one can wonder about the risks introduced by the necessary reliance on network infrastructures and remote sensors. What happens to remote operations when these are not fully, if at all, functional? How dangerously dependent on the digital infrastructure are the capabilities introduced by remote operations? Such questions take particular significance in the face of the cyber threat: cyber-attacks on digital assets and services can impair the capacity to perform ATM safely from remote. Resilience then represents the capacity to handle two interrelated, but different, disruptions: of ATM operations; and of digital services. In the first case, the primary emergency, the system needs to adapt to mitigate the impact on operations (e.g., switch to other modes of operations or divert traffic) and return to sound operations. In the second case, challenges are associated with the system’s capacity to identify, understand and address the cyber event. Re-establishing impaired digital services in a timely manner is critical because the adapted ATM operations are not sustainable. Inspired by crisis management, the paper explores challenges and strategies for resilient performance in the face of disruptions to the digital infrastructure.
Connectivity, Cybersecurity, Remote operations, Air Traffic Management
Copyright (c) 2019 Matthieu Branlat, Per Håkon Meland, Tor Erik Evjemo, Anthony Smoker http://creativecommons.org/licenses/by-nc/4.0
Who? What? Where? When? a scientometrics perspective on resilience engineering
This paper presents an exploratory research on the application of bibliometric methods to the field of Resilience Engineering. Starting from the Kuhnian idea on the structure of scientific revolutions, the aim of this research is to define centres of research and explore how their focus changes over time. The research developments have been traced by studying the science footprints revealed by scholarly publications. Such publications constitute a dynamic and self-organizing knowledge repository which is often difficult to understand systemically. By means of bibliometric indicators, this paper aims to identify who are the major authors in the field, what are the “invisible colleges”, which sources publish main documents, and the respective significant changes over years. A further analysis has been based on the usage of Pennant diagrams for scientometrics, with the purpose of exploring the relevance of an author within a certain literature database, and with respect to other authors. Through this multi-method exploratory research, we aim to provide an interpretative summary on the research of past and current community of resilience engineers. The analysis aims to define the structure of the scientific field and of the scientific community, proving the usability of meta-analytic tools coming from scientometrics for the analysis of an inter-disciplinary scientific domain such as Resilience Engineering.
scientometrics, bibliometric analysis, resilience engineering, review, Pennant diagrams.
Copyright (c) 2019 Patriarca Riccardo, Giulio Di Gravio, Francesco Costantino, Massimo Tronci http://creativecommons.org/licenses/by-nc/4.0
Approaching overload: diagnosis and response to anomalies in complex and automated systems
Web production software systems operate at an unprecedented scale today, requiring extensive automation to develop and maintain services. The systems are designed to regularly adapt to dynamic load to avoid the consequences of overloading portions of the network. As the software systems scale and complexity grows, it becomes more difficult to observe, model, and track how the systems function and malfunction. Anomalies inevitably arise, challenging incident responders or SREs to recognize and understand unusual behaviors as they plan and execute interventions to mitigate or resolve the threat of service outages. A study of four real cases reveals the interplay between the human and machine agents when problems disrupt the system. The analysis of the incidents directly links the cascade of disturbances below the line of representation (e.g. computer interfaces, monitoring tools) with the cognitive work of Site Reliability Engineers. The Above the Line / Below the Line Framework (ABL) changes the perspective in reviewing the cases post mortem in the tradition of Cognitive Systems Engineering and Resilience Engineering. The case study demonstrates specific and general patterns for complications to incident management in complex web operation systems, as well as directions for designing better tooling to support future, resilient work.
