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Primer_Brand__Text-module__Text--200____P1wy Primer_Brand__Text-module__Text--antialiased___TYoXS Primer_Brand__Text-module__Text--weight-medium___qJKf_ NavLink-module__title__Q7t0p"><svg data-component="Octicon" aria-hidden="true" focusable="false" class="octicon octicon-code NavLink-module__icon__ltGNM" viewBox="0 0 16 16" width="16" height="16" fill="currentColor" display="inline-block" overflow="visible" style="vertical-align:text-bottom"><path d="m11.28 3.22 4.25 4.25a.75.75 0 0 1 0 1.06l-4.25 4.25a.749.749 0 0 1-1.275-.326.749.749 0 0 1 .215-.734L13.94 8l-3.72-3.72a.749.749 0 0 1 .326-1.275.749.749 0 0 1 .734.215Zm-6.56 0a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042L2.06 8l3.72 3.72a.749.749 0 0 1-.326 1.275.749.749 0 0 1-.734-.215L.47 8.53a.75.75 0 0 1 0-1.06Z"></path></svg>Code Review</span><span class="Primer_Brand__Text-module__Text___XeGJJ Primer_Brand__Text-module__Text-font--mona-sans___a8XJD Primer_Brand__Text-module__Text--muted___rE6mh Primer_Brand__Text-module__Text--200____P1wy Primer_Brand__Text-module__Text--antialiased___TYoXS NavLink-module__subtitle__X4gkW">Manage code changes</span></span></a></li><li><a class="Primer_Brand__Link-module__Link___lF11y Primer_Brand__Link-module__Link--default___VRVW0 NavLink-module__link__EG3d4" href="https://github.com/features/code-quality" data-analytics-event="{"action":"code_quality","tag":"link","context":"platform","location":"navbar","label":"code_quality_link_platform_navbar"}"><span class="Primer_Brand__Text-module__Text___XeGJJ Primer_Brand__Text-module__Text-font--mona-sans___a8XJD Primer_Brand__Text-module__Text--default___GhPh_ Primer_Brand__Text-module__Text--200____P1wy Primer_Brand__Text-module__Text--antialiased___TYoXS Primer_Brand__Link-module__Link--label___jM8Ty"><span class="Primer_Brand__Text-module__Text___XeGJJ Primer_Brand__Text-module__Text-font--mona-sans___a8XJD Primer_Brand__Text-module__Text--default___GhPh_ Primer_Brand__Text-module__Text--200____P1wy Primer_Brand__Text-module__Text--antialiased___TYoXS Primer_Brand__Text-module__Text--weight-medium___qJKf_ NavLink-module__title__Q7t0p"><svg data-component="Octicon" aria-hidden="true" focusable="false" class="octicon octicon-codescan-checkmark NavLink-module__icon__ltGNM" viewBox="0 0 16 16" width="16" height="16" fill="currentColor" display="inline-block" overflow="visible" style="vertical-align:text-bottom"><path d="M10.28 6.28a.75.75 0 1 0-1.06-1.06L6.25 8.19l-.97-.97a.75.75 0 0 0-1.06 1.06l1.5 1.5a.75.75 0 0 0 1.06 0l3.5-3.5Z"></path><path d="M7.5 15a7.5 7.5 0 1 1 5.807-2.754l2.473 2.474a.749.749 0 0 1-.326 1.275.749.749 0 0 1-.734-.215l-2.474-2.473A7.472 7.472 0 0 1 7.5 15Zm0-13.5a6 6 0 1 0 4.094 10.386.748.748 0 0 1 .293-.292 6.002 6.002 0 0 0 1.117-6.486A6.002 6.002 0 0 0 7.5 1.5Z"></path></svg>Code Quality</span><span class="Primer_Brand__Text-module__Text___XeGJJ Primer_Brand__Text-module__Text-font--mona-sans___a8XJD Primer_Brand__Text-module__Text--muted___rE6mh Primer_Brand__Text-module__Text--200____P1wy Primer_Brand__Text-module__Text--antialiased___TYoXS NavLink-module__subtitle__X4gkW">Enforce quality at merge</span></span></a></li></ul></div></li><li><div class="NavGroup-module__group__W8SqJ"><span class="Primer_Brand__Text-module__Text___XeGJJ Primer_Brand__Text-module__Text-font--monospace___QXHDQ Primer_Brand__Text-module__Text--muted___rE6mh Primer_Brand__Text-module__Text--100___B2ueX Primer_Brand__Text-module__Text--weight-medium___qJKf_ NavGroup-module__title__Wzxz2" id="_R_dknd_">APPLICATION SECURITY</span><ul class="NavGroup-module__list__UCOFy" aria-labelledby="_R_dknd_"><li><a class="Primer_Brand__Link-module__Link___lF11y Primer_Brand__Link-module__Link--default___VRVW0 NavLink-module__link__EG3d4" href="https://github.com/security/advanced-security" data-analytics-event="{"action":"github_advanced_security","tag":"link","context":"platform","location":"navbar","label":"github_advanced_security_link_platform_navbar"}"><span class="Primer_Brand__Text-module__Text___XeGJJ Primer_Brand__Text-module__Text-font--mona-sans___a8XJD Primer_Brand__Text-module__Text--default___GhPh_ Primer_Brand__Text-module__Text--200____P1wy Primer_Brand__Text-module__Text--antialiased___TYoXS Primer_Brand__Link-module__Link--label___jM8Ty"><span class="Primer_Brand__Text-module__Text___XeGJJ Primer_Brand__Text-module__Text-font--mona-sans___a8XJD Primer_Brand__Text-module__Text--default___GhPh_ Primer_Brand__Text-module__Text--200____P1wy Primer_Brand__Text-module__Text--antialiased___TYoXS Primer_Brand__Text-module__Text--weight-medium___qJKf_ NavLink-module__title__Q7t0p"><svg data-component="Octicon" aria-hidden="true" focusable="false" class="octicon octicon-shield-check NavLink-module__icon__ltGNM" viewBox="0 0 16 16" width="16" height="16" fill="currentColor" display="inline-block" overflow="visible" style="vertical-align:text-bottom"><path d="m8.533.133 5.25 1.68A1.75 1.75 0 0 1 15 3.48V7c0 1.566-.32 3.182-1.303 4.682-.983 1.498-2.585 2.813-5.032 3.855a1.697 1.697 0 0 1-1.33 0c-2.447-1.042-4.049-2.357-5.032-3.855C1.32 10.182 1 8.566 1 7V3.48a1.75 1.75 0 0 1 1.217-1.667l5.25-1.68a1.748 1.748 0 0 1 1.066 0Zm-.61 1.429.001.001-5.25 1.68a.251.251 0 0 0-.174.237V7c0 1.36.275 2.666 1.057 3.859.784 1.194 2.121 2.342 4.366 3.298a.196.196 0 0 0 .154 0c2.245-.957 3.582-2.103 4.366-3.297C13.225 9.666 13.5 8.358 13.5 7V3.48a.25.25 0 0 0-.174-.238l-5.25-1.68a.25.25 0 0 0-.153 0ZM11.28 6.28l-3.5 3.5a.75.75 0 0 1-1.06 0l-1.5-1.5a.749.749 0 0 1 .326-1.275.749.749 0 0 1 .734.215l.97.97 2.97-2.97a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042Z"></path></svg>GitHub Advanced Security</span><span class="Primer_Brand__Text-module__Text___XeGJJ Primer_Brand__Text-module__Text-font--mona-sans___a8XJD Primer_Brand__Text-module__Text--muted___rE6mh Primer_Brand__Text-module__Text--200____P1wy Primer_Brand__Text-module__Text--antialiased___TYoXS NavLink-module__subtitle__X4gkW">Find and fix vulnerabilities</span></span></a></li><li><a class="Primer_Brand__Link-module__Link___lF11y Primer_Brand__Link-module__Link--default___VRVW0 NavLink-module__link__EG3d4" href="https://github.com/security/advanced-security/code-security" data-analytics-event="{"action":"code_security","tag":"link","context":"platform","location":"navbar","label":"code_security_link_platform_navbar"}"><span class="Primer_Brand__Text-module__Text___XeGJJ Primer_Brand__Text-module__Text-font--mona-sans___a8XJD Primer_Brand__Text-module__Text--default___GhPh_ Primer_Brand__Text-module__Text--200____P1wy Primer_Brand__Text-module__Text--antialiased___TYoXS Primer_Brand__Link-module__Link--label___jM8Ty"><span class="Primer_Brand__Text-module__Text___XeGJJ Primer_Brand__Text-module__Text-font--mona-sans___a8XJD Primer_Brand__Text-module__Text--default___GhPh_ Primer_Brand__Text-module__Text--200____P1wy Primer_Brand__Text-module__Text--antialiased___TYoXS Primer_Brand__Text-module__Text--weight-medium___qJKf_ NavLink-module__title__Q7t0p"><svg data-component="Octicon" aria-hidden="true" focusable="false" class="octicon octicon-code-square NavLink-module__icon__ltGNM" viewBox="0 0 16 16" width="16" height="16" fill="currentColor" display="inline-block" overflow="visible" style="vertical-align:text-bottom"><path d="M0 1.75C0 .784.784 0 1.75 0h12.5C15.216 0 16 .784 16 1.75v12.5A1.75 1.75 0 0 1 14.25 16H1.75A1.75 1.75 0 0 1 0 14.25Zm1.75-.25a.25.25 0 0 0-.25.25v12.5c0 .138.112.25.25.25h12.5a.25.25 0 0 0 .25-.25V1.75a.25.25 0 0 0-.25-.25Zm7.47 3.97a.75.75 0 0 1 1.06 0l2 2a.75.75 0 0 1 0 1.06l-2 2a.749.749 0 0 1-1.275-.326.749.749 0 0 1 .215-.734L10.69 8 9.22 6.53a.75.75 0 0 1 0-1.06ZM6.78 6.53 5.31 8l1.47 1.47a.749.749 0 0 1-.326 1.275.749.749 0 0 1-.734-.215l-2-2a.75.75 0 0 1 0-1.06l2-2a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042Z"></path></svg>Code security</span><span class="Primer_Brand__Text-module__Text___XeGJJ Primer_Brand__Text-module__Text-font--mona-sans___a8XJD Primer_Brand__Text-module__Text--muted___rE6mh Primer_Brand__Text-module__Text--200____P1wy Primer_Brand__Text-module__Text--antialiased___TYoXS NavLink-module__subtitle__X4gkW">Secure your code as you build</span></span></a></li><li><a class="Primer_Brand__Link-module__Link___lF11y Primer_Brand__Link-module__Link--default___VRVW0 NavLink-module__link__EG3d4" href="https://github.com/security/advanced-security/secret-protection" data-analytics-event="{"action":"secret_protection","tag":"link","context":"platform","location":"navbar","label":"secret_protection_link_platform_navbar"}"><span class="Primer_Brand__Text-module__Text___XeGJJ Primer_Brand__Text-module__Text-font--mona-sans___a8XJD Primer_Brand__Text-module__Text--default___GhPh_ Primer_Brand__Text-module__Text--200____P1wy Primer_Brand__Text-module__Text--antialiased___TYoXS Primer_Brand__Link-module__Link--label___jM8Ty"><span class="Primer_Brand__Text-module__Text___XeGJJ Primer_Brand__Text-module__Text-font--mona-sans___a8XJD Primer_Brand__Text-module__Text--default___GhPh_ Primer_Brand__Text-module__Text--200____P1wy Primer_Brand__Text-module__Text--antialiased___TYoXS Primer_Brand__Text-module__Text--weight-medium___qJKf_ NavLink-module__title__Q7t0p"><svg data-component="Octicon" aria-hidden="true" focusable="false" class="octicon octicon-lock NavLink-module__icon__ltGNM" viewBox="0 0 16 16" width="16" height="16" fill="currentColor" display="inline-block" overflow="visible" style="vertical-align:text-bottom"><path d="M4 4a4 4 0 0 1 8 0v2h.25c.966 0 1.75.784 1.75 1.75v5.5A1.75 1.75 0 0 1 12.25 15h-8.5A1.75 1.75 0 0 1 2 13.25v-5.5C2 6.784 2.784 6 3.75 6H4Zm8.25 3.5h-8.5a.25.25 0 0 0-.25.25v5.5c0 .138.112.25.25.25h8.5a.25.25 0 0 0 .25-.25v-5.5a.25.25 0 0 0-.25-.25ZM10.5 6V4a2.5 2.5 0 1 0-5 0v2Z"></path></svg>Secret protection</span><span class="Primer_Brand__Text-module__Text___XeGJJ Primer_Brand__Text-module__Text-font--mona-sans___a8XJD Primer_Brand__Text-module__Text--muted___rE6mh Primer_Brand__Text-module__Text--200____P1wy Primer_Brand__Text-module__Text--antialiased___TYoXS NavLink-module__subtitle__X4gkW">Stop leaks before they start</span></span></a></li></ul></div></li><li><div class="NavGroup-module__group__W8SqJ NavGroup-module__hasSeparator__FnMrN"><span class="Primer_Brand__Text-module__Text___XeGJJ Primer_Brand__Text-module__Text-font--monospace___QXHDQ Primer_Brand__Text-module__Text--muted___rE6mh Primer_Brand__Text-module__Text--100___B2ueX Primer_Brand__Text-module__Text--weight-medium___qJKf_ NavGroup-module__title__Wzxz2" id="_R_hknd_">EXPLORE</span><ul class="NavGroup-module__list__UCOFy" aria-labelledby="_R_hknd_"><li><a class="Primer_Brand__Link-module__Link___lF11y Primer_Brand__Link-module__Link--default___VRVW0" 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1.614.693 2.484 0 .572-.053 1.148-.254 1.656.066.228.098.429.126.612.012.076.024.148.037.218.924.385 1.522 1.471 1.591 2.095v1.872c0 .766-3.351 3.795-8.002 3.795Zm0-1.485c2.28 0 4.584-1.11 5.002-1.433V7.862l-.023-.116c-.49.21-1.075.291-1.727.291-1.146 0-2.059-.327-2.71-.991A3.222 3.222 0 0 1 8 6.303a3.24 3.24 0 0 1-.544.743c-.65.664-1.563.991-2.71.991-.652 0-1.236-.081-1.727-.291l-.023.116v4.255c.419.323 2.722 1.433 5.002 1.433ZM6.762 2.83c-.193-.206-.637-.413-1.682-.297-1.019.113-1.479.404-1.713.7-.247.312-.369.789-.369 1.554 0 .793.129 1.171.308 1.371.162.181.519.379 1.442.379.853 0 1.339-.235 1.638-.54.315-.322.527-.827.617-1.553.117-.935-.037-1.395-.241-1.614Zm4.155-.297c-1.044-.116-1.488.091-1.681.297-.204.219-.359.679-.242 1.614.091.726.303 1.231.618 1.553.299.305.784.54 1.638.54.922 0 1.28-.198 1.442-.379.179-.2.308-.578.308-1.371 0-.765-.123-1.242-.37-1.554-.233-.296-.693-.587-1.713-.7Z"></path><path d="M6.25 9.037a.75.75 0 0 1 .75.75v1.501a.75.75 0 0 1-1.5 0V9.787a.75.75 0 0 1 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<div id="js-flash-container" class="flash-container" data-turbo-replace>
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<template class="js-flash-template">
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<div class="flash flash-full {{ className }}">
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<div >
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<button autofocus class="flash-close js-flash-close" type="button" aria-label="Dismiss this message">
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<svg aria-hidden="true" data-component="Octicon" height="16" viewBox="0 0 16 16" version="1.1" width="16" data-view-component="true" class="octicon octicon-x">
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<path d="M3.72 3.72a.75.75 0 0 1 1.06 0L8 6.94l3.22-3.22a.749.749 0 0 1 1.275.326.749.749 0 0 1-.215.734L9.06 8l3.22 3.22a.749.749 0 0 1-.326 1.275.749.749 0 0 1-.734-.215L8 9.06l-3.22 3.22a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042L6.94 8 3.72 4.78a.75.75 0 0 1 0-1.06Z"></path>
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<div aria-atomic="true" role="alert" class="js-flash-alert">
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<div>{{ message }}</div>
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</template>
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<div
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class="application-main "
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data-commit-hovercards-enabled
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data-discussion-hovercards-enabled
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data-issue-and-pr-hovercards-enabled
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data-project-hovercards-enabled
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>
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<div itemscope itemtype="http://schema.org/SoftwareSourceCode" class="">
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<main id="js-repo-pjax-container" >
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<div id="repository-container-header" class="tmp-pt-3 hide-full-screen" style="background-color: var(--page-header-bgColor, var(--color-page-header-bg));" data-turbo-replace>
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<div class="d-flex flex-nowrap flex-justify-end tmp-mb-3 tmp-px-3 tmp-px-lg-5" style="gap: 1rem;">
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<div class="flex-auto min-width-0 width-fit">
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<div class=" d-flex flex-wrap flex-items-center wb-break-word f3 text-normal">
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</svg>
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<span class="author flex-self-stretch" itemprop="author">
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<a class="url fn" rel="author" data-hovercard-type="user" data-hovercard-url="/users/lorin/hovercard" data-octo-click="hovercard-link-click" data-octo-dimensions="link_type:self" href="/lorin">
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<span class="mx-1 flex-self-stretch color-fg-muted">/</span>
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<li data-view-component="true" class="d-inline-flex">
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Scott"},{"level":3,"text":"Concepts","anchor":"concepts-21","htmlText":"Concepts"},{"level":3,"text":"Selected publications","anchor":"selected-publications-38","htmlText":"Selected publications"},{"level":2,"text":"Steven Shorrock","anchor":"steven-shorrock","htmlText":"Steven Shorrock"},{"level":3,"text":"Selected publications","anchor":"selected-publications-39","htmlText":"Selected publications"},{"level":3,"text":"Selected talks","anchor":"selected-talks-9","htmlText":"Selected talks"},{"level":2,"text":"Diane Vaughan","anchor":"diane-vaughan","htmlText":"Diane Vaughan"},{"level":3,"text":"Concepts","anchor":"concepts-22","htmlText":"Concepts"},{"level":3,"text":"Selected publications","anchor":"selected-publications-40","htmlText":"Selected publications"},{"level":2,"text":"Barry Turner","anchor":"barry-turner","htmlText":"Barry Turner"},{"level":3,"text":"Selected publications","anchor":"selected-publications-41","htmlText":"Selected publications"},{"level":2,"text":"Robert L. Wears","anchor":"robert-l-wears","htmlText":"Robert L. Wears"},{"level":3,"text":"Concepts","anchor":"concepts-23","htmlText":"Concepts"},{"level":3,"text":"Selected publications","anchor":"selected-publications-42","htmlText":"Selected publications"},{"level":3,"text":"Selected talks","anchor":"selected-talks-10","htmlText":"Selected talks"},{"level":2,"text":"David Woods","anchor":"david-woods","htmlText":"David Woods"},{"level":3,"text":"Contributions","anchor":"contributions-6","htmlText":"Contributions"},{"level":4,"text":"The adaptive universe","anchor":"the-adaptive-universe","htmlText":"The adaptive universe"},{"level":4,"text":"Charting adaptive cycles","anchor":"charting-adaptive-cycles","htmlText":"Charting adaptive cycles"},{"level":3,"text":"Graceful extensibility","anchor":"graceful-extensibility","htmlText":"Graceful extensibility"},{"level":3,"text":"SCAD (Systemic Contributors Analysis and Diagram)","anchor":"scad-systemic-contributors-analysis-and-diagram","htmlText":"SCAD (Systemic Contributors Analysis and Diagram)"},{"level":3,"text":"Concepts","anchor":"concepts-24","htmlText":"Concepts"},{"level":3,"text":"Selected publications","anchor":"selected-publications-43","htmlText":"Selected publications"},{"level":3,"text":"Selected talks","anchor":"selected-talks-11","htmlText":"Selected talks"},{"level":3,"text":"Online courses","anchor":"online-courses","htmlText":"Online courses"},{"level":2,"text":"John Wreathall","anchor":"john-wreathall","htmlText":"John Wreathall"},{"level":3,"text":"Selected publications","anchor":"selected-publications-44","htmlText":"Selected publications"}]},"issueTemplate":null,"discussionTemplate":null,"richText":"\u003carticle class=\"markdown-body entry-content container-lg\" itemprop=\"text\"\u003e\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch1 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eResilience engineering papers\u003c/h1\u003e\u003ca id=\"user-content-resilience-engineering-papers\" class=\"anchor\" aria-label=\"Permalink: Resilience engineering papers\" href=\"#resilience-engineering-papers\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eOverview\u003c/h2\u003e\u003ca id=\"user-content-overview\" class=\"anchor\" aria-label=\"Permalink: Overview\" href=\"#overview\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eAlias: \u003ca href=\"http://resiliencepapers.club\" rel=\"nofollow\"\u003ehttp://resiliencepapers.club\u003c/a\u003e (thanks to \u003ca href=\"https://twitter.com/allspaw\" rel=\"nofollow\"\u003eJohn Allspaw\u003c/a\u003e).\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eThis doc contains notes about people active in resilience engineering, as well as some influential\nresearchers who are no longer with us, organized alphabetically. It also includes people and papers\nfrom related fields, such as cognitive systems engineering and naturalistic decision-making.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eIf you're not sure what to read first, check out \u003ca href=\"/lorin/resilience-engineering/blob/master/intro.md\"\u003eResilience engineering: Where do I start?\u003c/a\u003e\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eAnnotations\u003c/h2\u003e\u003ca id=\"user-content-annotations\" class=\"anchor\" aria-label=\"Permalink: Annotations\" href=\"#annotations\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eA \u003ca href=\"https://safety177496371.wordpress.com/\" rel=\"nofollow\"\u003eBH\u003c/a\u003e link indicates Ben Hutchinson's \u003ca href=\"https://safety177496371.wordpress.com/\" rel=\"nofollow\"\u003eSafety \u0026amp; Performance Research Summaries\u003c/a\u003e blog.\nBen writes summaries of safety papers, posting them to his blog as well as LinkedIOn.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eA \u003ca href=\"http://resilienceroundup.com\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e link indicates Thai Wood's \u003ca href=\"http://resilienceroundup.com\" rel=\"nofollow\"\u003eResilience Roundup\u003c/a\u003e. Thai publishes a newsletter that\nsummarizes resilience engineering papers.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eOther interesting links\u003c/h2\u003e\u003ca id=\"user-content-other-interesting-links\" class=\"anchor\" aria-label=\"Permalink: Other interesting links\" href=\"#other-interesting-links\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://resilienceinsoftware.org\" rel=\"nofollow\"\u003eresilienceinsoftware.org\u003c/a\u003e is the Resilience in Software Foundation, a community of software people who are interested in resilience engineering.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eFor a collection of talks, check out the \u003ca href=\"https://www.youtube.com/playlist?list=PLb1aZTnPf3-OMChMkrr6WsokRI6LOnuem\" rel=\"nofollow\"\u003eResilience Engineering, Cognitive Systems\nEngineering, and Human Factors Concepts in Software\nContexts\u003c/a\u003e\nYouTube playlist maintained by John Allspaw.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eYou might also be interested in my \u003ca href=\"https://github.com/lorin/res-eng-short-course-notes\"\u003enotes on David Woods's Resilience Engineering short course\u003c/a\u003e.