Risk & resilience in critical digital infrastructure
anomaly response, saturation, software systems, resilience
Copyright (c) 2019 Marisa Grayson http://creativecommons.org/licenses/by-nc/4.0
Patterns of performance variability: a meso-level understanding of psychiatric discharge
Incident reports, as well as surveys, indicate that there is a risk of healthcare injuries when psychiatric patients are discharged from the hospital, with continued treatment as an outpatient. In this study, we are ultimately interested in the resilience of psychiatric care in this risky discharge, i.e. how the system adapts to cope with the risks. We understand that there are margins of maneuver in everyday psychiatric work, with several strategies potentially leading to acceptable performance and we seek to map the performance variability of such strategies. The aim of this study is to visualize retrospective discharge and compare findings of variability within the Stockholm Center of Dependency Disorder different wards. To understand what is "normal" from an organizational point of view, the study will analyze patterns from clinic visits where patients had been discharged with a follow-up visit between 2009 and 2018. This is a retrospective longitudinal correlation study with a strategic selection. Data consist of 71 125 anonymous quantified patients, who have been hospitalized and who, at the time with discharge, have been booked to a revisit as an outpatient. Results are compared between 81 different wards in Stockholm County. Results show that a significant amount (42%) of the patients do not visit the outward as planned by health care, but instead seek help from the emergency ward. Further, a variance in cancellation of the follow-up visit appear as an outcome for the data. Retrospective analysis of quantified data seems to be a valuable tool for widening the understanding of performance variability and could help healthcare management understand where resources should be prioritized. The results also show how patients themselves have, and use, adaptive capacities in order to navigate the system, and that this has consequences at higher system levels.
Performance variability, Psychiatric discharge, Resilience, Retrospective analysis, Meso-level, Micro-level.
Copyright (c) 2019 Jakob Svensson, Johan Bergström http://creativecommons.org/licenses/by-nc/4.0
Resilience in the Swedish healthcare system
Background: Swedish healthcare has become increasingly under strain with problems to recruit and retain personnel, decreasing production and productivity as well as increasing queues. This more demanding situation raised the question if it also would affect the healthcare system’s ability to deal with disruptions. The ability of a healthcare system to handle both regular and extraordinary disruptions is essential to ensure care of citizens under varying conditions and trust in the system. Purpose: to assess the ability of the Swedish healthcare system to handle both regular and extraordinary disruptions in a short- and long-term perspective. Theory: a resilience-engineering framework of four system functions: monitoring, response, anticipation and learning, was used. Methods: quantitative (official statistics) and qualitative methods were combined. DRG statistics determined production and the productivity of Swedish healthcare regions. Document studies, interviews and workshops helped understand issues qualitatively. Results: Swedish healthcare has an adequate ability to respond to short-term extraordinary disturbances, but has more problems in handling regular challenges in operative care. Key reasons for these problems were insufficient monitoring and learning; as evidenced by problems to match capacity to needs and difficulty in realizing structural change towards a healthcare system based around primary care. Conclusions: Swedish healthcare exhibits a typical pattern in many organizations in which focus on short-term pressures crowds out longer-term strategic issues of system restructuring
Copyright (c) 2019 Patrik Hidefjäll http://creativecommons.org/licenses/by-nc/4.0
Exploring methodological procedures of TORC: an application experience
Training has proven to be effective in developing safety in complex systems, such as in aviation. Among recent training technologies for resilience skills and capabilities, TORC (Training for Operational Resilience Capabilities) was developed as a tool for training workers to handle critical situations. It is a non-specific domain gamification to address operational and organizational safety needs. Although it is a promising technology, some methodological procedures should be analyzed in order to promote its development and evaluation. In this study, we report our recent TORC experience with aviation pilots and we explore the methodological procedures in three phases of the game: preparation (i.e. objectives, game definitions and context), application (i.e. training process and training format) and analyses (i.e. discussion about relevance and training method). We adopted a multi-method approach, with one team of researchers taking part in TORC sessions and another team observing TORC dynamics. Data was cross-examined and a framework is proposed, which will offer a visual representation to guide the TORC sessions development. Results provide information for both researchers (concerned in the application of TORC and similar training dynamics) and practitioners (interested in TORC game).