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eThe papers linked here are also in the \u003ca href=\"https://www.zotero.org/groups/2335189/res-eng/items\" rel=\"nofollow\"\u003ezotero res-eng group\u003c/a\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003ePeople\u003c/h2\u003e\u003ca id=\"user-content-people\" class=\"anchor\" aria-label=\"Permalink: People\" href=\"#people\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eFor each person, I list concepts that they reference in their writings, along\nwith some publications. The publications lists aren't comprehensive:\nthey're ones I've read or have added to my to-read list.\u003c/p\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"#colette-alexander\"\u003eColette Alexander\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#john-allspaw\"\u003eJohn Allspaw\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#lisanne-bainbridge\"\u003eLisanne Bainbridge\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#andrea-baker\"\u003eAndrea Baker\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#e-asher-balkin\"\u003eE. Asher Balkin\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#johan-bergstr%C3%B6m\"\u003eJohan Bergström\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#matthieu-branlat\"\u003eMatthieu Branlat\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#sheuwen-chuang\"\u003eSheuwen Chuang\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#todd-conklin\"\u003eTodd Conklin\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#richard-i-cook\"\u003eRichard I. Cook\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#sidney-dekker\"\u003eSidney Dekker\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#jessica-devita\"\u003eJessica Devita\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#john-c-doyle\"\u003eJohn C. Doyle\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#bob-edwards\"\u003eBob Edwards\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#anders-ericsson\"\u003eAnders Ericsson\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#paul-feltovich\"\u003ePaul Feltovich\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://www.resilience-engineering-association.org/user/pedro/\" rel=\"nofollow\"\u003ePedro Ferreira\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#meir-finkel\"\u003eMeir Finkel\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#marisa-grayson\"\u003eMarisa Grayson\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#ivonne-andrade-herrera\"\u003eIvonne Andrade Herrera\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#cat-hicks\"\u003eCat Hicks\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#robert-hoffman\"\u003eRobert Hoffman\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#erik-hollnagel\"\u003eErik Hollnagel\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#leila-johannesen\"\u003eLeila Johannesen\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#gary-klein\"\u003eGary Klein\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#elizabeth-lay\"\u003eElizabeth Lay\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#jean-christophe-le-coze\"\u003eJean-Christophe Le Coze\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#nancy-leveson\"\u003eNancy Leveson\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#beth-long\"\u003eBeth Adele Long\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#carl-macrae\"\u003eCarl Macrae\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#laura-maguire\"\u003eLaura Maguire\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#courtney-nash\"\u003eCourtney Nash\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#christopher-nemeth\"\u003eChristopher Nemeth\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#anne-sophie-nyssen\"\u003eAnne-Sophie Nyssen\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#elinor-ostrom\"\u003eElinor Ostrom\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#jean-paries\"\u003eJean Pariès\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#emily-patterson\"\u003eEmily Patterson\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#charles-perrow\"\u003eCharles Perrow\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#shawna-j-perry\"\u003eShawna J. Perry\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#jens-rasmussen\"\u003eJens Rasmussen\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#mike-rayo\"\u003eMike Rayo\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#james-reason\"\u003eJames Reason\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#j-paul-reed\"\u003eJ. Paul Reed\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#emilie-m-roth\"\u003eEmilie M. Roth\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#nadine-sarter\"\u003eNadine Sarter\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#james-c-scott\"\u003eJames C. Scott\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#steven-shorrock\"\u003eSteven Shorrock\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#barry-turner\"\u003eBarry Turner\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#diane-vaughan\"\u003eDiane Vaughan\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#robert-l-wears\"\u003eRobert L. Wears\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#david-woods\"\u003eDavid Woods\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#john-wreathall\"\u003eJohn Wreathall\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSome big ideas\u003c/h2\u003e\u003ca id=\"user-content-some-big-ideas\" class=\"anchor\" aria-label=\"Permalink: Some big ideas\" href=\"#some-big-ideas\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"#the-adaptive-universe\"\u003eThe adaptive universe\u003c/a\u003e (David Woods)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#dynamic-safety-model\"\u003eDynamic safety model\u003c/a\u003e (Jens Rasmussen)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#safety-i-vs-safety-ii\"\u003eSafety-II\u003c/a\u003e (Erik Hollnagel)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#graceful-extensibility\"\u003eGraceful extensibility\u003c/a\u003e (David Woods)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#etto-principle\"\u003eETTO: Efficiency-tradeoff principle\u003c/a\u003e (Erik Hollnagel)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#drift-into-failure\"\u003eDrift into failure\u003c/a\u003e (Sidney Dekker)\u003c/li\u003e\n\u003cli\u003eRobust yet fragile (John C. Doyle)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"#stamp\"\u003eSTAMP: Systems-Theoretic Accident Model \u0026amp; Process\u003c/a\u003e (Nancy Leveson)\u003c/li\u003e\n\u003cli\u003ePolycentric governance (Elinor Ostrom)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp dir=\"auto\"\u003eNote: there are now \u003ca href=\"https://github.com/lorin/resilience-engineering/graphs/contributors\"\u003emultiple contributors\u003c/a\u003e to this repository.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eColette Alexander\u003c/h2\u003e\u003ca id=\"user-content-colette-alexander\" class=\"anchor\" aria-label=\"Permalink: Colette Alexander\" href=\"#colette-alexander\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://www.linkedin.com/in/colette-alexander-4168267/\" rel=\"nofollow\"\u003eAlexander\u003c/a\u003e is a Director of Engineering and researcher who previously held roles with IBM, Spotify, Cognite, and HashiCorp. She hosts the podcast This is Fine with co-host Clint Byrum.\nShe completed a Masters thesis at Lund titled \u003ca href=\"https://lup.lub.lu.se/luur/download?func=downloadFile\u0026amp;recordOId=9148570\u0026amp;fileOId=9148571\" rel=\"nofollow\"\u003eRisky Business: Quantitative Risk Assessments as Enabling Devices in Cybersecurity\u003c/a\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eJohn Allspaw\u003c/h2\u003e\u003ca id=\"user-content-john-allspaw\" class=\"anchor\" aria-label=\"Permalink: John Allspaw\" href=\"#john-allspaw\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eAllspaw is the former CTO of Etsy. He applies concepts from resilience engineering to the tech industry.\nHe is one of the founders \u003ca href=\"http://www.adaptivecapacitylabs.com/\" rel=\"nofollow\"\u003eAdaptive Capacity Labs\u003c/a\u003e, a resilience engineering consultancy.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eAllspaw tweets as \u003ca href=\"https://twitter.com/allspaw\" rel=\"nofollow\"\u003e@allspaw\u003c/a\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://snafucatchers.github.io/\" rel=\"nofollow\"\u003eSTELLA: Report from the SNAFUcatchers Workshop on Coping with Complexity\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/295011072_Trade-Offs_Under_Pressure_Heuristics_and_Observations_Of_Teams_Resolving_Internet_Service_Outages\" rel=\"nofollow\"\u003eTrade-Offs Under Pressure: Heuristics and Observations Of Teams Resolving Internet Service Outages\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://extfiles.etsy.com/DebriefingFacilitationGuide.pdf\" rel=\"nofollow\"\u003eEtsy Debrief Facilitation Guide\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://codeascraft.com/2012/05/22/blameless-postmortems/\" rel=\"nofollow\"\u003eBlameless PostMortems and a Just Culture\u003c/a\u003e (blog)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1145/2366316.2366331\" rel=\"nofollow\"\u003eResilience engineering: learning to embrace failure\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://queue.acm.org/detail.cfm?id=2353017\" rel=\"nofollow\"\u003eFault Injection in Production: Making the case for resiliency testing\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1109/MS.2017.99\" rel=\"nofollow\"\u003eTechnical Debt: Challenges and Perspectives\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://queue.acm.org/detail.cfm?id=3380776\" rel=\"nofollow\"\u003eRevealing the Critical Role of Human Performance in Software\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/343430302_SRE_Cognitive_Work\" rel=\"nofollow\"\u003eSRE Cognitive Work\u003c/a\u003e in \u003ca href=\"https://www.oreilly.com/library/view/seeking-sre/9781491978856/\" rel=\"nofollow\"\u003eSeeking SRE\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.oreilly.com/radar/the-infinite-hows/\" rel=\"nofollow\"\u003eThe infinite hows: An argument against the Five Whys and an alternative approach you can apply\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected talks\u003c/h3\u003e\u003ca id=\"user-content-selected-talks\" class=\"anchor\" aria-label=\"Permalink: Selected talks\" href=\"#selected-talks\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://devopsdays.org/events/2019-washington-dc/program/john-allspaw/\" rel=\"nofollow\"\u003eResilience Engineering: The What and How\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=8DtzmV1jiyQ\" rel=\"nofollow\"\u003eIncidents as we Imagine Them Versus How They Actually Are\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=xA5U85LSk0M\" rel=\"nofollow\"\u003eHow your systems keep running day after day\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=NxctiGRI2y8\" rel=\"nofollow\"\u003eProblem detection (papers we love)\u003c/a\u003e\n(presentation of \u003ca href=\"https://www.researchgate.net/publication/220579480_Problem_detection\" rel=\"nofollow\"\u003eProblem detection\u003c/a\u003e paper)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://paperswelove.org/2016/video/john-allspaw-common-ground/\" rel=\"nofollow\"\u003eCommon Ground and Coordination in Joint Activity (papers we love)\u003c/a\u003e (presentation of \u003ca href=\"http://jeffreymbradshaw.net/publications/Common_Ground_Single.pdf\" rel=\"nofollow\"\u003eCommon Ground and Coordination in Joint Activity\u003c/a\u003e paper)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.infoq.com/presentations/resilience-thinking-paradigm/\" rel=\"nofollow\"\u003eAmplifying sources of resilience\u003c/a\u003e (presentation about applying Resilience Engineering thinking \u0026amp; paradigms to the world of software engineering)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.adaptivecapacitylabs.com/blog/2020/03/30/incidents-what-is-often-missed-what-can-be-done-about-that/#fvp_10,1s\" rel=\"nofollow\"\u003eIncidents: What Is Often Missed \u0026amp; What Can Be Done About That\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.adaptivecapacitylabs.com/blog/2020/05/06/how-learning-is-different-than-fixing/\" rel=\"nofollow\"\u003eIncident Analysis: How \u003cem\u003eLearning\u003c/em\u003e is Different Than \u003cem\u003eFixing\u003c/em\u003e\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eLisanne Bainbridge\u003c/h2\u003e\u003ca id=\"user-content-lisanne-bainbridge\" class=\"anchor\" aria-label=\"Permalink: Lisanne Bainbridge\" href=\"#lisanne-bainbridge\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eBainbridge is a psychology researcher. She has a website at \u003ca href=\"http://www.complexcognition.co.uk/\" rel=\"nofollow\"\u003ehttp://www.complexcognition.co.uk/\u003c/a\u003e\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eContributions\u003c/h3\u003e\u003ca id=\"user-content-contributions\" class=\"anchor\" aria-label=\"Permalink: Contributions\" href=\"#contributions\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eIronies of automation\u003c/h4\u003e\u003ca id=\"user-content-ironies-of-automation\" class=\"anchor\" aria-label=\"Permalink: Ironies of automation\" href=\"#ironies-of-automation\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eBainbridge is famous for her 1983 \u003ca href=\"https://www.sciencedirect.com/science/article/abs/pii/0005109883900468\" rel=\"nofollow\"\u003eIronies of automation\u003c/a\u003e paper, which continues to\nbe frequently cited.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h2\u003e\u003ca id=\"user-content-concepts\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eautomation\u003c/li\u003e\n\u003cli\u003edesign errors\u003c/li\u003e\n\u003cli\u003ehuman factors/ ergonomics\u003c/li\u003e\n\u003cli\u003ecognitive modelling\u003c/li\u003e\n\u003cli\u003ecognitive architecture\u003c/li\u003e\n\u003cli\u003emental workload\u003c/li\u003e\n\u003cli\u003esituation awareness\u003c/li\u003e\n\u003cli\u003ecognitive error\u003c/li\u003e\n\u003cli\u003eskill and training\u003c/li\u003e\n\u003cli\u003einterface design\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h2\u003e\u003ca id=\"user-content-selected-publications-1\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-1\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.sciencedirect.com/science/article/abs/pii/0005109883900468\" rel=\"nofollow\"\u003eIronies of automation\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/35/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.sciencedirect.com/science/article/abs/pii/S0020737379800358\" rel=\"nofollow\"\u003eVerbal reports as evidence of the process operator's knowledge\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eAndrea Baker\u003c/h2\u003e\u003ca id=\"user-content-andrea-baker\" class=\"anchor\" aria-label=\"Permalink: Andrea Baker\" href=\"#andrea-baker\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://www.thehopmentor.com/\" rel=\"nofollow\"\u003eBaker\u003c/a\u003e is a practitioner who provides\ntraining services in human and organizational performance (HOP) and learning\nteams.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eBaker tweets as \u003ca href=\"https://twitter.com/thehopmentor\" rel=\"nofollow\"\u003e@thehopmentor\u003c/a\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-1\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-1\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eHuman and organizational performance (HOP)\u003c/li\u003e\n\u003cli\u003eLearning teams\u003c/li\u003e\n\u003cli\u003eIndustrial empathy\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-2\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-2\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://docs.wixstatic.com/ugd/1a0149_21bcf20f158540098d3d7987ffbf3f58.pdf\" rel=\"nofollow\"\u003eA bit about HOP\u003c/a\u003e (editorial)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://www.safetydifferently.com/a-short-introduction-to-human-and-organizational-performance-hop-and-learning-teams/\" rel=\"nofollow\"\u003eA short introduction to human and organizational performance (hop) and learning teams\u003c/a\u003e (blog post)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eE. Asher Balkin\u003c/h2\u003e\u003ca id=\"user-content-e-asher-balkin\" class=\"anchor\" aria-label=\"Permalink: E. Asher Balkin\" href=\"#e-asher-balkin\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-3\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-3\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/330222613_Resiliency_Trade_Space_Study_The_Interaction_of_Degraded_C2_Link_and_Detect_and_Avoid_Autonomy_on_Unmanned_Aircraft\" rel=\"nofollow\"\u003eResiliency Trade Space Study: The Interaction of Degraded C2 Link and Detect and Avoid Autonomy on Unmanned Aircraft\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://journals.sagepub.com/doi/10.1177/1071181322661334\" rel=\"nofollow\"\u003eDeveloping Systemic Contributors and Adaptations Diagramming (SCAD): systemic insights, multiple pragmatic implementations\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected talks\u003c/h3\u003e\u003ca id=\"user-content-selected-talks-1\" class=\"anchor\" aria-label=\"Permalink: Selected talks\" href=\"#selected-talks-1\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=kK6t-gttsJw\" rel=\"nofollow\"\u003eRoot cause and the wrong path\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eJohan Bergström\u003c/h2\u003e\u003ca id=\"user-content-johan-bergström\" class=\"anchor\" aria-label=\"Permalink: Johan Bergström\" href=\"#johan-bergström\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"http://www.jbsafety.se/p/about-me.html\" rel=\"nofollow\"\u003eBergström\u003c/a\u003e is a safety research and\nconsultant. He runs the \u003ca href=\"http://www.humanfactors.lth.se/msc-programme/\" rel=\"nofollow\"\u003eMaster Program of Human Factors and Systems\nSafety\u003c/a\u003e at Lund University.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eBergström tweets as \u003ca href=\"https://twitter.com/bergstrom_johan\" rel=\"nofollow\"\u003e@bergstrom_johan\u003c/a\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-2\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-2\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eAnalytical traps in accident investigation\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eCounterfactual reasoning\u003c/li\u003e\n\u003cli\u003eNormative language\u003c/li\u003e\n\u003cli\u003eMechanistic reasoning\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/li\u003e\n\u003cli\u003eGeneric competencies\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-4\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-4\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.sciencedirect.com/science/article/pii/S0925753516306130\" rel=\"nofollow\"\u003eResilience engineering: Current status of the research and future challenges\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/50917226_Rule-_and_role_retreat_An_empirical_study_of_procedures_and_resilience\" rel=\"nofollow\"\u003eRule- and role retreat: An empirical study of procedures and resilience\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://portal.research.lu.se/ws/files/1376441/3014838.pdf\" rel=\"nofollow\"\u003eTeam Coordination in Escalating Situations: An Empirical Study Using Mid-Fidelity Simulation\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected talks\u003c/h3\u003e\u003ca id=\"user-content-selected-talks-2\" class=\"anchor\" aria-label=\"Permalink: Selected talks\" href=\"#selected-talks-2\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=TqaFT-0cY7U\" rel=\"nofollow\"\u003eThree analytical traps in accident investigation\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=rHeukoWWtQ8\" rel=\"nofollow\"\u003eTwo Views on Human Error\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=BtJIumyCrtE\u0026amp;feature=youtu.be\" rel=\"nofollow\"\u003eWhat, Where and When is Risk in System Design?