Copyright (c) 2019 Éder Henriqson, Felipe Lando, Marina Gaspareto http://creativecommons.org/licenses/by-nc/4.0
Governance, complexity and deep system threats
Aviation, health care and financial services are increasingly stretched due to aspects that pose deep enduring systemic threats to our societies, challenging our ability to respond with commensurate socio-technical solutions. It has been argued that complex systems like these are intractable, defying generalisable analysis that could support prediction and control, and hence are not amenable to compliance models of regulation. Instead it is argued here that this ability can be developed with applying governance to a knowledge system. The knowledge system needs to identify relevant system properties with leverage on operational risk. Big data analysis plus model-based reasoning, can identify generic socio-technical system characteristics. To make sense of the relations between system and outcome a complementary capability to model the functionality of producing the data is needed. Our socio-technical analysis model is based on the following principles: purposive human systems have outcomes and produce value; this involves at least a minimal sequence of activity with related dependencies; it is the reciprocal nature of social relations that makes that sequence possible, and the flow of knowledge and information enables these productive roles of people. A governance system is required to assure that this works. A governance system should generate a motivation, an “obligation to act” to use the knowledge directly within operations, to implement and validate solutions, and to manage risk across the system. This behaviour needs to be sustained in three cycles of governance: Operational, Improvement and Strategic. The operational feedback loop maintains its role to ensure close monitoring of the operational impact of the system change, maintaining a close link between strategic implementation and operational experience. Safety is not something distinct and separate from other aspects of system functionality, but it needs to be integrated into a new evidence-based governance of operational risk which is outlined in this paper.
operational risk, governance, sociotechnical system analysis
Copyright (c) 2019 Nick McDonald, Pernilla Ulfvengren http://creativecommons.org/licenses/by-nc/4.0
Use of human hazard analysis to enhance resilient performance of helicopter maintenance systems
When designing a new helicopter, the manufacturer must consider the maintenance tasks required to keep the aircraft airworthy with maximum efficiency. This is based on the performance of previous designs and as much as possible, the experience of real maintenance engineers bought into the team. This is rarely perfect but the system displays resilient performance, driven from the flexibility and adaptability of maintenance engineers overcoming the real-life challenges of the maintenance environment to ensure we continue to deliver safe and available aircraft. This presentation will explore Human Hazard Analysis, a process to compare the ‘Work-as-Imagined’ in design to the ‘Work-as-Done’ in the real maintenance environment to reveal design and organisational limitations, but more importantly the strengths of those conducting the maintenance. The process builds upon the “Safety-I” data collected, formally and informally, on how the system has failed, but introduces a “Safety-II” focus on the workarounds developed. We bring together groups of people from across the industry with the aim of having a different conversation. Attendees include design engineers, manufacturer technical representatives, accident investigators, experienced and novice maintenance engineers, technical directors and human factors specialists. The ground rules are simple, that openness is key. The benefit comes from honest conversations, actively avoiding the risks of defending positions, rushing to assign blame, avoiding the acceptance of blame and protecting perceived reputations. From the insights generated we are addressing weaknesses in helicopter design and documentation, organisational norms and training, and formalising the adaptive processes employed to improve the safety and efficiency of the maintenance process.