\u003c/a\u003e (Velocity 2013)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eMatthieu Branlat\u003c/h2\u003e\u003ca id=\"user-content-matthieu-branlat\" class=\"anchor\" aria-label=\"Permalink: Matthieu Branlat\" href=\"#matthieu-branlat\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-5\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-5\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/284324002_Basic_patterns_in_how_adaptive_systems_fail\" rel=\"nofollow\"\u003eBasic patterns in how adaptive systems fail\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/34/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.sciencedirect.com/science/article/abs/pii/S0951832015000812\" rel=\"nofollow\"\u003eA practitioner’s experiences operationalizing Resilience Engineering\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.taylorfrancis.com/chapters/edit/10.1201/9781315605708-18/noticing-brittleness-designing-resilience-elizabeth-lay-matthieu-branlat\" rel=\"nofollow\"\u003eNoticing Brittleness, Designing for Resilience\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSheuwen Chuang\u003c/h2\u003e\u003ca id=\"user-content-sheuwen-chuang\" class=\"anchor\" aria-label=\"Permalink: Sheuwen Chuang\" href=\"#sheuwen-chuang\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-6\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-6\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1016/j.burns.2018.12.003\" rel=\"nofollow\"\u003eBeyond surge: Coping with mass burn casualty in the closest hospital to the Formosa Fun Coast Dust Explosion\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/335366770_Coping_With_a_Mass_Casualty_Insights_into_a_Hospital's_Emergency_Response_and_Adaptations_After_the_Formosa_Fun_Coast_Dust_Explosion\" rel=\"nofollow\"\u003eCoping With a Mass Casualty: Insights into a Hospital’s Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/76/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eTodd Conklin\u003c/h2\u003e\u003ca id=\"user-content-todd-conklin\" class=\"anchor\" aria-label=\"Permalink: Todd Conklin\" href=\"#todd-conklin\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eConklin's books are on my reading list, but I haven't read anything by him\nyet. I have listened to his great \u003ca href=\"https://preaccidentpodcast.podbean.com/\" rel=\"nofollow\"\u003ePreaccident investigation\npodcast\u003c/a\u003e.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eConklin tweets as \u003ca href=\"https://twitter.com/preaccident\" rel=\"nofollow\"\u003e@preaccident\u003c/a\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-7\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-7\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Pre-Accident-Investigations-Todd-Conklin/dp/1409447820\" rel=\"nofollow\"\u003ePre-accident investigations: an introduction to organizational safety\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/gp/product/1472486137\" rel=\"nofollow\"\u003ePre-accident investigations: better questions - an applied approach to\noperational learning\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Do-Safety-Differently-Sidney-Dekker/dp/B09RM3Z17V\" rel=\"nofollow\"\u003eDo Safety Differently\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected talks\u003c/h3\u003e\u003ca id=\"user-content-selected-talks-3\" class=\"anchor\" aria-label=\"Permalink: Selected talks\" href=\"#selected-talks-3\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eQuanta - \u003ca href=\"https://www.youtube.com/watch?v=5WTbeFj2kJY\u0026amp;feature=youtu.be\" rel=\"nofollow\"\u003eRisk and Safety Conf 2019\u003c/a\u003e\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eRichard I. Cook\u003c/h2\u003e\u003ca id=\"user-content-richard-i-cook\" class=\"anchor\" aria-label=\"Permalink: Richard I. Cook\" href=\"#richard-i-cook\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://en.wikipedia.org/wiki/Richard_Cook_(safety_researcher)\" rel=\"nofollow\"\u003eCook\u003c/a\u003e was an anasthesiologist who studies failures in complex systems. He is one of the founders \u003ca href=\"http://www.adaptivecapacitylabs.com/\" rel=\"nofollow\"\u003eAdaptive Capacity Labs\u003c/a\u003e, a resilience engineering consultancy.\nHe tweeted as \u003ca href=\"https://twitter.com/ri_cook\" rel=\"nofollow\"\u003e@ri_cook\u003c/a\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-3\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-3\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003ehow complex systems fail\u003c/li\u003e\n\u003cli\u003edegraded mode\u003c/li\u003e\n\u003cli\u003esharp end (c.f. Reason's blunt end)\u003c/li\u003e\n\u003cli\u003eGoing solid\u003c/li\u003e\n\u003cli\u003eCycle of error\u003c/li\u003e\n\u003cli\u003e\"new look\"\u003c/li\u003e\n\u003cli\u003efirst vs second stories\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-8\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-8\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/371403498_A_celebration_of_the_work_of_Richard_Cook_MD_A_pioneer_in_understanding_accidents_safety_human_factors_and_resilience\" rel=\"nofollow\"\u003eA celebration of the work of Richard Cook, MD: A pioneer in understanding accidents, safety, human factors, and resilience\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.adaptivecapacitylabs.com/HowComplexSystemsFail.pdf\" rel=\"nofollow\"\u003eHow complex systems fail\u003c/a\u003e (\u003ca href=\"https://safety177496371.wordpress.com/2022/11/04/how-complex-systems-fail-a-classic-from-richard-cook/\" rel=\"nofollow\"\u003eBH\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.adaptivecapacitylabs.com/BriefLookAtTheNewLook.pdf\" rel=\"nofollow\"\u003eA brief look at the New Look in complex system failure, error, safety, and resilience\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.snafucatchers.com/single-post/2017/11/14/void-Incidents-as-Untyped-Pointers\" rel=\"nofollow\"\u003evoid *: Incidents as Untyped Pointers. \u003cem\u003eWhere\u003c/em\u003e complex systems fail\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/292504703_Distancing_through_differencing_An_obstacle_to_organizational_learning_following_accidents\" rel=\"nofollow\"\u003eDistancing through differencing: An obstacle to organizational learning following accidents\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://csel.eng.ohio-state.edu/productions/woodscta/media/beingbump.pdf\" rel=\"nofollow\"\u003eBeing bumpable\u003c/a\u003e (\u003ca href=\"https://www.getrevue.co/profile/resilience/issues/resilience-roundup-being-bumpable-issue-33-177340\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Behind-Human-Error-David-Woods/dp/0754678342\" rel=\"nofollow\"\u003eBehind Human Error\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/292504952_Incidents_-_markers_of_resilience_or_brittleness\" rel=\"nofollow\"\u003eIncidents - markers of resilience or brittleness?\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://qualitysafety.bmj.com/content/14/2/130\" rel=\"nofollow\"\u003e“Going solid”: a model of system dynamics and consequences for patient safety\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/going-solid-a-model-of-system-dynamics-and-consequences-for-patient-safety/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/313407259_Operating_at_the_Sharp_End_The_Complexity_of_Human_Error\" rel=\"nofollow\"\u003eOperating at the Sharp End: The Complexity of Human Error\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/312624891_Patient_boarding_in_the_emergency_department_as_a_symptom_of_complexity-induced_risks\" rel=\"nofollow\"\u003ePatient boarding in the emergency department as a symptom of complexity-induced risks\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/220579381_Sensemaking_Safety_and_Cooperative_Work_in_the_Intensive_Care_Unit\" rel=\"nofollow\"\u003eSensemaking, Safety, and Cooperative Work in the Intensive Care Unit\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.taylorfrancis.com/books/e/9781317164777/chapters/10.1201/9781315572529-4\" rel=\"nofollow\"\u003eMedication Reconciliation Is a Window into “Ordinary” Work\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://ntrs.nasa.gov/search.jsp?R=19910011398\" rel=\"nofollow\"\u003eCognitive consequences of clumsy automation on high workload, high consequence human performance\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1016/S0952-8180(96)90009-4\" rel=\"nofollow\"\u003eImplications of automation surprises in aviation for the future of total intravenous anesthesia (TIVA)\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1109%2FTSMCA.2004.836802\" rel=\"nofollow\"\u003eThe Messy Details: Insights From the Study of Technical Work in Healthcare\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/profile/David_Woods11/publication/224649052_Nosocomial_automation_technology-induced_complexity_and_human_performance/links/59399b1da6fdcc58ae902c49/Nosocomial-automation-technology-induced-complexity-and-human-performance.pdf\" rel=\"nofollow\"\u003eNosocomial automation: technology-induced complexity and human performance\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/67f7/53ec089e5a8879f241e2be867dad0a2026fb.pdf\" rel=\"nofollow\"\u003eThe New Look at Error, Safety, and Failure: A Primer for Health Care\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/1bed/356b5aa67c701f5bad6d943768622095f418.pdf\" rel=\"nofollow\"\u003eGrounding explanations in evolving, diagnostic situations\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/245102691_A_Tale_of_Two_Stories_Contrasting_Views_of_Patient_Safety\" rel=\"nofollow\"\u003eA Tale of Two Stories: Contrasting Views of Patient Safety\u003c/a\u003e (appendix B, starting on page 64 (numbered 52) contains the talk by Charles Billings, MD, Chief Scientist (retired), NASA Ames on the lessons learned from incident reporting in aviation. Dr. Billings designed, started, and managed the Aviation Safety REporting System)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.623.5749\u0026amp;rep=rep1\u0026amp;type=pdf\" rel=\"nofollow\"\u003e\"Those found responsible have been sacked\": some observations on the usefulness of error\u003c/a\u003e (\u003ca href=\"https://safety177496371.wordpress.com/2025/01/26/those-found-responsible-have-been-sacked-some-observations-on-the-usefulness-of-error/\" rel=\"nofollow\"\u003eBH\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.nifc.gov/PUBLICATIONS/acc_invest_march2010/speakers/Perspectives%20on%20Human%20Error.pdf\" rel=\"nofollow\"\u003ePerspectives on Human Error: Hindsight Biases and Local Rationality\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/328149714_Mistaking_Error\" rel=\"nofollow\"\u003eMistaking Error\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/14230576_Adapting_to_New_Technology_in_the_Operating_Room\" rel=\"nofollow\"\u003eAdapting to new technology in the operating room\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/3657912_Verite_abstraction_and_ordinateur_systems_in_the_evolution_of_complex_process_control\" rel=\"nofollow\"\u003eVerite, Abstraction, and Ordinateur Systems in the Evolution of Complex Process Control\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/220579448_Collaborative_Cross-Checking_to_Enhance_Resilience\" rel=\"nofollow\"\u003eCollaborative Cross-Checking to Enhance Resilience\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/73/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/a0d3/9cc66adc64e297048a32b71aeee209a451af.pdf\" rel=\"nofollow\"\u003eResilience Engineering: New directions for measuring and maintaining safety in complex systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/232191704_The_Role_of_Automation_in_Complex_System_Failures\" rel=\"nofollow\"\u003eThe Role of Automation in Complex System Failures\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/228352596_Thinking_about_accidents_and_systems\" rel=\"nofollow\"\u003eThinking about accidents and systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.taylorfrancis.com/books/e/9781315605739/chapters/10.1201/9781315605739-11\" rel=\"nofollow\"\u003eThe Stockholm blizzard of 2012\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/2484621_New_Arctic_Air_Crash_Aftermath_Role-Play_Simulation_Orchestrating_a_Fundamental_Surprise\" rel=\"nofollow\"\u003eNew Arctic Air Crash Aftermath Role-Play Simulation Orchestrating a Fundamental Surprise\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.nap.edu/read/13269/chapter/14\" rel=\"nofollow\"\u003eDissenting Statement: Health IT Is a Class III Medical Device\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://csel.eng.ohio-state.edu/productions/pexis/readings/submod4/nine%20steps%20CTW2002.pdf\" rel=\"nofollow\"\u003eNine Steps to Move Forward From Error\u003c/a\u003e (\u003ca href=\"https://safety177496371.wordpress.com/2022/11/03/nine-steps-to-move-forward-from-error/\" rel=\"nofollow\"\u003eBH\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117777/\" rel=\"nofollow\"\u003eGaps in the continuity of care and progress on patient safety\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://queue.acm.org/detail.cfm?id=3380777\" rel=\"nofollow\"\u003eAbove the Line, Below the Line\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/68/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/335366770_Coping_With_a_Mass_Casualty_Insights_into_a_Hospital's_Emergency_Response_and_Adaptations_After_the_Formosa_Fun_Coast_Dust_Explosion\" rel=\"nofollow\"\u003eCoping With a Mass Casualty: Insights into a Hospital’s Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/76/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/343430302_SRE_Cognitive_Work\" rel=\"nofollow\"\u003eSRE Cognitive Work\u003c/a\u003e in \u003ca href=\"https://www.oreilly.com/library/view/seeking-sre/9781491978856/\" rel=\"nofollow\"\u003eSeeking SRE\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.sciencedirect.com/science/article/pii/S0003687020301903\" rel=\"nofollow\"\u003eBuilding and revising adaptive capacity sharing for technical incident response: A case of resilience engineering\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/building-and-revising-adaptive-capacity-sharing-for-technical-incident-response-a-case-of-resilience-engineering/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1016/j.ress.2006.01.009\" rel=\"nofollow\"\u003eAutomation, interaction, complexity, and failure: A case study\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://dx.doi.org/10.13140/RG.2.2.29675.36648\" rel=\"nofollow\"\u003eHuman Performance in Anesthesia\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/285346573_Two_years_before_the_mast_Learning_how_to_learn_about_patient_safety\" rel=\"nofollow\"\u003eTwo years before the mast: Learning how to learn about patient safety\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/profile/Robert-Wears/publication/225108705_Resilience_is_Not_Control_Healthcare_Crisis_Management_and_ICT/links/00b49532b2c7f3ed62000000/Resilience-is-Not-Control-Healthcare-Crisis-Management-and-ICT.pdf\" rel=\"nofollow\"\u003eResilience is not control: healthcare, crisis management, and ICT\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.taylorfrancis.com/chapters/edit/10.1201/9781315605685-19/taking-things-one-stride-cognitive-features-two-resilient-performances-richard-cook-christopher-nemeth\" rel=\"nofollow\"\u003eTaking Things in One’s Stride: Cognitive Features of Two Resilient Performances\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/347964304_Human_Performance_in_Anesthesia_Human_Performance_in_Anesthesia_Human_Performance_in_Anesthesia\" rel=\"nofollow\"\u003eHuman Performance in Anesthesia: A Corpus of Cases\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://europepmc.org/article/NBK/nbk43670\" rel=\"nofollow\"\u003eMinding the Gaps: Creating Resilience in Health Care\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://citeseerx.ist.psu.edu/document?repid=rep1\u0026amp;type=pdf\u0026amp;doi=ffe74633027ee354ebbf0ff9a6418e75f3b7a047\" rel=\"nofollow\"\u003eFrom Counting Failures to Anticipating Risks: Possible Futures for Patient Safety\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/a0d3/9cc66adc64e297048a32b71aeee209a451af.pdf\" rel=\"nofollow\"\u003eResilience Engineering: New directions for measuring and maintaining safety in complex systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://citeseerx.ist.psu.edu/document?repid=rep1\u0026amp;type=pdf\u0026amp;doi=15f31969c4e1f4f599c5c68aa63f3bf930e0406f\" rel=\"nofollow\"\u003eBehind Human Error: Taming Complexity to Improve Patient Safety\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://onlinelibrary.wiley.com/doi/pdf/10.1197/j.aem.2004.07.001\" rel=\"nofollow\"\u003eThe Illusion of Explanation\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected talks\u003c/h3\u003e\u003ca id=\"user-content-selected-talks-4\" class=\"anchor\" aria-label=\"Permalink: Selected talks\" href=\"#selected-talks-4\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=2S0k12uZR14\" rel=\"nofollow\"\u003eHow Complex Systems Fail\u003c/a\u003e (Velocity 2012)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=PGLYEDpNu60\u0026amp;feature=youtu.be\" rel=\"nofollow\"\u003eResilience in Complex Adaptive Systems: Operating at the Edge of Failure\u003c/a\u003e (Velocity 2013)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/playlist?list=PLb1aZTnPf3-OEU1by77zZQQYckvXUGmNY\" rel=\"nofollow\"\u003eLectures on the study of cognitive work\u003c/a\u003e (Graduate student lecture-discussions at The Royal Institute of Technology, Huddinge, SWEDEN in 2012 )\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=gtxtb9z_4FY\u0026amp;feature=youtu.be\" rel=\"nofollow\"\u003ePanel discussion: Safety Culture, Lean, and DevOps\u003c/a\u003e (DOES 2017)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=3ZP98stDUf0\u0026amp;feature=youtu.be\" rel=\"nofollow\"\u003eWorking at the center of the Cyclone\u003c/a\u003e (DOES 2018)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=8LbePBiOvZ4\" rel=\"nofollow\"\u003eA Few Observations on the Marvelous Resilience of Bone \u0026amp; Resilience Engineering\u003c/a\u003e (REdeploy 2019)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eJean-Christophe Le Coze\u003c/h2\u003e\u003ca id=\"user-content-jean-christophe-le-coze\" class=\"anchor\" aria-label=\"Permalink: Jean-Christophe Le Coze\" href=\"#jean-christophe-le-coze\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eLe Coze is research director at INERIS (National Institute for the Industrial Environment and Risks) in France.\nHe frequently writes on historical views of safety.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eLe Coze tweets as \u003ca href=\"https://twitter.com/JcLeCoze\" rel=\"nofollow\"\u003e@JcLeCoze\u003c/a\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-9\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-9\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.academia.edu/36790092/Managing_the_unexpected\" rel=\"nofollow\"\u003eManaging the Unexpected\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.sciencedirect.com/science/article/abs/pii/S0925753522001928\" rel=\"nofollow\"\u003eThe 'new view' of human error. Origins, ambiguities, success and critiques\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.academia.edu/15301538/1984_2014_Normal_Accident_Was_Charles_Perrow_right_for_the_wrong_reasons\" rel=\"nofollow\"\u003e1984-2014. Normal Accident. Was Charles Perrow right for the wrong reasons?\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://dx.doi.org/10.1016/j.ssci.2020.104660\" rel=\"nofollow\"\u003eGood and bad reasons: The Swiss cheese model and its critics\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1016/j.apergo.2016.10.002\" rel=\"nofollow\"\u003eRecurring themes in the legacy of Jens Rasmussen\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.sciencedirect.com/science/article/pii/S0925753514000848\" rel=\"nofollow\"\u003eReflecting on Jens Rasmussen’s legacy. A strong program for a hard problem\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.sciencedirect.com/science/article/abs/pii/S0003687015300429\" rel=\"nofollow\"\u003eReflecting on Jens Rasmussen's legacy (2) behind and beyond, a ‘constructivist turn’\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSidney Dekker\u003c/h2\u003e\u003ca id=\"user-content-sidney-dekker\" class=\"anchor\" aria-label=\"Permalink: Sidney Dekker\" href=\"#sidney-dekker\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eDekker is a human factors and safety researcher with a background in aviation.\nHis books aimed at a lay audience (Drift Into Failure, Just Culture, The Field Guide to 'Human Error' investigations)\nhave been enormously influential. He was a founder of the MSc programme in Human Factors \u0026amp; Systems Safety at Lund University.\nHis PhD advisor is \u003ca href=\"#david-woods\"\u003eDavid Woods\u003c/a\u003e.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eDekker tweets as \u003ca href=\"https://twitter.com/sidneydekkercom\" rel=\"nofollow\"\u003e@sidneydekkercom\u003c/a\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eContributions\u003c/h3\u003e\u003ca id=\"user-content-contributions-1\" class=\"anchor\" aria-label=\"Permalink: Contributions\" href=\"#contributions-1\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eDrift into failure\u003c/h4\u003e\u003ca id=\"user-content-drift-into-failure\" class=\"anchor\" aria-label=\"Permalink: Drift into failure\" href=\"#drift-into-failure\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eDekker developed the theory of \u003cem\u003edrift\u003c/em\u003e, characterized by five concepts:\u003c/p\u003e\n\u003col dir=\"auto\"\u003e\n\u003cli\u003eScarcity and competition\u003c/li\u003e\n\u003cli\u003eDecrementalism, or small steps\u003c/li\u003e\n\u003cli\u003eSensitive dependence on initial conditions\u003c/li\u003e\n\u003cli\u003eUnruly technology\u003c/li\u003e\n\u003cli\u003eContribution of the protective structure\u003c/li\u003e\n\u003c/ol\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eJust Culture\u003c/h4\u003e\u003ca id=\"user-content-just-culture\" class=\"anchor\" aria-label=\"Permalink: Just Culture\" href=\"#just-culture\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eDekker examines how cultural norms defining justice can be re-oriented to minimize the negative impact and maximize learning when things go wrong.