Human factors, Maintainability, Resilient performance, Maintenance, Human hazard analysis, Helicopter
Copyright (c) 2019 Simon Gill http://creativecommons.org/licenses/by-nc/4.0
Building bridges, minding the gaps: involving the perspectives of older people in creating resilient healthcare infrastructure to disasters
Introduction: Natural disasters have increased over the last decades. As the world population is also ageing, older people have become more exposed to disasters, with the United Nations highlighting the critical role of healthcare infrastructure in disaster contexts. Traditionally, research on disaster resilience has focused mainly on disasters’ negative effects on older people as a vulnerable group, and there is scarce research in engineering that incorporates older people’s needs and experiences as a group that is also capable and resilient. This project responds to the lack of research that incorporates the assessment of resilience in healthcare facilities that incorporates the perspectives of older people as its final users. Objective: This paper presents a methodological approach to integrating the physical assessment of resilience in healthcare facilities with the perspectives of older people. It corresponds to a study still being conducted in the central zone of Chile. This region is regularly exposed to earthquakes and concentrates the largest number of complex healthcare facilities in the nation, targeting around 40% of its older population. Methods: A collaboration between two PhD research projects is assessing healthcare facilities’ experience of large earthquakes and the relationships between facilities in disaster contexts and the perspectives of older people. This is a mixed-methods study, that will combine a qualitative approach (semi-structured interviews and focus groups) with seismic engineering resilience modelling. Results: Preliminary results helped identify earthquakes’ potential effects on functionality from the perspectives of older people and the relationships between healthcare facilities. This study can contribute to healthcare facilities’ earthquake resilience by offering a broader perspective on the links between older people’s disaster experiences and healthcare facilities.
earthquake resilience, healthcare facilities, older people
Copyright (c) 2019 Yvonne Merino, Andrea Vásquez, Katitza Marinkovic http://creativecommons.org/licenses/by-nc/4.0
Resilience Assessment Grid (RAG) for facilitating safety consciousness of nuclear power plant personnel
Our experience of applying the Resilience Assessment Grid (RAG) method to nuclear power plant personnel is described. Various countermeasures have been introduced in every Japanese nuclear power plant (NPP) in order to meet regulatory requirements issued after the severe accident at Fukushima-Daiichi NPP. These requirements cover diverse hardware installation, human resource enhancement, and managerial improvement. However, although these countermeasures will improve the safety of NPPs in principle, they may also have negative impacts. The most likely negative impact of such strict regulations is loss of operational flexibility, i.e. degradation of resilience potential. The RAG method has been introduced to avoid degradation of resilience potential. However, in a preliminary stage of applying the method, the plant personnel were reluctant to accept the idea of improving operational resilience. They believed that any anomaly could be handled by following predefined operational procedures, and were reluctant to rely on resilient behavior to handle unexpected situations. Therefore, the RAG questionnaire was modified to overcome their reluctance. The first modification was to ask interviewees to answer a set of questions related to a class of anomalies that may lead to a severe accident. This version of the modified RAG is called the restrictive RAG. In the second modification, the NPP operators were asked to answer mainly questions about the potential to respond and the potential to monitor, while the plant personnel in the safety division, who are responsible for developing procedures, were asked to mainly answer questions concerning the potential to learn and the potential to anticipate. This modified version of RAG was called the cross-divisional RAG. Finally, in the third modification, the set of questions focused on envisioning potential difficulties in conducting tasks that the interviewee is assigned to. This version of RAG was called the brittleness- oriented RAG. Through attempts over several years, the brittleness-oriented RAG was found to be useful as an introductory practice for other RAG surveys. In addition, the brittleness- oriented RAG itself was found to be a useful tool for facilitating consciousness concerning possible weak points of the NPP even after implementing various countermeasures. Enhancing safety consciousness seems to be indispensable for developing resilience potential in the organization.
resilience assessment grid (RAG), safety consciousness, nuclear power plant
Copyright (c) 2019 Hiroshi Sakuda, Masaharu Kitamura http://creativecommons.org/licenses/by-nc/4.0
Resilience Shift program: objectives, execution and preliminary results
The Resilience Shift (RS) was established in 2016 to address the recommendations of the Lloyd's Register Foundation's 'Foresight review of resilience engineering'. The initial 5-year programme is funded by Lloyd's Register Foundation, with Arup as host institution. Its aim is to inspire and empower a shift in critical infrastructure resilience thinking and practice so that engineered structures and infrastructure will be not only safer but also better. This paper provides a summary of the Resilience Shift’s aims and objectives and explains the programme execution. Building resilience of critical infrastructure requires decisionmakers working in different industry sectors to understand ‘what’ can be done, ‘why’ it should be done, and ‘how’ to put it into practice. All results from the Resilience Shift programme are publicly available through the organisation’s website, which can be accessed at: https://www.resilienceshift.org/.