\u003c/p\u003e\n\u003col dir=\"auto\"\u003e\n\u003cli\u003eRetributive justice as society's traditional idea of justice: distributing punishment to those responsible based on severity of the violation\u003c/li\u003e\n\u003cli\u003eRestorative justice as an improvement for both victims and practicioners: distributing obligations of rebuilding trust to those responsible based on who is hurt and what they need\u003c/li\u003e\n\u003cli\u003eFirst, second, and third victims: an incident's negative impact is felt by more than just the obvious victims\u003c/li\u003e\n\u003cli\u003eLearning theory: people break rules when they have learned there are no negative consequences, and there are actually positive consequences - in other words, they break rules to get things done to meet production pressure\u003c/li\u003e\n\u003cli\u003eReporting culture: contributing to reports of adverse events is meant to help the organization understand what went wrong and how to prevent recurrence, but accurate reporting requires appropriate and proportionate accountability actions\u003c/li\u003e\n\u003cli\u003eComplex systems: normal behavior of practicioners and professionals in the context of a complex system can appear abnormal or deviant in hindsight, particularly in the eyes of non-expert juries and reviewers\u003c/li\u003e\n\u003cli\u003eThe nature of practicioners: professionals want to do good work, and therefore want to be held accountable for their mistakes; they generally want to help similarly-situated professionals avoid the same mistake.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSafety Differently\u003c/h3\u003e\u003ca id=\"user-content-safety-differently\" class=\"anchor\" aria-label=\"Permalink: Safety Differently\" href=\"#safety-differently\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eThere is a difference between the organization's prescribed processes for completing work and how work is actually completed. (work as imagined vs work as done)\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eThe difference between work as imagined and work as done is the result of the expertise that exists in your workers from contact with real-life pressures, heuristics, and unexpected conditions.\u003c/li\u003e\n\u003cli\u003eOld View: People are the problem to control with process\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eThey did something wrong\u003c/li\u003e\n\u003cli\u003eThey need more rules and enforcement\u003c/li\u003e\n\u003cli\u003eThey need to try harder\u003c/li\u003e\n\u003cli\u003eWe need to get rid of \"bad apples\"\u003c/li\u003e\n\u003cli\u003eFocus on the \"sharp end\" of the organization - the people closest to the work\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/li\u003e\n\u003cli\u003eNew View: Work is done adaptively in an uncertain world\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eThings go wrong all the time\u003c/li\u003e\n\u003cli\u003eWorkers often detect and correct these problems\u003c/li\u003e\n\u003cli\u003eLocal adaptations are a source of organizational expertise\u003c/li\u003e\n\u003cli\u003e\"What conditions existed that made the selected course of action seem correct to the people involved?\"\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/li\u003e\n\u003cli\u003eTraditional safety interventions have diminishing yields with increasing overhead. Accumulated compliance burden and \"safety clutter\" makes it harder to get work done \u003cem\u003eand\u003c/em\u003e to do so safely.\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eSafety Clutter is accountable to safety bureaucracy and compliance rather than the safety of the workers or the process\u003c/li\u003e\n\u003cli\u003eSafety Clutter is produced by the \"blunt end\" of the organization without local expertise of what is practicable or practical in-situ\u003c/li\u003e\n\u003cli\u003eSafety Clutter represents a broader \"deprofessionalization\" - a removal of trust and confidence in professionals to do their job well, removing their pride, autonomy, and achievement.\u003c/li\u003e\n\u003cli\u003eParadoxically, Safety Clutter can result from government deregulation - organizations need to self-impose risk controls in the absence of external guidelines.\u003c/li\u003e\n\u003cli\u003eSadly for organizations with Safety Clutter, more internal rules do not equal better legal protection.\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/li\u003e\n\u003cli\u003eWhen a process is relatively safe or stable, measurements of bad outcomes lack statistical significance to understand trends or tie trends to interventions.\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eFundamental Regulator Paradox: regulating a system so well that there are no useful measurements left to understand how the system is performing\u003c/li\u003e\n\u003cli\u003eZero Paradox: A study of construction contractors showed more fatal accidents in firms with \"goal zero\" safety policies than in those without. Non-fatal accidents were similar.\u003c/li\u003e\n\u003cli\u003eRisk Secrecy: \"goal zero\" commitments result in injury underreporting and hiding of incidents which prevents learning, particularly when tied to financial incentives for leadership.\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/li\u003e\n\u003cli\u003eThere are patterns (capacities) that help things go well\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003cem\u003eDiversity of opinion\u003c/em\u003e - possibility to voice dissent\u003c/li\u003e\n\u003cli\u003e\u003cem\u003eKeeping the discussion on risk alive\u003c/em\u003e even when things go well\u003c/li\u003e\n\u003cli\u003e\u003cem\u003eDeference to expertise\u003c/em\u003e that already exists in people at the sharp end\u003c/li\u003e\n\u003cli\u003e\u003cem\u003ePsychological safety\u003c/em\u003e / \"stop\" ability\u003c/li\u003e\n\u003cli\u003e\u003cem\u003eLow barriers\u003c/em\u003e to interaction between organizational groups\u003c/li\u003e\n\u003cli\u003e\u003cem\u003eSharp end improvements\u003c/em\u003e to existing systems based on local expertise\u003c/li\u003e\n\u003cli\u003e\u003cem\u003ePride in work\u003c/em\u003e - process and results\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/li\u003e\n\u003cli\u003eRapid problem-solving can prevent effective problem-understanding\u003c/li\u003e\n\u003cli\u003eLeadership buy-in and practice of New View safety is imperative to its success. It's also difficult to foster.\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eWorker buy-in is rapid and fits their existing mental model\u003c/li\u003e\n\u003cli\u003eLeadership must abandon the mental model that has governed their past work and decision-making - difficult for anyone.\u003c/li\u003e\n\u003cli\u003ePeer discussions are especially helpful for leadership\u003c/li\u003e\n\u003cli\u003eHighlighting how local adaptations helped things go well also helps\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-4\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-4\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eDrift into failure\u003c/li\u003e\n\u003cli\u003eSafety differently\u003c/li\u003e\n\u003cli\u003eNew view vs old view of human performance \u0026amp; error\u003c/li\u003e\n\u003cli\u003eJust culture\u003c/li\u003e\n\u003cli\u003ecomplexity\u003c/li\u003e\n\u003cli\u003ebroken part\u003c/li\u003e\n\u003cli\u003eNewton-Descartes\u003c/li\u003e\n\u003cli\u003ediversity\u003c/li\u003e\n\u003cli\u003esystems theory\u003c/li\u003e\n\u003cli\u003eunruly technology\u003c/li\u003e\n\u003cli\u003edecrementalism\u003c/li\u003e\n\u003cli\u003egeneric competencies\u003c/li\u003e\n\u003cli\u003ework as imagined vs work as done\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-10\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-10\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Drift-into-Failure-Sidney-Dekker/dp/1409422216\" rel=\"nofollow\"\u003eDrift into failure\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.411.4985\u0026amp;rep=rep1\u0026amp;type=pdf\" rel=\"nofollow\"\u003eReconstructing human contributions to accidents: the new view on error and performance\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Field-Guide-Understanding-Human-Error/dp/1472439058s://www.amazon.com/Field-Guide-Understanding-Human-Error/dp/1472439058\" rel=\"nofollow\"\u003eThe field guide to understanding 'human error'\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Behind-Human-Error-David-Woods/dp/0754678342\" rel=\"nofollow\"\u003eBehind Human Error\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/50917226_Rule-_and_role_retreat_An_empirical_study_of_procedures_and_resilience?enrichId=rgreq-23625e555a0d8e5250c74f24b5fd01ca-XXX\u0026amp;enrichSource=Y292ZXJQYWdlOzUwOTE3MjI2O0FTOjk3MzU5NjY5MjM1NzQ1QDE0MDAyMjM3NjI5NDY%3D\u0026amp;el=1_x_2\u0026amp;_esc=publicationCoverPdf\" rel=\"nofollow\"\u003eRule- and role retreat: An empirical study of procedures and resilience\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/247512351_Anticipating_the_effects_of_technological_change_A_new_era_of_dynamics_for_human_factors\" rel=\"nofollow\"\u003eAnticipating the effects of technological change: A new era of dynamics for human factors\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://www.safetydifferently.com/why-do-things-go-right/\" rel=\"nofollow\"\u003eWhy do things go right?\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://www.humanfactors.lth.se/fileadmin/lusa/Sidney_Dekker/articles/2007/SafetyScienceMonitor.pdf\" rel=\"nofollow\"\u003eSix stages to the new view of human error\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://sidneydekker.com/wp-content/uploads/2014/08/DekkerPS2014.pdf\" rel=\"nofollow\"\u003eEmployees: A Problem to Control or Solution to Harness?\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://portal.research.lu.se/ws/files/1376441/3014838.pdf\" rel=\"nofollow\"\u003eTeam Coordination in Escalating Situations: An Empirical Study Using Mid-Fidelity Simulation\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/a0d3/9cc66adc64e297048a32b71aeee209a451af.pdf\" rel=\"nofollow\"\u003eResilience Engineering: New directions for measuring and maintaining safety in complex systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://www.humanfactors.lth.se/fileadmin/lusa/Sidney_Dekker/articles/2003_and_before/Illusions_of_explanation.pdf\" rel=\"nofollow\"\u003eIllusions of explanation: A critical essay on error classification\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.606.3361\u0026amp;rep=rep1\u0026amp;type=pdf\" rel=\"nofollow\"\u003eFailure to adapt or adaptations that fail: contrasting models on procedures and safety\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://link.springer.com/article/10.1007%2Fs10111-003-0136-9\" rel=\"nofollow\"\u003eHuman factors and folk models\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://sidneydekker.com/wp-content/uploads/2013/01/CH005.pdf\" rel=\"nofollow\"\u003eThe High Reliability Organization Perspective\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/09/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://www.humanfactors.lth.se/fileadmin/lusa/Sidney_Dekker/articles/2003_and_before/Illusions_of_explanation.pdf\" rel=\"nofollow\"\u003eIllusions of explanation: A critical essay on error classification\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/42/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1016/j.ress.2019.106740\" rel=\"nofollow\"\u003eSafety II professionals: How resilience engineering can transform safety practice\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/64/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://static1.squarespace.com/static/53b78765e4b0949940758017/t/5722beb0d51cd4d11675a69c/1461894833950/Dekker%2C+Cilliers+and+Hofmeyr+-+The+Complexity+of+Failure.pdf\" rel=\"nofollow\"\u003eThe complexity of failure: implications of complexity theory for safety investigation\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Safety-Anarchist-innovation-bureaucracy-compliance/dp/1138300462\" rel=\"nofollow\"\u003eThe Safety Anarchist\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Compliance-Capitalism-Overregulated-Management-Neoliberalism/dp/1032012366\" rel=\"nofollow\"\u003eCompliance Capitalism\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/a0d3/9cc66adc64e297048a32b71aeee209a451af.pdf\" rel=\"nofollow\"\u003eResilience Engineering: New directions for measuring and maintaining safety in complex systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://maritimesafetyinnovationlab.org/wp-content/uploads/2021/03/DekkerDriftRiskChapter2013.pdf\" rel=\"nofollow\"\u003eDrifting into failure: Complexity theory and the management of risk\u003c/a\u003e (\u003ca href=\"https://safety177496371.wordpress.com/2025/05/03/drifting-into-failure-complexity-theory-and-the-management-of-risk/\" rel=\"nofollow\"\u003eBH 1\u003c/a\u003e \u003ca href=\"https://safety177496371.wordpress.com/2025/05/03/complex-systems-and-drifting-into-failure-further-extracts-from-dekker-2013/\" rel=\"nofollow\"\u003eBH 2\u003c/a\u003e)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected talks\u003c/h3\u003e\u003ca id=\"user-content-selected-talks-5\" class=\"anchor\" aria-label=\"Permalink: Selected talks\" href=\"#selected-talks-5\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=gtxtb9z_4FY\u0026amp;feature=youtu.be\" rel=\"nofollow\"\u003ePanel discussion: Safety Culture, Lean, and DevOps\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eJessica Devita\u003c/h2\u003e\u003ca id=\"user-content-jessica-devita\" class=\"anchor\" aria-label=\"Permalink: Jessica Devita\" href=\"#jessica-devita\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eDevita is a software engineering manager and researcher in software resilience engineering. She has previously held roles at Microsoft, Netflix, and Google. Her master thesis \u003ca href=\"https://lup.lub.lu.se/student-papers/search/publication/9149521\" rel=\"nofollow\"\u003eTo Deploy, or Not to Deploy, That is the Question A qualitative study of the decision-making experiences of engineers deploying software changes in production\u003c/a\u003e focused on software deployments and decision making.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eJohn C. Doyle\u003c/h2\u003e\u003ca id=\"user-content-john-c-doyle\" class=\"anchor\" aria-label=\"Permalink: John C. Doyle\" href=\"#john-c-doyle\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"http://www.cds.caltech.edu/~doyle/wiki/index.php?title=Main_Page\" rel=\"nofollow\"\u003eDoyle\u003c/a\u003e is a\ncontrol systems researcher. He is seeking to identify the universal laws that capture the\nbehavior of resilient systems, and is concerned with the architecture of such\nsystems.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-5\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-5\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eRobust yet fragile\u003c/li\u003e\n\u003cli\u003elayered architectures\u003c/li\u003e\n\u003cli\u003econstraints that deconstrain\u003c/li\u003e\n\u003cli\u003eprotocol-based architectures\u003c/li\u003e\n\u003cli\u003eemergent constraints\u003c/li\u003e\n\u003cli\u003eUniversal laws and architectures\u003c/li\u003e\n\u003cli\u003econservation laws\u003c/li\u003e\n\u003cli\u003euniversal architectures\u003c/li\u003e\n\u003cli\u003eHighly optimized tolerance\u003c/li\u003e\n\u003cli\u003eDoyle's catch\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eDoyle's catch\u003c/h4\u003e\u003ca id=\"user-content-doyles-catch\" class=\"anchor\" aria-label=\"Permalink: Doyle's catch\" href=\"#doyles-catch\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003cem\u003eDoyle's catch\u003c/em\u003e is a term introduced by David Woods, but attributed to John Doyle. Here's how\n\u003ca href=\"https://www.researchgate.net/publication/303832480_The_Risks_of_Autonomy_Doyles_Catch\" rel=\"nofollow\"\u003eWoods quotes Doyle\u003c/a\u003e:\u003c/p\u003e\n\u003cblockquote\u003e\n\u003cp dir=\"auto\"\u003eComputer-based simulation and rapid prototyping tools are now broadly available and powerful enough that it is\nrelatively easy to demonstrate almost anything, provided that conditions are made sufficiently idealized.\nHowever, the real world is typically far from idealized, and thus a system must have enough robustness in order to close\nthe gap between demonstration and the real thing.\u003c/p\u003e\n\u003c/blockquote\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-11\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-11\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"http://www.cis.upenn.edu/~ngns/docs/Review_2010/Doyle%20MURI%202010.pdf\" rel=\"nofollow\"\u003eUniversal Laws and Architectures\u003c/a\u003e (slides)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://dx.doi.org/10.1109/TSMCA.2010.2048027\" rel=\"nofollow\"\u003eContrasting Views of Complexity and Their Implications For Network-Centric Infrastructures\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.pnas.org/content/108/Supplement_3/15624\" rel=\"nofollow\"\u003eArchitecture, constraints, and behavior\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1073/pnas.0501426102\" rel=\"nofollow\"\u003eThe “robust yet fragile” nature of the Internet\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://dx.doi.org/10.1103/physrevlett.84.2529\" rel=\"nofollow\"\u003eHighly Optimized Tolerance: Robustness and Design in Complex Systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1073/pnas.1401883111\" rel=\"nofollow\"\u003eRobust efficiency and actuator saturation explain healthy heart rate control and variability\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eBob Edwards\u003c/h2\u003e\u003ca id=\"user-content-bob-edwards\" class=\"anchor\" aria-label=\"Permalink: Bob Edwards\" href=\"#bob-edwards\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"http://hopcoach.net/\" rel=\"nofollow\"\u003eEdwards\u003c/a\u003e is a practitioner who provides\ntraining services in human and organizational performance (HOP).\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eEdwards tweets as \u003ca href=\"https://twitter.com/thehopcoach\" rel=\"nofollow\"\u003e@thehopcoach\u003c/a\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eAnders Ericsson\u003c/h2\u003e\u003ca id=\"user-content-anders-ericsson\" class=\"anchor\" aria-label=\"Permalink: Anders Ericsson\" href=\"#anders-ericsson\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eEricsson introduced the idea of \u003cem\u003edeliberate practice\u003c/em\u003e as a mechanism for\nachieving high level of expertise.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eEricsson isn't directly associated with the field of resilience engineering.\nHowever, Gary Klein's work is informed by his, and I have a particular\ninterest in how people improve in expertise, so I'm including him here.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-6\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-6\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eExpertise\u003c/li\u003e\n\u003cli\u003eDeliberate practice\u003c/li\u003e\n\u003cli\u003eProtocol analysis\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-12\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-12\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Peak-Secrets-New-Science-Expertise/dp/1531864880/\" rel=\"nofollow\"\u003ePeak: secrets from the new science of expertise\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Protocol-Analysis-Revd-Verbal-Reports/dp/0262550237\" rel=\"nofollow\"\u003eProtocol analysis: verbal reports as data\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003ePaul Feltovich\u003c/h2\u003e\u003ca id=\"user-content-paul-feltovich\" class=\"anchor\" aria-label=\"Permalink: Paul Feltovich\" href=\"#paul-feltovich\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://www.ihmc.us/groups/pfeltovich/\" rel=\"nofollow\"\u003eFeltovich\u003c/a\u003e is a retired Senior Research Scientist at the Florida Institute for Human \u0026amp; Machine Cognition (IHMC),\nwho has done extensive reserach in human expertise.