Resilience, Critical infrastructure systems, value chain, socio-technical systems
Copyright (c) 2019 Jan Reier Huse, Oliver Pritchard, Juliet Mian, Xavier Aldea Borruel http://creativecommons.org/licenses/by-nc/4.0
Reducing the gap between work as done and work as imagined on construction safety supported by UAS
Safety management (SM) is considered a complex task during the construction phase, given the number of high-risk activities that can lead to accidents. The differences between work as done (WAD) and work as imagined (WAI) is one of the main barriers faced by safety management. The Resilience Engineering stand out that improving in safety performance cannot be simply achieved through the use of procedures and barriers, but through the continuous monitoring. On the other hand, the use of Unmanned Aerial Systems (UAS) technology can contribute to the safety management system to support the monitoring of the daily work. This study aims to evaluate how work is performed from RE perspective through the application of the safety checklist based on the assets collected with UASs on site, focusing on the cast-in-place concrete wall constructive process, once it involves high risk of accidents during construction. For this, an exploratory case study in a construction project was conducted in Brazil, involving the following steps: (a) development of a safety monitoring protocol using UASs, (b) field tests for monitoring safety conditions with UASs along 35 weeks, and (c) data analysis. As contribution, this work identifies potential improvements on safety procedures aiming to reduce the differences between prescribed and actual work. In addition, the UASs can be used to perform regular and redundant safety inspections providing information to support managers’ decision-making.
Safety Monitoring, Resilience Engineering, Unmanned Aerial Systems (UAS), Work as done (WAD), Prescribed and actual work, Construction sites
Copyright (c) 2019 Roseneia Melo, Dayana Costa http://creativecommons.org/licenses/by-nc/4.0
Contemporary fisheries risks and SME resilience Dutch fishing vessel (re)designing 1988-2018
The North Sea flatfish fisheries can be characterized by small, family owned enterprises (SME), where the fishermen have a decisive voice in (re)designing and adapting to socio-technical system capacity, safety-wellbeing and resilient business performances. In particular, the Dutch safety- and sustainability awareness reflect on engineering (reliability) and business models. Where maritime resilience goes further than a mere socio-organizational approach on safety consequences and recovery from mishap and disaster. Since the 80s the Dutch fishing vessels had to adapt to three major socio-political changes, at the same time becoming key (re)design drivers: from traditional to Safe & Health Environment (SHE; Kindunos; safety-integrated re-design), from SHE to Corporate Social Responsibility (CSR; MDV-1; disruptive new design) and currently from sustainable to integration of the Circular Economy Principles (CE; prospective CE-(re)design concepts). On existing vessels the required safety-and sustainable modifications came with very high transition costs, especially under conditions of the 2008 economic crisis. This severely hampered the ability of individual SME’s to invest in mid-life upgrades, let alone in disruptive new buildings. The new socio-political challenges dictate change in (re)design approaches, in which sound safety aspects stay consistent and vital. In order to remain flexible and resilient to future fishery system changes, the fishing vessel design process must become more transparent and already start at conceptual level. Firstly with identification of future-proof design aims and sound business models, rather than further restrictive detailing and extensive quantification of current performance indicators. Such an effort requires disruptive design approaches at corporate- and sector level rather than adaptation at a strict organizational level. However, the resilience engineering essential abilities are a good start-up integrating multiple- sustainability change drivers. It requires an integration of fisheries engineering expertise, sectoral and public support and new cyclic innovation strategies. Such a integrative top-down/bottom-up (design)cooperation facilitate foresight on future SME behavior and viable exploitation of fishing vessels in a life cycle innovation strategies. Such a integrative top-down/bottom-up (design)cooperation facilitate foresight on future SME behavior and viable exploitation of fishing vessels in a life cycle approach; making them less dependent on constantly changing socio-economic market mechanisms for the short and medium term as well as socio-political change drivers on the long term.