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-13\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-13\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"http://jeffreymbradshaw.net/publications/Common_Ground_Single.pdf\" rel=\"nofollow\"\u003eCommon Ground and Coordination in Joint Activity\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/232465540_Issue_of_expert_flexibility_in_contexts_characterized_by_complexity_and_change\" rel=\"nofollow\"\u003eIssue of expert flexibility in contexts characterized by complexity and change\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/3454029_A_rose_by_any_other_namewould_probably_be_given_an_acronym\" rel=\"nofollow\"\u003eA rose by any other name...would probably be given an acronym\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/234818797_Learners'_misunderstanding_of_important_and_difficult_concepts_a_challenge_to_smart_machines_in_education\" rel=\"nofollow\"\u003eLearners' (mis)understanding of important and difficult concepts: a challenge to smart machines in education\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://ieeexplore.ieee.org/abstract/document/1363742\" rel=\"nofollow\"\u003eTen challenges for making automation a team player\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/ten-challenges-for-making-automation-a-team-player-in-joint-human-agent-activity/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/232465540_Issue_of_expert_flexibility_in_contexts_characterized_by_complexity_and_change\" rel=\"nofollow\"\u003eIssue of expert flexibility in contexts characterized by complexity and change\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eMeir Finkel\u003c/h2\u003e\u003ca id=\"user-content-meir-finkel\" class=\"anchor\" aria-label=\"Permalink: Meir Finkel\" href=\"#meir-finkel\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eFinkel is a Colonel in the Israeli Defense Force (IDF) and the Director of the IDF's Ground Forces Concept Development and Doctrine Department\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-14\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-14\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Flexibility-Recovery-Technological-Doctrinal-Battlefield/dp/0804774897/ref=sr_1_3?ie=UTF8\u0026amp;qid=1546046916\u0026amp;sr=8-3\u0026amp;keywords=on+flexibility\" rel=\"nofollow\"\u003eOn Flexibility: Recovery from Technological and Doctrinal Surprise on the Battlefield\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eMarisa Grayson\u003c/h2\u003e\u003ca id=\"user-content-marisa-grayson\" class=\"anchor\" aria-label=\"Permalink: Marisa Grayson\" href=\"#marisa-grayson\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://www.linkedin.com/in/marisa-grayson/\" rel=\"nofollow\"\u003eGrayson\u003c/a\u003e is a cognitive systems engineer at Mile Two, LLC.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected Publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-15\" class=\"anchor\" aria-label=\"Permalink: Selected Publications\" href=\"#selected-publications-15\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/333091997_Approaching_Overload_Diagnosis_and_Response_to_Anomalies_in_Complex_and_Automated_Production_Software_Systems\" rel=\"nofollow\"\u003eApproaching Overload: Diagnosis and Response to Anomalies in Complex and Automated Production Software Systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://queue.acm.org/detail.cfm?id=3380778\" rel=\"nofollow\"\u003eCognitive Work of Hypothesis Exploration During Anomaly Response\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eIvonne Andrade Herrera\u003c/h2\u003e\u003ca id=\"user-content-ivonne-andrade-herrera\" class=\"anchor\" aria-label=\"Permalink: Ivonne Andrade Herrera\" href=\"#ivonne-andrade-herrera\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://www.ntnu.edu/employees/ivonne.a.herrera\" rel=\"nofollow\"\u003eHerrera\u003c/a\u003e is an associate professor in\nthe department of industrial economics and technology management at NTNU and a\nsenior research scientist at SINTEF. Her areas of expertise include safety management and\nresilience engineering in avionics and air traffic management.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-16\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-16\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.sintef.no/globalassets/upload/teknologi_og_samfunn/sikkerhet-og-palitelighet/rapporter/sintef-a17034-organisational-accidents-and-resilience-organisations-six-perspectives.-revision-2.pdf\" rel=\"nofollow\"\u003eOrganisational accidents and resilient organisations: six perspectives\u003c/a\u003e (SINTEF A17034 report)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp dir=\"auto\"\u003eSee also: \u003ca href=\"https://wo.cristin.no/as/WebObjects/cristin.woa/wa/fres?sort=ar\u0026amp;pnr=30556\u0026amp;action=sok\" rel=\"nofollow\"\u003elist of publications\u003c/a\u003e\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eCat Hicks\u003c/h2\u003e\u003ca id=\"user-content-cat-hicks\" class=\"anchor\" aria-label=\"Permalink: Cat Hicks\" href=\"#cat-hicks\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://www.drcathicks.com/\" rel=\"nofollow\"\u003eHicks\u003c/a\u003e is a psychological scientist and researcher who creates open science to drive change for people doing technical work. She holds a PhD in Quantitative Experimental Psychology from UC San Diego and is the founder and principal scientist of Catharsis Consulting, a scientific consultancy that helps organizations transform with human-centered evidence strategies.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected Publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-17\" class=\"anchor\" aria-label=\"Permalink: Selected Publications\" href=\"#selected-publications-17\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.routledge.com/The-Psychology-of-Software-Teams/Hicks/p/book/9781032963389\" rel=\"nofollow\"\u003eThe Psychology of Software Teams\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://ieeexplore.ieee.org/stamp/stamp.jsp?arnumber=10491133\" rel=\"nofollow\"\u003eDeveloper Thriving: four sociocognitive factors that create resilient productivity on software teams\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://osf.io/preprints/psyarxiv/2gej5\" rel=\"nofollow\"\u003eThe New Developer: AI Skill Threat, Identity Change \u0026amp; Developer Thriving in the Transition to AI-Assisted Software Development\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://scholar.google.com/citations?user=MotKyQcAAAAJ\u0026amp;hl=en\" rel=\"nofollow\"\u003eGoogle Scholar\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eRobert Hoffman\u003c/h2\u003e\u003ca id=\"user-content-robert-hoffman\" class=\"anchor\" aria-label=\"Permalink: Robert Hoffman\" href=\"#robert-hoffman\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://www.ihmc.us/groups/rhoffman/\" rel=\"nofollow\"\u003eHoffman\u003c/a\u003e is a senior research scientist at Florida Institute for Human \u0026amp; Machine Cognition (IHMC),\nwho has done extensive reserach in human expertise.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-18\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-18\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://journals.sagepub.com/doi/abs/10.1177/0018720816686248\" rel=\"nofollow\"\u003eMeasuring resilience\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/326000581_Myths_of_automation_and_their_implications_for_military_procurement\" rel=\"nofollow\"\u003eMyths of automation and their implications for military procurement\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/260304859_The_Seven_Deadly_Myths_of_Autonomous_Systems\" rel=\"nofollow\"\u003eThe Seven Deadly Myths of \"Autonomous Systems\"\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/3454029_A_rose_by_any_other_namewould_probably_be_given_an_acronym\" rel=\"nofollow\"\u003eA rose by any other name...would probably be given an acronym\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://cmapspublic3.ihmc.us/rid=1G9NSY15K-N7MJMZ-LC5/SeeingTheInvisible.pdf\" rel=\"nofollow\"\u003eSeeing the invisible: perceptual-cognitive aspects of expertise\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/3454245_Toward_a_Theory_of_Complex_and_Cognitive_Systems\" rel=\"nofollow\"\u003eToward a Theory of Complex and Cognitive Systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/df74/b2909f54b41a485cd4c0189fc4aa19d176d0.pdf\" rel=\"nofollow\"\u003eMacrocognition\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/62/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-7\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-7\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSeven deadly myths of autonomous systems\u003c/h4\u003e\u003ca id=\"user-content-seven-deadly-myths-of-autonomous-systems\" class=\"anchor\" aria-label=\"Permalink: Seven deadly myths of autonomous systems\" href=\"#seven-deadly-myths-of-autonomous-systems\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003col dir=\"auto\"\u003e\n\u003cli\u003e\"Autonomy\" is unidimensional.\u003c/li\u003e\n\u003cli\u003eThe conceptualization of \"levels of autonomy\" is a useful scientific grounding for the development of autonomous system roadmaps.\u003c/li\u003e\n\u003cli\u003eAutonomy is a widget.\u003c/li\u003e\n\u003cli\u003eAutonomous systems are autonomous.\u003c/li\u003e\n\u003cli\u003eOnce achieved, full autonomy obviates the need for human-machine collaboration.\u003c/li\u003e\n\u003cli\u003eAs machines acquire more autonomy, they will work as simple sibstitutes (or multipliers) of human capability\u003c/li\u003e\n\u003cli\u003e\"Full autonomy\" is not only possible, but is always desireable.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eErik Hollnagel\u003c/h2\u003e\u003ca id=\"user-content-erik-hollnagel\" class=\"anchor\" aria-label=\"Permalink: Erik Hollnagel\" href=\"#erik-hollnagel\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eContributions\u003c/h3\u003e\u003ca id=\"user-content-contributions-2\" class=\"anchor\" aria-label=\"Permalink: Contributions\" href=\"#contributions-2\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eETTO principle\u003c/h4\u003e\u003ca id=\"user-content-etto-principle\" class=\"anchor\" aria-label=\"Permalink: ETTO principle\" href=\"#etto-principle\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eHollnagel proposed that there is always a fundamental tradeoff between\nefficiency and thoroughness, which he called the \u003cem\u003eETTO principle\u003c/em\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSafety-I vs. Safety-II\u003c/h4\u003e\u003ca id=\"user-content-safety-i-vs-safety-ii\" class=\"anchor\" aria-label=\"Permalink: Safety-I vs. Safety-II\" href=\"#safety-i-vs-safety-ii\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eSafety-I: avoiding things that go wrong\u003c/p\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003elooking at what goes wrong\u003c/li\u003e\n\u003cli\u003ebimodal view of work and activities (acceptable vs unacceptable)\u003c/li\u003e\n\u003cli\u003efind-and-fix approach\u003c/li\u003e\n\u003cli\u003eprevent transition from 'normal' to 'abnormal'\u003c/li\u003e\n\u003cli\u003ecausality credo: believe that adverse outcomes happen because something goes\nwrong (they have causes that can be found and treated)\u003c/li\u003e\n\u003cli\u003eit either works or it doesn't\u003c/li\u003e\n\u003cli\u003esystems are decomposable\u003c/li\u003e\n\u003cli\u003efunctioning is bimodal\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp dir=\"auto\"\u003eSafety-II: performance variability rather than bimodality\u003c/p\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003ethe system’s ability to succeed under varying conditions, so that the number\nof intended and acceptable outcomes (in other words, everyday activities) is\nas high as possible\u003c/li\u003e\n\u003cli\u003eperformance is always variable\u003c/li\u003e\n\u003cli\u003eperformance variation is ubiquitous\u003c/li\u003e\n\u003cli\u003ethings that go right\u003c/li\u003e\n\u003cli\u003efocus on frequent events\u003c/li\u003e\n\u003cli\u003eremain sensitive to possibility of failure\u003c/li\u003e\n\u003cli\u003ebe thorough as well as efficient\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eFRAM\u003c/h4\u003e\u003ca id=\"user-content-fram\" class=\"anchor\" aria-label=\"Permalink: FRAM\" href=\"#fram\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eHollnagel proposed the Functional Resonance Analysis Method (FRAM) for modeling\ncomplex socio-technical systems.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eFour abilities necessary for resilient performance\u003c/h4\u003e\u003ca id=\"user-content-four-abilities-necessary-for-resilient-performance\" class=\"anchor\" aria-label=\"Permalink: Four abilities necessary for resilient performance\" href=\"#four-abilities-necessary-for-resilient-performance\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003erespond\u003c/li\u003e\n\u003cli\u003emonitor\u003c/li\u003e\n\u003cli\u003elearn\u003c/li\u003e\n\u003cli\u003eanticipate\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-8\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-8\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eETTO (efficiency thoroughness tradeoff) principle\u003c/li\u003e\n\u003cli\u003eFRAM (functional resonance analysis method)\u003c/li\u003e\n\u003cli\u003eSafety-I and Safety-II\u003c/li\u003e\n\u003cli\u003ethings that go wrong vs things that go right\u003c/li\u003e\n\u003cli\u003ecausality credo\u003c/li\u003e\n\u003cli\u003eperformance variability\u003c/li\u003e\n\u003cli\u003ebimodality\u003c/li\u003e\n\u003cli\u003eemergence\u003c/li\u003e\n\u003cli\u003ework-as-imagined vs. work-as-done\u003c/li\u003e\n\u003cli\u003ejoint cognitive systems\u003c/li\u003e\n\u003cli\u003esystems of the first, second, third, fourth kind\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-19\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-19\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/ETTO-Principle-Efficiency-Thoroughness-Trade-Off-Sometimes/dp/0754676781/ref=sr_1_1?s=books\u0026amp;ie=UTF8\u0026amp;qid=1545965837\u0026amp;sr=1-1\u0026amp;keywords=etto+principle\" rel=\"nofollow\"\u003eThe ETTO Principle: Efficiency-Thoroughness Trade-Off: Why Things That Go Right Sometimes Go Wrong\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.skybrary.aero/bookshelf/books/2437.pdf\" rel=\"nofollow\"\u003eFrom Safety-I to Safety-II: A White Paper\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Safety-II-Practice-Developing-Resilience-Potentials/dp/1138708925\" rel=\"nofollow\"\u003eSafety-II in Practice\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/gp/product/1472423089/ref=dbs_a_def_rwt_bibl_vppi_i0\" rel=\"nofollow\"\u003eSafety-I and Safety-II: The past and future of safety management\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/gp/product/B010WIDYE8/ref=dbs_a_def_rwt_bibl_vppi_i15\" rel=\"nofollow\"\u003eFRAM: The Functional Resonance Analysis Method: Modelling Complex Socio-technical System\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/gp/product/0849339332/ref=x_gr_w_bb?ie=UTF8\u0026amp;tag=x_gr_w_bb-20\u0026amp;linkCode=as2\u0026amp;camp=1789\u0026amp;creative=9325\u0026amp;creativeASIN=0849339332\u0026amp;SubscriptionId=1MGPYB6YW3HWK55XCGG2\" rel=\"nofollow\"\u003eJoint Cognitive Systems: Patterns in Cognitive Systems Engineering\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/gp/product/B009KNDF64/ref=x_gr_w_glide_bb?ie=UTF8\u0026amp;tag=x_gr_w_glide_bb-20\u0026amp;linkCode=as2\u0026amp;camp=1789\u0026amp;creative=9325\u0026amp;creativeASIN=B009KNDF64\u0026amp;SubscriptionId=1MGPYB6YW3HWK55XCGG2\" rel=\"nofollow\"\u003eResilience Engineering: Concepts and Precepts\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://dx.doi.org/10.1007/s10111-012-0237-4\" rel=\"nofollow\"\u003eI want to believe: some myths about the management of industrial safety\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://www.ptil.no/getfile.php/1325150/PDF/Seminar%202013/Integrerte%20operasjoner/Hollnagel_RIO_presentation.pdf\" rel=\"nofollow\"\u003eResilience engineering – Building a Culture of Resilience\u003c/a\u003e (slides)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://docs.wixstatic.com/ugd/3ad081_f46dda684154447583c8a5b282b60cc2.pdf\" rel=\"nofollow\"\u003eAnomaly Response\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.ida.liu.se/~729A15/mtrl/CSEnew.pdf?utm_campaign=Resilience%20Roundup\u0026amp;utm_medium=email\u0026amp;utm_source=Revue%20newsletter\" rel=\"nofollow\"\u003eCognitive Systems Engineering: New wine in new bottles\u003c/a\u003e (\u003ca href=\"https://www.getrevue.co/profile/resilience/issues/resilience-roundup-cognitive-systems-engineering-new-wine-in-new-bottles-issue-32-175912\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/265074845_Epilogue_Resilience_Engineering_Precepts\" rel=\"nofollow\"\u003eEpilogue: Resilience Engineering Precepts\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/a0d3/9cc66adc64e297048a32b71aeee209a451af.pdf\" rel=\"nofollow\"\u003eResilience Engineering: New directions for measuring and maintaining safety in complex systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://erikhollnagel.com/ideas/resilience-engineering.html\" rel=\"nofollow\"\u003eResilience Engineering\u003c/a\u003e (web essay)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://erikhollnagel.com/onewebmedia/RAG%20Outline%20V2.pdf\" rel=\"nofollow\"\u003eRAG - Resilience Analysis Grid\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.crcpress.com/Resilience-Engineering-in-Practice-A-Guidebook/Paries-Wreathall-Hollnagel/p/book/9781472420749\" rel=\"nofollow\"\u003eResilience engineering in practice: a guidebook\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/220108174_Mapping_Cognitive_Demands_in_Complex_Problem-Solving_Worlds%3CPaste%3E\" rel=\"nofollow\"\u003eMapping Cognitive Demands in Complex Problem-Solving Worlds\u003c/a\u003e (mentions disturbance management)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://link.springer.com/article/10.1007%2Fs10111-003-0136-9\" rel=\"nofollow\"\u003eHuman factors and folk models\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/4213914_Designing_for_joint_cognitive_systems\" rel=\"nofollow\"\u003eDesigning for joint cognitive systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/df74/b2909f54b41a485cd4c0189fc4aa19d176d0.pdf\" rel=\"nofollow\"\u003eMacrocognition\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/62/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.sciencedirect.com/science/article/abs/pii/S0925753521004719\" rel=\"nofollow\"\u003eA day when (Almost) nothing happened\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://europepmc.org/article/NBK/nbk43670\" rel=\"nofollow\"\u003eMinding the Gaps: Creating Resilience in Health Care\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/a0d3/9cc66adc64e297048a32b71aeee209a451af.pdf\" rel=\"nofollow\"\u003eResilience Engineering: New directions for measuring and maintaining safety in complex systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/3973687_Understanding_accidents-from_root_causes_to_performance_variability\" rel=\"nofollow\"\u003eUnderstanding Accidents - From Root Causes to Performance Variability\u003c/a\u003e (\u003ca href=\"https://safety177496371.wordpress.com/2025/03/12/understanding-accidents-from-root-causes-to-performance-variability/\" rel=\"nofollow\"\u003eBH\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://onlinelibrary.wiley.com/doi/abs/10.1002/9780470713181.ch9\" rel=\"nofollow\"\u003eHuman error: trick or treat\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://incrementalsafety.com/onewebmedia/fifth%20paradox%20oct%2031.pdf\" rel=\"nofollow\"\u003eTHe 5th paradox of safety\u003c/a\u003e (\u003ca href=\"https://safetyinsights.org/2026/01/09/the-fifth-paradox-of-safety-new-article-from-erik-hollnagel/\" rel=\"nofollow\"\u003eBH\u003c/a\u003e)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eLeila Johannesen\u003c/h2\u003e\u003ca id=\"user-content-leila-johannesen\" class=\"anchor\" aria-label=\"Permalink: Leila Johannesen\" href=\"#leila-johannesen\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://www.linkedin.com/in/leilajohannesen/\" rel=\"nofollow\"\u003eJohannesen\u003c/a\u003e is currently a UX researcher and community advocate at IBM.\nHer PhD dissertation work examined how humans cooperate, including studies of anesthesiologists.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-9\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-9\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003ecommon ground\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-20\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-20\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/1bed/356b5aa67c701f5bad6d943768622095f418.pdf\" rel=\"nofollow\"\u003eGrounding explanations in evolving, diagnostic situations\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.abdn.ac.uk/iprc/documents/Communication%20Book%20Chapter.pdf\" rel=\"nofollow\"\u003eMaintaining common ground: an analysis of cooperative communication in the operating room\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Behind-Human-Error-David-Woods/dp/0754678342\" rel=\"nofollow\"\u003eBehind Human Error\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eGary Klein\u003c/h2\u003e\u003ca id=\"user-content-gary-klein\" class=\"anchor\" aria-label=\"Permalink: Gary Klein\" href=\"#gary-klein\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eKlein studies how experts are able to quickly make effective decisions in high-tempo situations.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eKlein tweets as \u003ca href=\"https://twitter.com/KleInsight\" rel=\"nofollow\"\u003e@KleInsight\u003c/a\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-10\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-10\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003enaturalistic decision making (NDM)\u003c/li\u003e\n\u003cli\u003eintuitive expertise\u003c/li\u003e\n\u003cli\u003ecognitive task analysis\u003c/li\u003e\n\u003cli\u003ecommon ground\u003c/li\u003e\n\u003cli\u003eproblem detection\u003c/li\u003e\n\u003cli\u003eautomation as a \"team player\"\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-21\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-21\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/gp/product/0262534290/ref=dbs_a_def_rwt_bibl_vppi_i0\" rel=\"nofollow\"\u003eSources of power: how people make decisions\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://jeffreymbradshaw.net/publications/Common_Ground_Single.pdf\" rel=\"nofollow\"\u003eCommon Ground and Coordination in Joint Activity\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/gp/product/0262532816/ref=dbs_a_def_rwt_bibl_vppi_i5\" rel=\"nofollow\"\u003eWorking minds: a practitioner's guide to cognitive task analysis\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/262449980_Patterns_in_Cooperative_Cognition\" rel=\"nofollow\"\u003ePatterns in Cooperative Cognition\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://journals.sagepub.com/doi/abs/10.1177/1555343416637520?journalCode=edma\" rel=\"nofollow\"\u003eCan We Trust Best Practices? Six Cognitive Challenges of Evidence-Based Approaches\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://dx.doi.org/10.1037/a0016755\" rel=\"nofollow\"\u003eConditions for intuitive expertise: a failure to disagree\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/220579480_Problem_detection\" rel=\"nofollow\"\u003eProblem detection\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://ieeexplore.ieee.org/abstract/document/1363742\" rel=\"nofollow\"\u003eTen challenges for making automation a team player\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/66\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://www.macrocognition.com/documents/Decision-Making-in-Action-Models-and-Methods-0316.pdf\" rel=\"nofollow\"\u003eDecision making in action: models and methods\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://ieeexplore.ieee.org/document/31053\" rel=\"nofollow\"\u003eCritical decision method for eliciting knowledge\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/0672/092ecc507fb41d81e82d2986cf86c4bff14f.pdf\" rel=\"nofollow\"\u003eA recognition-primed decision (RPD) model of rapid decision making\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://cmapspublic3.ihmc.us/rid=1G9NSY15K-N7MJMZ-LC5/SeeingTheInvisible.pdf\" rel=\"nofollow\"\u003eSeeing the invisible: perceptual-cognitive aspects of expertise\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/262449980_Patterns_in_Cooperative_Cognition\" rel=\"nofollow\"\u003ePatterns in Cooperative Cognition\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://link.springer.com/article/10.1007/s10111-005-0024-6\" rel=\"nofollow\"\u003eThe strengths and limitations of teams for detecting problems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/df74/b2909f54b41a485cd4c0189fc4aa19d176d0.pdf\" rel=\"nofollow\"\u003eMacrocognition\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/62/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected talks\u003c/h3\u003e\u003ca id=\"user-content-selected-talks-6\" class=\"anchor\" aria-label=\"Permalink: Selected talks\" href=\"#selected-talks-6\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=UXx51qK4ItQ\u0026amp;feature=emb_title\" rel=\"nofollow\"\u003eProblem detection\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eElizabeth Lay\u003c/h2\u003e\u003ca id=\"user-content-elizabeth-lay\" class=\"anchor\" aria-label=\"Permalink: Elizabeth Lay\" href=\"#elizabeth-lay\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eElizabeth Lay is a resilience engineering practitioner. She is currently a director of safety and human performance at Lewis Tree Service.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-22\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-22\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.taylorfrancis.com/chapters/edit/10.1201/9781315605708-18/noticing-brittleness-designing-resilience-elizabeth-lay-matthieu-branlat\" rel=\"nofollow\"\u003eNoticing Brittleness, Designing for Resilience\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.sciencedirect.com/science/article/abs/pii/S0951832015000812\" rel=\"nofollow\"\u003eA practitioner’s experiences operationalizing Resilience Engineering\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eNancy Leveson\u003c/h2\u003e\u003ca id=\"user-content-nancy-leveson\" class=\"anchor\" aria-label=\"Permalink: Nancy Leveson\" href=\"#nancy-leveson\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eNancy Leveson is a computer science researcher with a focus in software safety.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eContributions\u003c/h3\u003e\u003ca id=\"user-content-contributions-3\" class=\"anchor\" aria-label=\"Permalink: Contributions\" href=\"#contributions-3\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSTAMP\u003c/h4\u003e\u003ca id=\"user-content-stamp\" class=\"anchor\" aria-label=\"Permalink: STAMP\" href=\"#stamp\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eLeveson developed the accident causality model known as STAMP: the Systems-Theoretic Accident Model and Process.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eSee \u003ca href=\"/lorin/resilience-engineering/blob/master/STAMP.md\"\u003eSTAMP\u003c/a\u003e for some more detailed notes of mine.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-11\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-11\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eSoftware safety\u003c/li\u003e\n\u003cli\u003eSTAMP (systems-theoretic accident model and processes)\u003c/li\u003e\n\u003cli\u003eSTPA (system-theoretic process analysis) hazard analysis technique\u003c/li\u003e\n\u003cli\u003eCAST (causal analysis based on STAMP) accident analysis technique\u003c/li\u003e\n\u003cli\u003eSystems thinking\u003c/li\u003e\n\u003cli\u003ehazard\u003c/li\u003e\n\u003cli\u003einteractive complexity\u003c/li\u003e\n\u003cli\u003esystem accident\u003c/li\u003e\n\u003cli\u003edysfunctional interactions\u003c/li\u003e\n\u003cli\u003esafety constraints\u003c/li\u003e\n\u003cli\u003econtrol structure\u003c/li\u003e\n\u003cli\u003edead time\u003c/li\u003e\n\u003cli\u003etime constants\u003c/li\u003e\n\u003cli\u003efeedback delays\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-23\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-23\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"http://sunnyday.mit.edu/accidents/safetyscience-single.pdf\" rel=\"nofollow\"\u003eA New Accident Model for Engineering Safer Systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://mitpress.mit.edu/books/engineering-safer-world\" rel=\"nofollow\"\u003eEngineering a safer world\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://psas.scripts.mit.edu/home/get_file.php?name=STPA_handbook.pdf\" rel=\"nofollow\"\u003eSTPA Handbook\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Safeware-Computers-Nancy-G-Leveson/dp/0201119722\" rel=\"nofollow\"\u003eSafeware\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/gp/product/B009KNDF64/ref=x_gr_w_glide_bb?ie=UTF8\u0026amp;tag=x_gr_w_glide_bb-20\u0026amp;linkCode=as2\u0026amp;camp=1789\u0026amp;creative=9325\u0026amp;creativeASIN=B009KNDF64\u0026amp;SubscriptionId=1MGPYB6YW3HWK55XCGG2\" rel=\"nofollow\"\u003eResilience Engineering: Concepts and Precepts\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://dx.doi.org/10.1145/143062.143076\" rel=\"nofollow\"\u003eHigh-pressure steam engines and computer software\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/gp/product/B009KNDF64/ref=x_gr_w_glide_bb?ie=UTF8\u0026amp;tag=x_gr_w_glide_bb-20\u0026amp;linkCode=as2\u0026amp;camp=1789\u0026amp;creative=9325\u0026amp;creativeASIN=B009KNDF64\u0026amp;SubscriptionId=1MGPYB6YW3HWK55XCGG2\" rel=\"nofollow\"\u003eResilience Engineering: Concepts and Precepts\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eBeth Long\u003c/h2\u003e\u003ca id=\"user-content-beth-long\" class=\"anchor\" aria-label=\"Permalink: Beth Long\" href=\"#beth-long\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://www.linkedin.com/in/beth-adele-long/\" rel=\"nofollow\"\u003eLong\u003c/a\u003e is a software engineer, product manager, and Principal at software incident analysis company Adaptive Capacity Labs. She previously held roles at New Relic, Jeli, and who co-authored the paper \u003ca href=\"https://www-sciencedirect-com.proxy.lib.ohio-state.edu/science/article/pii/S0003687020301903\" rel=\"nofollow\"\u003eBuilding and revising adaptive capacity sharing for technical incident response: A case of resilience engineering\u003c/a\u003e with Dr. Richard Cook.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eCarl Macrae\u003c/h2\u003e\u003ca id=\"user-content-carl-macrae\" class=\"anchor\" aria-label=\"Permalink: Carl Macrae\" href=\"#carl-macrae\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://www.nottingham.ac.uk/business/people/lizcjm.html\" rel=\"nofollow\"\u003eMacrae\u003c/a\u003e is a social psychology\nresearcher who has done safety research in multiple domains, including aviation\nand healthcare. He helped set up the new healthcare investigation agency in\nEngland. He is currently a professor of organizational behavior and psychology\nat the Notthingham University Business School.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eMacrae tweets at \u003ca href=\"https://twitter.com/CarlMacrae\" rel=\"nofollow\"\u003e@CarlMacrae\u003c/a\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-12\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-12\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003erisk resilience\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-24\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-24\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"http://www.closecalls.cc/\" rel=\"nofollow\"\u003eClose calls\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://qualitysafety.bmj.com/content/23/6/440\" rel=\"nofollow\"\u003eEarly warnings, weak signals and learning from healthcare disasters\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eLaura Maguire\u003c/h2\u003e\u003ca id=\"user-content-laura-maguire\" class=\"anchor\" aria-label=\"Permalink: Laura Maguire\" href=\"#laura-maguire\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://www.linkedin.com/in/lauramaguire/\" rel=\"nofollow\"\u003eMaguire\u003c/a\u003e is a cognitive systems\nengineer and ressearcher with a PhD from Ohio State University. Maguire has done safety work in multiple domains, including forestry, healthcare, oil \u0026amp; gas, wildland firefighting, mountain safety, and software services. She formerly led research \u0026amp; development at \u003ca href=\"/lorin/resilience-engineering/blob/master/jeli.io\"\u003ejeli.io\u003c/a\u003e, is the a Director of the [Resilience \u0026amp; Proactive Safety Initiative(\u003ca href=\"https://u.osu.edu/csel/resilienceproactivesafetyinitiative/\" rel=\"nofollow\"\u003ehttps://u.osu.edu/csel/resilienceproactivesafetyinitiative/\u003c/a\u003e) at The Ohio State University's Cognitive Systems Engineering Lab and is the founder of \u003ca href=\"https://www.tracecognitive.com/\" rel=\"nofollow\"\u003eTrace Cognitive Engineering\u003c/a\u003e and \u003ca href=\"/lorin/resilience-engineering/blob/master/cognitioninthewild.com\"\u003eCognition In The Wild\u003c/a\u003e translating theory into practice for software and other industries. She also supervises Masters thesis projects for the College of Engineering at Lund University for the Human Factors \u0026amp; Systems Safety program. She was a founding member of the \u003ca href=\"https://www.snafucatchers.com/\" rel=\"nofollow\"\u003eSNAFUCatchers Consortium\u003c/a\u003e conducting focused cognitive systems and resilience engineering research on software companies.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eMaguire (rarely) tweets as \u003ca href=\"https://twitter.com/lauramdmaguire\" rel=\"nofollow\"\u003e@LauraMDMaguire\u003c/a\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-25\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-25\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://ieeexplore.ieee.org/document/10493156/\" rel=\"nofollow\"\u003eJoint Cognitive Systems: Ideas With Impact for Designing Safer, More Resilient Automated Systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://ieeexplore.ieee.org/document/10339148\" rel=\"nofollow\"\u003eCognitive Skills in Software Engineering: Operating Complex, Adaptive Systems at Speed and Scale\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://ieeexplore.ieee.org/document/10372510\" rel=\"nofollow\"\u003eAutomation doesn't work the way we think it does\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://dl.acm.org/doi/abs/10.1109/MS.2024.3480768\" rel=\"nofollow\"\u003eRealizing the Benefits of Human Machine Teaming for Safe Software Operations\u003c/a\u003e (with Laura Nolan)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.computer.org/csdl/magazine/so/2025/03/10953345/25ICFoAidsk\" rel=\"nofollow\"\u003eNavigating tradeoffs in software failures\u003c/a\u003e (with Fred Hebert)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://queue.acm.org/detail.cfm?id=3380779\" rel=\"nofollow\"\u003eManaging the Hidden Costs of Coordination\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://rave.ohiolink.edu/etdc/view?acc_num=osu1593661547087969\" rel=\"nofollow\"\u003eControlling the Costs of Coordination in Large-scale Distributed Software Systems\u003c/a\u003e (PhD dissertation)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.jeli.io/howie-the-post-incident-guide/\" rel=\"nofollow\"\u003eHowie: The Post-Incident Guide\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://snafucatchers.github.io/\" rel=\"nofollow\"\u003eSTELLA: Report from the SNAFUcatchers Workshop on Coping With Complexity\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003ePre-prints of many of her paywalled publications are available on \u003ca href=\"https://www.researchgate.net/profile/Laura-Maguire-2\" rel=\"nofollow\"\u003eResearchgate\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected talks\u003c/h3\u003e\u003ca id=\"user-content-selected-talks-7\" class=\"anchor\" aria-label=\"Permalink: Selected talks\" href=\"#selected-talks-7\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.usenix.org/conference/srecon24americas/presentation/maguire\" rel=\"nofollow\"\u003eHard Choices, Tight Timelines: A Closer Look at Skip-Level Tradeoff Decisions During Incidents\u003c/a\u003e (With Courtney Nash)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=m6NlJFsfimw\" rel=\"nofollow\"\u003eFollowship: A Cognitive Systems approach to coordination in software incidents\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.infoq.com/presentations/incident-command-system/\" rel=\"nofollow\"\u003eHow Many Is Too Much? Exploring Costs of Coordination During Outages\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=VEprjLtHzg0\" rel=\"nofollow\"\u003eMental models – why saying “I didn’t know it worked that way” is a sign of expertise not incompetence\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://re-deploy.io/videos/27-maguire.html\" rel=\"nofollow\"\u003eOperating at the edge of the envelope\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eCourtney Nash\u003c/h2\u003e\u003ca id=\"user-content-courtney-nash\" class=\"anchor\" aria-label=\"Permalink: Courtney Nash\" href=\"#courtney-nash\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eNash is a researcher and founder of [The Void] (\u003ca href=\"https://www.thevoid.community/\" rel=\"nofollow\"\u003ehttps://www.thevoid.community/\u003c/a\u003e), a community-contributed collection of software-related incident reports, aimed at making the internet a safer and more resilient place.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eChristopher Nemeth\u003c/h2\u003e\u003ca id=\"user-content-christopher-nemeth\" class=\"anchor\" aria-label=\"Permalink: Christopher Nemeth\" href=\"#christopher-nemeth\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://www.linkedin.com/in/christopher-nemeth-6651204\" rel=\"nofollow\"\u003eNemeth\u003c/a\u003e is a principal scientist at Applied Resesarch Associates, Inc.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-26\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-26\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.458.7283\u0026amp;rep=rep1\u0026amp;type=pdf\" rel=\"nofollow\"\u003eReplacing Hindsight With Insight: Toward Better Understanding of Diagnostic Failures\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/profile/Robert-Wears/publication/225108705_Resilience_is_Not_Control_Healthcare_Crisis_Management_and_ICT/links/00b49532b2c7f3ed62000000/Resilience-is-Not-Control-Healthcare-Crisis-Management-and-ICT.pdf\" rel=\"nofollow\"\u003eResilience is not control: healthcare, crisis management, and ICT\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.taylorfrancis.com/chapters/edit/10.1201/9781315605685-19/taking-things-one-stride-cognitive-features-two-resilient-performances-richard-cook-christopher-nemeth\" rel=\"nofollow\"\u003eTaking Things in One’s Stride: Cognitive Features of Two Resilient Performances\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://europepmc.org/article/NBK/nbk43670\" rel=\"nofollow\"\u003eMinding the Gaps: Creating Resilience in Health Care\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eLaura Nolan\u003c/h2\u003e\u003ca id=\"user-content-laura-nolan\" class=\"anchor\" aria-label=\"Permalink: Laura Nolan\" href=\"#laura-nolan\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://www.linkedin.com/in/lauralifts/details/experience/\" rel=\"nofollow\"\u003eNolan\u003c/a\u003e is a Principal Software Engineer and researcher who previously held roles at Google, Slack, Stanza. Her forthcoming masters thesis from Lund university studied expert troubleshooting during outages in production software environments.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eShe currently works at Reddit.\u003c/p\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://dl.acm.org/doi/abs/10.1109/MS.2024.3480768\" rel=\"nofollow\"\u003eRealizing the Benefits of Human Machine Teaming for Safe Software Operations\u003c/a\u003e (with Laura Maguire)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eAnne-Sophie Nyssen\u003c/h2\u003e\u003ca id=\"user-content-anne-sophie-nyssen\" class=\"anchor\" aria-label=\"Permalink: Anne-Sophie Nyssen\" href=\"#anne-sophie-nyssen\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"http://www.lecit.ulg.ac.be/equipe/anne-sophie-nyssen/\" rel=\"nofollow\"\u003eNyssen\u003c/a\u003e is a psychology professor at the University of Liège,\nwho does research on human error in complex systems, in particular in medicine.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eA list of publications can be found on her website linked above.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eElinor Ostrom\u003c/h2\u003e\u003ca id=\"user-content-elinor-ostrom\" class=\"anchor\" aria-label=\"Permalink: Elinor Ostrom\" href=\"#elinor-ostrom\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"http://www.elinorostrom.com/\" rel=\"nofollow\"\u003eOstrom\u003c/a\u003e was a Nobel-prize winning economics and\npolitical science researcher.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-27\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-27\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.annualreviews.org/doi/abs/10.1146/annurev.polisci.2.1.493\" rel=\"nofollow\"\u003eCoping with tragedies of the commons\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Governing-Commons-Evolution-Institutions-Collective/dp/1107569788\" rel=\"nofollow\"\u003eGoverning the Commons: The Evolution of Institutions for Collective Action\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-13\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-13\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003etragedy of the commons\u003c/li\u003e\n\u003cli\u003epolycentric governance\u003c/li\u003e\n\u003cli\u003esocial-ecological system framework\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eJean Pariès\u003c/h2\u003e\u003ca id=\"user-content-jean-pariès\" class=\"anchor\" aria-label=\"Permalink: Jean Pariès\" href=\"#jean-pariès\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003ePariès is the president of \u003ca href=\"http://www.dedale.net/dedale_en/\" rel=\"nofollow\"\u003eDédale\u003c/a\u003e, a safety and human factors consultancy.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-28\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-28\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.crcpress.com/Resilience-Engineering-in-Practice-A-Guidebook/Paries-Wreathall-Hollnagel/p/book/9781472420749\" rel=\"nofollow\"\u003eResilience engineering in practice: a guidebook\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected talks\u003c/h3\u003e\u003ca id=\"user-content-selected-talks-8\" class=\"anchor\" aria-label=\"Permalink: Selected talks\" href=\"#selected-talks-8\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"/lorin/resilience-engineering/blob/master/paries-keynote-2015.pptx\"\u003ePredicting The fatal flaws: The challenge of The unpredictable...\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eEmily Patterson\u003c/h2\u003e\u003ca id=\"user-content-emily-patterson\" class=\"anchor\" aria-label=\"Permalink: Emily Patterson\" href=\"#emily-patterson\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://hrs.osu.edu/faculty-and-staff/faculty-directory/patterson-emily\" rel=\"nofollow\"\u003ePatterson\u003c/a\u003e\nis a researcher who applies human factors engineering to improve patient safety\nin healthcare.