Copyright (c) 2019 Frans Veestra, Hendrik Kramer http://creativecommons.org/licenses/by-nc/4.0
Copyright (c) 2019 Johan Karltun, Anette Karltun, Karin Havemose, Sofia Kjellström https://creativecommons.org/licenses/by-nc/4.0
Copyright (c) 2019 Hiroshi Sakuda, Masaharu Kitamura https://creativecommons.org/licenses/by-nc/4.0
Training resilient decision-making with a serious game: how effective is this resilience intervention?
The Dutch National Institute for Public Health and the Environment (Dutch acronym: RIVM) developed an intervention to train resilient decision-making to improve occupational safety. It consists of a training using a serious game that aims to contribute to the management of uncertainty in unforeseen, hazardous work situations that are not covered by normal procedures. This training uses a decision dilemma under time pressure that needs to be solved during a role-playing game. The game consists of multiple elements, for example Storycards with a resilience vocabulary, a Storyboard and resilience safety quadrants. To evaluate the effectiveness of this safety intervention, a pilot study was undertaken in five Dutch organizations. Kirkpatrick’s theoretical framework, more specific the first two levels (reaction and leaning), was used to evaluate the training. Teams working within these organizations (in total 38 employees) participated by playing the serious game supervised by game trainers. The effectiveness measurement consisted of three parts: a questionnaire, a participant-generated word list and observations carried out by the researcher. The participants filled out the questionnaire both before and after the training. The questions covered a number of topics, for instance the participants’ general attitude towards serious games and learning effects they attribute to the resilience training. The participants were also asked to write down words they associate with safety in unexpected and unforeseen situations, both before and after the training. Based on the first measurable results of this effectiveness evaluation, it is concluded that the training with the resilience serious game was positively assessed by the participants and that it contributes to their understanding about resilience. The observations served as input to further develop the game (materials) and implement the training into Dutch organizations.
Copyright (c) 2019 Monique Chambon, Marre Lammers https://creativecommons.org/licenses/by-nc/4.0
Resilience of UK water and wastewater systems: why we need to get wise before we get smart
Resilience of critical water and wastewater infrastructure has been given particular impetus in the UK by the work of the National Infrastructure Commission and the water industry regulator Ofwat, which has a statutory duty to promote resilience. Ofwat advocates the adoption of a systems-based approach and a holistic concept of resilience ‘in the round’. However, translating this into effective planning tools and processes is challenging. At the same time, many water companies are turning to ICT based ‘smart’ solutions, as a low-cost way to extend the life of ageing infrastructure systems which are too expensive to replace or fundamentally re-engineer. This means that complexity and dependency on third-party systems will increase. The infrastructure providing the service to the customer will become an increasingly complex system-of-systems transcending organisational boundaries and creating new and unpredictable vulnerabilities for the services provided. In the face of this emerging complexity, the trend has been to try to simplify and breakdown the planning process into discrete and independent ‘bite-sized’ pieces, constrained by budgets, organisational capacity and technical capability. This carries the risk of creating a false sense of assurance that ‘we have addressed resilience as best we can’ when in reality we need a paradigm shift in thinking, to raise expectations and accelerate developments in modelling and understanding the challenge. We also need to facilitate collaboration, beyond organisational boundaries, to develop the most effective solutions. This presentation will explore how far the UK water sector has come in tackling the challenge of critical infrastructure resilience, drawing on the presenter’s own experience and other published case studies and set out a potential roadmap to ensure that our planning processes and capability keep pace with the accelerating pace of change in a complex world.