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-29\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-29\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/312624891_Patient_boarding_in_the_emergency_department_as_a_symptom_of_complexity-induced_risks\" rel=\"nofollow\"\u003ePatient boarding in the emergency department as a symptom of complexity-induced risks\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/profile/Emily_Patterson2/publication/237138704_USING_OBSERVATIONAL_STUDY_AS_A_TOOL_FOR_DISCOVERY_UNCOVERING_COGNITIVE_AND_COLLABORATIVE_DEMANDS_AND_ADAPTIVE_STRATEGIES/links/0deec52c8e310b385a000000.pdf\" rel=\"nofollow\"\u003eUsing observational study as a tool for discovery: uncovering cognitive and collaborative demands and adaptive strategies\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.semanticscholar.org/paper/Voice-Loops-as-Coordination-Aids-in-Space-Shuttle-Patterson-Watts-Perotti/068dfee1a859a63fa2ef82f008d239e6a81ed004\" rel=\"nofollow\"\u003eVoice Loops as Coordination Aids in Space Shuttle Mission Control\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/3657906_Functionally_distributed_coordination_during_anomaly_response_inspace_shuttle_mission_control\" rel=\"nofollow\"\u003eFunctionally distributed coordination during anomaly response in space shuttle mission control\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/262449980_Patterns_in_Cooperative_Cognition\" rel=\"nofollow\"\u003ePatterns in Cooperative Cognition\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/220579448_Collaborative_Cross-Checking_to_Enhance_Resilience\" rel=\"nofollow\"\u003eCollaborative Cross-Checking to Enhance Resilience\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/73/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/2484621_New_Arctic_Air_Crash_Aftermath_Role-Play_Simulation_Orchestrating_a_Fundamental_Surprise\" rel=\"nofollow\"\u003eNew Arctic Air Crash Aftermath Role-Play Simulation Orchestrating a Fundamental Surprise\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/8648890_Handoff_strategies_in_settings_with_high_consequences_for_failure_Lessons_for_health_care_operations\" rel=\"nofollow\"\u003eHandoff strategies in settings with high consequences for failure: lessons for health care operations\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/56\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://csel.eng.ohio-state.edu/productions/laws/laws_mediapaper/2_4_escalation.pdf\" rel=\"nofollow\"\u003eHow Unexpected Events Produce An Escalation Of Cognitive And Coordinative Demands\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/how-unexpected-events-produce-an-escalation-of-cognitive-and-coordinative-demands/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1876978/\" rel=\"nofollow\"\u003eCommunication Strategies from High-reliability Organizations: Translation is Hard Work\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/communication-strategies-from-high-reliability-organizations-translation-is-hard-work/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/228809190_Understanding_rigor_in_information_analysis\" rel=\"nofollow\"\u003eUnderstanding rigor in information analysis\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://citeseerx.ist.psu.edu/document?repid=rep1\u0026amp;type=pdf\u0026amp;doi=15f31969c4e1f4f599c5c68aa63f3bf930e0406f\" rel=\"nofollow\"\u003eBehind Human Error: Taming Complexity to Improve Patient Safety\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eCharles Perrow\u003c/h2\u003e\u003ca id=\"user-content-charles-perrow\" class=\"anchor\" aria-label=\"Permalink: Charles Perrow\" href=\"#charles-perrow\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003ePerrow is a sociologist who studied the Three Mile Island disaster. \"Normal Accidents\" is cited by numerous other influential systems engineering publications such as \u003ca href=\"#diane-vaughan\"\u003eVaughan's\u003c/a\u003e \"The Challenger Launch Decision\".\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-14\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-14\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eComplex systems: A system of tightly-coupled components with common mode connections that is prone to unintended feedback loops, complex controls, low observability, and poorly-understood mechanisms. They are not always high-risk, and thus their failure is not always catastrophic.\u003c/li\u003e\n\u003cli\u003eNormal accidents: Complex systems with many components exhibit unexpected interactions in the face of inevitable component failures. When these components are tightly-coupled, failed parts cannot be isolated from other parts, resulting in unpredictable system failures. Crucially, adding more safety devices and automated system controls often makes these coupling problems worse.\u003c/li\u003e\n\u003cli\u003eCommon-mode: The failure of one component that serves multiple purposes results in multiple associated failures, often with high interactivity and low linearity - both ingredients for unexpected behavior that is difficult to control.\u003c/li\u003e\n\u003cli\u003eProduction pressures and safety: Organizations adopt processes and devices to improve safety and efficiency, but production pressure often defeats any safety gained from the additions: the safety devices allow or encourage more risky behavior. As an unfortunate side-effect, the system is now also more complex.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-30\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-30\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Normal-Accidents-Living-Technologies-Updated-ebook/dp/B00CHRINUI\" rel=\"nofollow\"\u003eNormal Accidents: Living With High-Risk Technologies\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eShawna J. Perry\u003c/h2\u003e\u003ca id=\"user-content-shawna-j-perry\" class=\"anchor\" aria-label=\"Permalink: Shawna J. Perry\" href=\"#shawna-j-perry\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003ePerry is a medical researcher who studies emergency medicine.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-15\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-15\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eUnderground adaptations\u003c/li\u003e\n\u003cli\u003eArticulated functions vs. important functions\u003c/li\u003e\n\u003cli\u003eUnintended effects\u003c/li\u003e\n\u003cli\u003eApparent success vs real success\u003c/li\u003e\n\u003cli\u003eExceptions\u003c/li\u003e\n\u003cli\u003eDynamic environments\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-31\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-31\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1007/s10111-011-0207-2\" rel=\"nofollow\"\u003eUnderground adaptations: case studies from health care\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://journals.sagepub.com/doi/abs/10.1177/1555343416637520?journalCode=edma\" rel=\"nofollow\"\u003eCan We Trust Best Practices? Six Cognitive Challenges of Evidence-Based Approaches\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/232191704_The_Role_of_Automation_in_Complex_System_Failures\" rel=\"nofollow\"\u003eThe Role of Automation in Complex System Failures\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/1423/f18530599b9de186af0eee4852bb7e619384.pdf\" rel=\"nofollow\"\u003eExtemporaneous Adaptation to Evolving Complexity: A Case Study of Resilience in Healthcare\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/55\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1016/j.ress.2006.01.009\" rel=\"nofollow\"\u003eAutomation, interaction, complexity, and failure: A case study\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eOther\u003c/h3\u003e\u003ca id=\"user-content-other\" class=\"anchor\" aria-label=\"Permalink: Other\" href=\"#other\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://open.spotify.com/episode/7lHcgt2KuDoLyvTP9wMbEn?si=nPIyk9L8QB2Iuck2fKKrNA\" rel=\"nofollow\"\u003eInterview on Naturalistic Decision Making podcast\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eJens Rasmussen\u003c/h2\u003e\u003ca id=\"user-content-jens-rasmussen\" class=\"anchor\" aria-label=\"Permalink: Jens Rasmussen\" href=\"#jens-rasmussen\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eJens Rasmussen was an enormously influential researcher in human factors and safety systems. In particular, you can see his influence in the work of Sidney Dekker, Nancy Leveson, David Woods.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eContributions\u003c/h3\u003e\u003ca id=\"user-content-contributions-4\" class=\"anchor\" aria-label=\"Permalink: Contributions\" href=\"#contributions-4\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSkill-rule-knowledge (SKR) model\u003c/h4\u003e\u003ca id=\"user-content-skill-rule-knowledge-skr-model\" class=\"anchor\" aria-label=\"Permalink: Skill-rule-knowledge (SKR) model\" href=\"#skill-rule-knowledge-skr-model\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eRasmussen proposed three models of human performance.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003e\u003cstrong\u003eSkill-based\u003c/strong\u003e behavior doesn't require conscious attention. The prototypical example is riding a bicycle.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003e\u003cstrong\u003eRule-based\u003c/strong\u003e behavior is based on a set of rules that we have internalized in\nadvance. We select which rule to use based on experience, and then carry it\nout. An example would be: if threads are blocked, restart the server. You can think of rule-based behavior as a memorized runbook.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003e\u003cstrong\u003eKnowledge-based\u003c/strong\u003e behavior comes into play when facing an unfamiliar\nsituation. The person generates a set of plans based on their understanding of\nthe environment, and then selects which one to use. The challenging incidents\nare the ones that require knowledge-based behavior to resolve.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eHe also proposed three types of information that humans process as they perform work.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003e\u003cstrong\u003eSignals\u003c/strong\u003e. Example: weather vane\u003c/p\u003e\n\u003cp dir=\"auto\"\u003e\u003cstrong\u003eSigns\u003c/strong\u003e. Example: stop sign\u003c/p\u003e\n\u003cp dir=\"auto\"\u003e\u003cstrong\u003eSymbols\u003c/strong\u003e. Example: written language\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eAbstraction hierarchy\u003c/h4\u003e\u003ca id=\"user-content-abstraction-hierarchy\" class=\"anchor\" aria-label=\"Permalink: Abstraction hierarchy\" href=\"#abstraction-hierarchy\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eRasmussen proposed a model of how operators reason about the behavior of a\nsystem they are supervising called the \u003cem\u003eabstraction hierarchy\u003c/em\u003e.\nThe levels in the hierarchy are\u003c/p\u003e\n\u003col dir=\"auto\"\u003e\n\u003cli\u003efunctional purpose\u003c/li\u003e\n\u003cli\u003eabstract functions\u003c/li\u003e\n\u003cli\u003egeneral functions\u003c/li\u003e\n\u003cli\u003ephysical funcitons\u003c/li\u003e\n\u003cli\u003ephysical form\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp dir=\"auto\"\u003eThe hierarchy forms a means-ends relationship: proper function is described top-down (ends), and problems are explained bottom-up (means)\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eDynamic safety model\u003c/h4\u003e\u003ca id=\"user-content-dynamic-safety-model\" class=\"anchor\" aria-label=\"Permalink: Dynamic safety model\" href=\"#dynamic-safety-model\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eRasmussen proposed a state-based model of a socio-technical system as a system\nthat moves within a region of a state space. The region is surrounded by\ndifferent boundaries:\u003c/p\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eeconomic failure\u003c/li\u003e\n\u003cli\u003eunacceptable work load\u003c/li\u003e\n\u003cli\u003efunctionality acceptable performance\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp dir=\"auto\"\u003e\u003ca target=\"_blank\" rel=\"noopener noreferrer\" href=\"/lorin/resilience-engineering/blob/master/boundary.png\"\u003e\u003cimg src=\"/lorin/resilience-engineering/raw/master/boundary.png\" alt=\"Migration to the boundary\" style=\"max-width: 100%;\"\u003e\u003c/a\u003e\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eSource: \u003ca href=\"https://doi.org/10.1016/S0925-7535(97)00052-0\" rel=\"nofollow\"\u003eRisk management in a dynamic society: a modelling problem\u003c/a\u003e\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eIncentives push the system towards the boundary of acceptable performance:\naccidents happen when the boundary is exceeded.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eAcciMaps\u003c/h4\u003e\u003ca id=\"user-content-accimaps\" class=\"anchor\" aria-label=\"Permalink: AcciMaps\" href=\"#accimaps\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eThe AcciMaps approach is a technique for reasoning about the causes of an accident, using a diagram.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eRisk management framework\u003c/h4\u003e\u003ca id=\"user-content-risk-management-framework\" class=\"anchor\" aria-label=\"Permalink: Risk management framework\" href=\"#risk-management-framework\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eRasmussen proposed a multi-layer view of socio-technical systems:\u003c/p\u003e\n\u003cp dir=\"auto\"\u003e\u003ca target=\"_blank\" rel=\"noopener noreferrer\" href=\"/lorin/resilience-engineering/blob/master/risk-management-framework.png\"\u003e\u003cimg src=\"/lorin/resilience-engineering/raw/master/risk-management-framework.png\" alt=\"Risk management framework\" style=\"max-width: 100%;\"\u003e\u003c/a\u003e\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eSource: \u003ca href=\"https://doi.org/10.1016/S0925-7535(97)00052-0\" rel=\"nofollow\"\u003eRisk management in a dynamic society: a modelling problem\u003c/a\u003e\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-16\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-16\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eDynamic safety model\u003c/li\u003e\n\u003cli\u003eMigration toward accidents\u003c/li\u003e\n\u003cli\u003eRisk management framework\u003c/li\u003e\n\u003cli\u003eBoundaries:\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eboundary of functionally acceptable performance\u003c/li\u003e\n\u003cli\u003eboundary to economic failure\u003c/li\u003e\n\u003cli\u003eboundary to unacceptable work load\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/li\u003e\n\u003cli\u003eCognitive systems engineering\u003c/li\u003e\n\u003cli\u003eSkill-rule-knowledge (SKR) model\u003c/li\u003e\n\u003cli\u003eAcciMaps\u003c/li\u003e\n\u003cli\u003eMeans-ends hierarchy\u003c/li\u003e\n\u003cli\u003eEcological interface design\u003c/li\u003e\n\u003cli\u003eSystems approach\u003c/li\u003e\n\u003cli\u003eControl-theoretic\u003c/li\u003e\n\u003cli\u003edecisions, acts, and errors\u003c/li\u003e\n\u003cli\u003ehazard source\u003c/li\u003e\n\u003cli\u003eanatomy of accidents\u003c/li\u003e\n\u003cli\u003eenergy\u003c/li\u003e\n\u003cli\u003esystems thinking\u003c/li\u003e\n\u003cli\u003etrial and error experiments\u003c/li\u003e\n\u003cli\u003edefence in depth (fallacy)\u003c/li\u003e\n\u003cli\u003eRole of managers\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eInformation\u003c/li\u003e\n\u003cli\u003eCompetency\u003c/li\u003e\n\u003cli\u003eAwareness\u003c/li\u003e\n\u003cli\u003eCommitment\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/li\u003e\n\u003cli\u003eGoing solid\u003c/li\u003e\n\u003cli\u003eobservability\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-32\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-32\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.tandfonline.com/doi/abs/10.1080/00140137408931355\" rel=\"nofollow\"\u003eMental procedures in real-life tasks: a case study of electronic trouble shooting\u003c/a\u003e (1974)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://orbit.dtu.dk/en/publications/coping-with-complexity\" rel=\"nofollow\"\u003eCoping with complexity\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.iwolm.com/wp-content/downloads/SkillsRulesAndKnowledge-Rasmussen.pdf\" rel=\"nofollow\"\u003eSkills, rules, and knowledge; signals, signs, and symbols, and other distinctions in human performance models\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://qualitysafety.bmj.com/content/14/2/130\" rel=\"nofollow\"\u003e“Going solid”: a model of system dynamics and consequences for patient safety\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.ida.liu.se/~729A71/Literature/Human%20Error_T/Rasmussen_1990.pdf\" rel=\"nofollow\"\u003eHuman error and the problem of causality in analysis of accidents\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/human-error-and-the-problem-of-causality-in-analysis-of-accidents/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://backend.orbit.dtu.dk/ws/portalfiles/portal/158020073/ERTAX1.PDF\" rel=\"nofollow\"\u003eHuman Errors: A Taxonomy for Describing Human Malfunction in Industrial Installations\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://core.ac.uk/download/pdf/13788397.pdf\" rel=\"nofollow\"\u003eEcological interfaces: A technological imperative in high‐tech systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Information-Processing-Human-Machine-Interaction-North-Holland/dp/0444009876\" rel=\"nofollow\"\u003eInformation processing and human-machine interaction: an approach to cognitive engineering\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://backend.orbit.dtu.dk/ws/files/158019622/HISMC.PDF\" rel=\"nofollow\"\u003eThe role of hierarchical knowledge representation in decisionmaking and system management\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://core.ac.uk/download/pdf/13777954.pdf\" rel=\"nofollow\"\u003eA Model of Human Decision Making in Complex Systems and its Use for Design of System Control Strategies\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://qualitysafety.bmj.com/content/qhc/12/5/377.full.pdf\" rel=\"nofollow\"\u003eThe role of error in organizing behaviour\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/the-role-of-error-in-organizing-behaviour/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.osti.gov/biblio/7011990-information-processing-human-machine-interaction\" rel=\"nofollow\"\u003eInformation processing and human-machine interaction\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1016/S0925-7535(97)00052-0\" rel=\"nofollow\"\u003eRisk management in a dynamic society: a modelling problem\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://rib.msb.se/Filer/pdf/16252.pdf\" rel=\"nofollow\"\u003eProactive risk management in a dynamic society\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://backend.orbit.dtu.dk/ws/portalfiles/portal/137294535/TREND.PDF\" rel=\"nofollow\"\u003eTrends in Human Reliability Analysis\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://backend.orbit.dtu.dk/ws/portalfiles/portal/158019622/HISMC.PDF\" rel=\"nofollow\"\u003eThe role of hierarchical knowledge representation in decisionmaking and system management\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://backend.orbit.dtu.dk/ws/portalfiles/portal/137538698/ERRROLE_1_.PDF\" rel=\"nofollow\"\u003eThe role of error in organizing behaviour\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://backend.orbit.dtu.dk/ws/portalfiles/portal/158018718/ROYSOC.PDF\" rel=\"nofollow\"\u003eHuman error and the problem of causality in analysis of accidents\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://citeseerx.ist.psu.edu/document?repid=rep1\u0026amp;type=pdf\u0026amp;doi=5fb7644d205b342aa52c594b7982a9e208086238\" rel=\"nofollow\"\u003eCoping with human errors through system design: implications for ecological interface design\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.sciencedirect.com/science/article/abs/pii/S0925753500000369\" rel=\"nofollow\"\u003eGraphic representation of accident scenarios: mapping system structure and the causation of accidents\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://backend.orbit.dtu.dk/ws/portalfiles/portal/158017532/DIAACT.PDF\" rel=\"nofollow\"\u003eDiagnostic reasoning in action\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://orbit.dtu.dk/en/publications/a-framework-for-cognitive-task-analysis-in-systems-design\" rel=\"nofollow\"\u003eA framework for cognitive task analysis in systems design\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://backend.orbit.dtu.dk/ws/portalfiles/portal/158019864/LEPRAS.PDF\" rel=\"nofollow\"\u003eAnalysis of human errors in industrial incidents and accidents for mprovement of work safety\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://documents1.worldbank.org/curated/ru/535511468766200820/pdf/multi0page.pdf\" rel=\"nofollow\"\u003eWhy do complex organizational systems fail?