Copyright (c) 2019 Brendan McAndrew https://creativecommons.org/licenses/by-nc/4.0
From Cheese to STEW: incorporating a systems’ approach to critical incident analysis
The Canadian Incident Analysis Framework (CPSI, 2012) supports healthcare providers that are involved, manage, analyse and learn from patient safety incidents, with the goal of increasing the effectiveness of incident analysis and enhancing the safety and quality of patient care. Although the framework incorporates multiple methods to analyse incidents, the identification of contributing factors is solely based on a linear and root cause understanding of what, how and why an event happened; the Swiss Cheese Model acts as a fundamental concept that supports the framework’s incident management pathway. An alternative and practical approach to support critical incident analysis and supplement the CPSI framework is STEW: Systems Thinking for Everyday Work (NHS, 2018). These discussion cards frame team conversations and support systematic group discussion in order to analyse patient safety incidents by understanding the current system (work-as-imagined to work-as-done), understand why decisions made sense at the time, explore performance variability, analyse interactions and flow, and identify improvement priorities. At our hospital and after a recent medication error, we applied the 6 principles of STEW to explore and better understand the medication event – with the premise that things normally work and go right with no unintended outcomes – in order to identify opportunities for improvement and sustain resilience. A team that brought multiple perspectives analysed the incident, identified short and long term change ideas into the current work system, and continue to monitor and evaluate change. Understanding performance variability allowed the team to identify areas to increase performance and staff to feel supported, resilient and valued. With a value for restorative just culture, STEW gave means to switch from a reactive find-and-fix mode, to a proactive patient safety management and better understanding of everyday work performance and flexibility.
Copyright (c) 2019 Sarah Carriere https://creativecommons.org/licenses/by-nc/4.0
Resilience in a world of barriers: an update on resilience within the swedish nuclear industry
To what extent is the nuclear industry embracing resilience engineering (RE)? What are the challenges of implementing RE in this industry? This presentation will argue that nuclear might be the industry where it is needed the most.The nuclear industry is taking some actions reflecting an implementation of resilience engineering, without using that vocabulary. Three characteristics of the nuclear industry will be presented that both support and, at the same time, slows down the use of RE as a concept. Today RE is notan established concept in nuclear industry at large. However, there is a search for new solutions to old problems within nuclear and RE might be a part of the answer. In the nuclear industry the embrace of RE is driven by a scattered crowd of resilience engineering enthusiasts, most of the safety professionals, ambitiously employing the concepts of RE where they can and where they find it suitable.Lastly it will be discussed what new actions can be taken in order to truly speed up the embrace of resilience engineering in practice.
Copyright (c) 2019 Helen Alm http://creativecommons.org/licenses/by-nc/4.0
Combining structural and functional modelling: exploring the relationship between the built environment and resilient healthcare
Several studies indicate that the built environment plays a role on both patients ́ outcomes and providers ́ performance in healthcare. Thus, the built environment is part of the joint cognitive system involved in patient care, and it can either hinder or support resilience. This study explores the relationship between the built environment and system resilience in a 39-beds intensive care unit (ICU). Six steps were followed: (i) the structural modelling of the ICU, using Building Information Modelling (BIM) – this tool allows for the multidimensional modelling of physical areas and information management; (ii) the identification of the structural requirements (i.e. those arising from human interactions with the built environment); (iii) the functional modelling of the ICU, using the FRAM; (iv) the identification of the functional requirements (i.e. those arising from organizational design and routines); (v) the assessment of the extent to which the ICU complied with those requirements; and (vi) an analysis of the relationships between the structural and functional requirements, as well as of how these influence the ICU resilience. This analysis was supported by the FRAM model, which included two functions referred to as <comply with structural requirements> and <comply with functional requirements>. The outputs of these functions were coupled to the preconditions of the regular ICU functions, supporting the exploration of possibilities of functional resonance resulting from no compliance with the requirements. The sources of data for all steps were the same, involving interviews with professionals, observations of ICU operations, and the analysis of regulations that set mandatory requirements. The findings from this study offered insight into improvement opportunities in the design of a new more resilient ICU, which is under construction.
built environment, intensive care unit, resilient healthcare, requirements management
Copyright (c) 2019 Natália Ransolin, Tarcisio A. Saurin, Carlos T. Formoso https://creativecommons.org/licenses/by-nc/4.0