\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://orbit.dtu.dk/en/publications/notes-on-human-error-analysis-and-prediction\" rel=\"nofollow\"\u003eNotes on human error analysis and prediction\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp dir=\"auto\"\u003e(These are written but others about Rasmussen's work)\u003c/p\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.sciencedirect.com/science/article/abs/pii/S0003687016302150?via%3Dihub\" rel=\"nofollow\"\u003eRecurring themes in the legacy of Jens Rasmussen\u003c/a\u003e - special issue of Applied Ergonomics\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1016/j.ssci.2014.03.015\" rel=\"nofollow\"\u003eReflecting on Jens Rasmussen’s legacy. A strong program for a hard problem\u003c/a\u003e (\u003ca href=\"https://github.com/lorin/booknotes/blob/master/papers/Reflecting-on-Jens-Rasmussens-Legacy.md\"\u003emy notes\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1016/j.apergo.2015.07.013\" rel=\"nofollow\"\u003eReflecting on Jens Rasmussen's legacy (2) behind and beyond, a ‘constructivist turn’\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.sciencedirect.com/science/article/abs/pii/S0003687015301009?via%3Dihub\" rel=\"nofollow\"\u003eMusings on Models and the Genius of Jens Rasmussen\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eMike Rayo\u003c/h2\u003e\u003ca id=\"user-content-mike-rayo\" class=\"anchor\" aria-label=\"Permalink: Mike Rayo\" href=\"#mike-rayo\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eRayo is the Director of the Cognitive Systems Engineering Laboratory at the Ohio State University.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-17\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-17\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eSCAD (Systematic Contributors Analysis and Diagram)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected Publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-33\" class=\"anchor\" aria-label=\"Permalink: Selected Publications\" href=\"#selected-publications-33\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://journals.sagepub.com/doi/10.1177/1071181322661334\" rel=\"nofollow\"\u003eDeveloping Systemic Contributors and Adaptations Diagramming (SCAD): systemic insights, multiple pragmatic implementations\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/308194080_Multiple_Systemic_Contributors_versus_Root_Cause_Learning_from_a_NASA_Near_Miss\" rel=\"nofollow\"\u003eMultiple Systemic Contributors versus Root Cause: Learning from a NASA Near Miss\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://thebulletin.org/2025/05/the-silicon-valley-way-move-fast-and-breakaviation-safety/\" rel=\"nofollow\"\u003eThe Silicon Valley Way: Move fast and break…aviation safety?\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eJames Reason\u003c/h2\u003e\u003ca id=\"user-content-james-reason\" class=\"anchor\" aria-label=\"Permalink: James Reason\" href=\"#james-reason\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eReason is a psychology researcher who did work on understanding and categorizing human error.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eContributions\u003c/h3\u003e\u003ca id=\"user-content-contributions-5\" class=\"anchor\" aria-label=\"Permalink: Contributions\" href=\"#contributions-5\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eAccident causation model (Swiss cheese model)\u003c/h4\u003e\u003ca id=\"user-content-accident-causation-model-swiss-cheese-model\" class=\"anchor\" aria-label=\"Permalink: Accident causation model (Swiss cheese model)\" href=\"#accident-causation-model-swiss-cheese-model\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eReason developed an accident causation model that is sometimes known as the \u003cem\u003eswiss cheese\u003c/em\u003e model of accidents.\nIn this model, Reason introduced the terms \"sharp end\" and \"blunt end\".\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eHuman Error model: Slips, lapses and mistakes\u003c/h4\u003e\u003ca id=\"user-content-human-error-model-slips-lapses-and-mistakes\" class=\"anchor\" aria-label=\"Permalink: Human Error model: Slips, lapses and mistakes\" href=\"#human-error-model-slips-lapses-and-mistakes\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eReason developed a model of the types of errors that humans make:\u003c/p\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eslips\u003c/li\u003e\n\u003cli\u003elapses\u003c/li\u003e\n\u003cli\u003emistakes\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-18\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-18\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eBlunt end\u003c/li\u003e\n\u003cli\u003eHuman error\u003c/li\u003e\n\u003cli\u003eSlips, lapses and mistakes\u003c/li\u003e\n\u003cli\u003eSwiss cheese model\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-34\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-34\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/gp/product/0521314194/ref=dbs_a_def_rwt_bibl_vppi_i0\" rel=\"nofollow\"\u003eHuman error\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Organizational-Accidents-Revisited-James-Reason/dp/1472447689\" rel=\"nofollow\"\u003eOrganizational Accidents Revisited\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eJ. Paul Reed\u003c/h2\u003e\u003ca id=\"user-content-j-paul-reed\" class=\"anchor\" aria-label=\"Permalink: J. Paul Reed\" href=\"#j-paul-reed\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://jpaulreed.com/\" rel=\"nofollow\"\u003eReed\u003c/a\u003e is a Senior Applied Resilience engineer at Netflix and runs \u003ca href=\"https://re-deploy.io\" rel=\"nofollow\"\u003eREdeploy\u003c/a\u003e, a conference focused on Resilience Engineering in the software development and operations industry.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eReed tweets as \u003ca href=\"https://twitter.com/jpaulreed\" rel=\"nofollow\"\u003e@jpaulreed\u003c/a\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected Publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-35\" class=\"anchor\" aria-label=\"Permalink: Selected Publications\" href=\"#selected-publications-35\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e[Maps, Context, and Tribal Knowledge: On the Structure and Use of Post-Incident Analysis Artifacts in Software Development and Operations](\u003ca href=\"https://lup.lub.lu.se/student-papers/search/publication/8966930j\" rel=\"nofollow\"\u003ehttps://lup.lub.lu.se/student-papers/search/publication/8966930j\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://queue.acm.org/detail.cfm?id=3380780d\" rel=\"nofollow\"\u003eBeyond the \"Fix-it\" Treadmill\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-19\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-19\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://jpaulreed.com/blame-aware\" rel=\"nofollow\"\u003eBlame \"Aware\"\u003c/a\u003e (versus \"Blameless\") Culture\u003c/li\u003e\n\u003cli\u003ePostmortem Artifact \u003cem\u003eArchetypes\u003c/em\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eEmilie M. Roth\u003c/h2\u003e\u003ca id=\"user-content-emilie-m-roth\" class=\"anchor\" aria-label=\"Permalink: Emilie M. Roth\" href=\"#emilie-m-roth\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"http://www.rothsite.com/resume.html\" rel=\"nofollow\"\u003eRoth\u003c/a\u003e is a cognitive psychologist who\nserves as the principal scientist at \u003ca href=\"http://www.rothsite.com/\" rel=\"nofollow\"\u003eRoth Cognitive Engineering\u003c/a\u003e, a small\ncompany that conducts research and application in the areas of human factors\nand applied cognitive psychology (cognitive engineering)\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-36\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-36\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"http://citeseerx.ist.psu.edu/viewdoc/summary?doi=10.1.1.564.2044\" rel=\"nofollow\"\u003eUncovering the Requirements of Cognitive Work\u003c/a\u003e (\u003ca href=\"https://www.getrevue.co/profile/resilience/issues/resilience-roundup-uncovering-the-requirements-of-cognitive-work-issue-30-173410\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/profile/Emily_Patterson2/publication/237138704_USING_OBSERVATIONAL_STUDY_AS_A_TOOL_FOR_DISCOVERY_UNCOVERING_COGNITIVE_AND_COLLABORATIVE_DEMANDS_AND_ADAPTIVE_STRATEGIES/links/0deec52c8e310b385a000000.pdf\" rel=\"nofollow\"\u003eUsing observational study as a tool for discovery: uncovering cognitive and collaborative demands and adaptive strategies\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/8648890_Handoff_strategies_in_settings_with_high_consequences_for_failure_Lessons_for_health_care_operations\" rel=\"nofollow\"\u003eHandoff strategies in settings with high consequences for failure: lessons for health care operations\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/56\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/313737506_Bootstrapping_multiple_converging_cognitive_task_analysis_techniques_for_system_design\" rel=\"nofollow\"\u003eBootstrapping multiple converging cognitive task analysis techniques for system design\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/70\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eOther\u003c/h3\u003e\u003ca id=\"user-content-other-1\" class=\"anchor\" aria-label=\"Permalink: Other\" href=\"#other-1\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://open.spotify.com/episode/3XqAhdpyrszLoB59VcRJWG\" rel=\"nofollow\"\u003eInterview on Naturalistic Decision Making podcast\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eNadine Sarter\u003c/h2\u003e\u003ca id=\"user-content-nadine-sarter\" class=\"anchor\" aria-label=\"Permalink: Nadine Sarter\" href=\"#nadine-sarter\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://ioe.engin.umich.edu/people/nadine-sarter/\" rel=\"nofollow\"\u003eSarter\u003c/a\u003e is a researcher in industrial and operations engineering.\nShe is the director of the Center for Ergonomics at the University of Michigan.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-20\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-20\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003ecognitive ergonomics\u003c/li\u003e\n\u003cli\u003eorganization safety\u003c/li\u003e\n\u003cli\u003ehuman-automation/robot interaction\u003c/li\u003e\n\u003cli\u003ehuman error / error management\u003c/li\u003e\n\u003cli\u003eattention / interruption management\u003c/li\u003e\n\u003cli\u003edesign of decision support systems\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-37\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-37\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/19980016965.pdf\" rel=\"nofollow\"\u003eLearning from Automation Surprises and \"Going Sour\" Accidents: Progress on Human-Centered Automation\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Behind-Human-Error-David-Woods/dp/0754678342\" rel=\"nofollow\"\u003eBehind Human Error\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Cognitive-Systems-Engineering-Expertise-Applications-ebook/dp/B076TDR6H9/ref=sr_1_1?keywords=cognitive+systems+engineering\u0026amp;qid=1554075974\u0026amp;s=gateway\u0026amp;sr=8-1\" rel=\"nofollow\"\u003eDesigned-Induced Error and Error-Informed Design: A Two-Way Street\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.taylorfrancis.com/books/e/9780429134845\" rel=\"nofollow\"\u003eThe Critical Incident Technique: A Method for Identifying System Strengths and Weaknesses Based on Observational Data\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/326000581_Myths_of_automation_and_their_implications_for_military_procurement\" rel=\"nofollow\"\u003eMyths of automation and their implications for military procurement\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/270960170_Automation_surprises\" rel=\"nofollow\"\u003eAutomation surprises\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/12195752_Team_Play_with_a_Powerful_and_Independent_Agent_A_Full-Mission_Simulation_Study\" rel=\"nofollow\"\u003eTeam Play with a Powerful and Independent Agent: A Full-Mission Simulation Study\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/team-play-with-a-powerful-and-independent-agent-a-full-mission-simulation-study/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eJames C. Scott\u003c/h2\u003e\u003ca id=\"user-content-james-c-scott\" class=\"anchor\" aria-label=\"Permalink: James C. Scott\" href=\"#james-c-scott\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eScott is an anthropologist who also does research in political science. While\nScott is not a member of a resilience engineering community, his book \u003cem\u003eSeeing\nlike a state\u003c/em\u003e has long been a staple of the cognitive systems engineering and\nresilience engineering communities.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-21\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-21\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eauthoritarian high-modernism\u003c/li\u003e\n\u003cli\u003elegibility\u003c/li\u003e\n\u003cli\u003emētis\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-38\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-38\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Seeing-like-State-Certain-Condition/dp/0300078153/ref=sr_1_1\" rel=\"nofollow\"\u003eSeeing like a state: how certain schemes to improve the human condition have failed\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSteven Shorrock\u003c/h2\u003e\u003ca id=\"user-content-steven-shorrock\" class=\"anchor\" aria-label=\"Permalink: Steven Shorrock\" href=\"#steven-shorrock\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eShorrock is a chartered psychologist and a chartered ergonomist and human\nfactors specialist. He is the editor-in-chief of EUROCONTROL\n\u003ca href=\"https://www.skybrary.aero/index.php/HindSight_-_EUROCONTROL\" rel=\"nofollow\"\u003eHindSight\u003c/a\u003e\nmagazine. He runs the excellent \u003ca href=\"https://humanisticsystems.com/\" rel=\"nofollow\"\u003eHumanistic Systems\u003c/a\u003e blog.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eShorrock tweets as \u003ca href=\"https://twitter.com/StevenShorrock\" rel=\"nofollow\"\u003e@StevenShorrock\u003c/a\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-39\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-39\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://skybrary.aero/sites/default/files/bookshelf/2882.pdf\" rel=\"nofollow\"\u003eSystems Thinking for Safety: Ten Principles A White Paper Moving towards Safety-II\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.crcpress.com/Human-Factors-and-Ergonomics-in-Practice-Improving-System-Performance-and/Shorrock-Williams/p/book/9781472439253\" rel=\"nofollow\"\u003eHuman Factors and Ergonomics in Practice: Improving System Performance and Human Well-Being in the Real World\u003c/a\u003e (book)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1080/00140139.2021.1953615\" rel=\"nofollow\"\u003eState of science: evolving perspectives on ‘human error’\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected talks\u003c/h3\u003e\u003ca id=\"user-content-selected-talks-9\" class=\"anchor\" aria-label=\"Permalink: Selected talks\" href=\"#selected-talks-9\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://www.youtube.com/watch?v=STU3Or6ZU60\" rel=\"nofollow\"\u003eLife After Human Error\u003c/a\u003e (Velocity Europe 2014 keynote)\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eDiane Vaughan\u003c/h2\u003e\u003ca id=\"user-content-diane-vaughan\" class=\"anchor\" aria-label=\"Permalink: Diane Vaughan\" href=\"#diane-vaughan\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eVaughan is a sociology researcher who did a famous study of the NASA Challenger accident, concluding that it was the result of organizational failure rather than a technical failure. Specifically, production pressure overrode the rigorous scientific safety culture in place at NASA.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-22\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-22\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eStructural Secrecy: Organizational structure, processes, and information exchange patterns can systematically undermine the ability to \"see the whole picture\" and conceal risky decisions.\u003c/li\u003e\n\u003cli\u003eSocial Construction of Risk: Out of the necessity to balance risk with the associated reward, any group of people will develop efficient heuristics to solve the problems they face. The understanding of risk that faces one subgroup may not match that of another subgroup or of the whole group. The ability of an individual to change a social construction of risk, formed over years with good intentions and often with evidence, is limited. (Though the evidence is usually accurate, the conclusion might not be, leading to an inadvertent scientific paradigm.)\u003c/li\u003e\n\u003cli\u003eNormalization of Deviance: During operation of a complex system, inadvertent deviations from system design may occur and not result in a system failure. Because the intial construction of risk is usually conservative, the deviation is seen as showing that the system and its redundancies \"worked\", leading to a new accepted safe operating envelope.\u003c/li\u003e\n\u003cli\u003eSignals of potential danger: Information gained through the operation of a system that may indicate the system does not work as designed. Most risk constructions are based on a comprehensive understanding of the operation of the system, so information to the contrary is a sign that the system could leave the safe operation envelope in unexpected ways - a danger.\u003c/li\u003e\n\u003cli\u003eWeak signals, mixed signals, missed signals: signals of potential danger that have been interpreted as non-threats or acceptable risk because at the time they didn't represent a clear and present danger sufficient to overcome the Social Construction of Risk. Often, post-hoc, these are seen as causes due to cherry-picking - such signals were ignored before with no negative consequences.\u003c/li\u003e\n\u003cli\u003eCompetition for Scarce Resources: An ongoing need to justify investment to customers leads to Efficiency-Thoroughness Tradeoffs (ETTOs). In NASA's case, justifying the cost of the Space Shuttle program to taxpayers and their congressional representatives meant pressure to quickly develop payload delivery capability at the lowest cost possible.\u003c/li\u003e\n\u003cli\u003eBelief in Redundancy: Constructing risk from a signal of potential danger such that a redundant subsystem becomes part of the normal operating strategy for a primary subsystem. In NASA's case, signals that the primary O-ring assembly did not operate as expected formed an acceptable risk because a secondary O-ring would contain a failure. Redundancy was eliminated from the design in this construction of risk - the secondary system now became part of the primary system, eliminating system redundancy.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-40\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-40\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Challenger-Launch-Decision-Technology-Deviance/dp/022634682X/ref=sr_1_1?ie=UTF8\u0026amp;qid=1545966442\u0026amp;sr=8-1\u0026amp;keywords=diane+vaughan\" rel=\"nofollow\"\u003eThe Challenger Launch Decision: Risky Technology, Culture, and Deviance at\nNASA\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eBarry Turner\u003c/h2\u003e\u003ca id=\"user-content-barry-turner\" class=\"anchor\" aria-label=\"Permalink: Barry Turner\" href=\"#barry-turner\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://www.tandfonline.com/doi/pdf/10.1080/10245289508523441\" rel=\"nofollow\"\u003eTurner\u003c/a\u003e was a sociologist who greatly influenced the field of organization studies.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-41\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-41\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Man-Made-Disasters-Second-Barry-Turner/dp/0750620870/ref=sr_1_1\" rel=\"nofollow\"\u003eMan-made disasters\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eRobert L. Wears\u003c/h2\u003e\u003ca id=\"user-content-robert-l-wears\" class=\"anchor\" aria-label=\"Permalink: Robert L. Wears\" href=\"#robert-l-wears\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://en.wikipedia.org/wiki/Robert_Wears\" rel=\"nofollow\"\u003eWears\u003c/a\u003e was a medical researcher who also had a PhD in industrial safety.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-23\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-23\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eUnderground adaptations\u003c/li\u003e\n\u003cli\u003eArticulated functions vs. important functions\u003c/li\u003e\n\u003cli\u003eUnintended effects\u003c/li\u003e\n\u003cli\u003eApparent success vs real success\u003c/li\u003e\n\u003cli\u003eExceptions\u003c/li\u003e\n\u003cli\u003eDynamic environments\u003c/li\u003e\n\u003cli\u003eSystems of care are intrinsically hazardous\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-42\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-42\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://linkinghub.elsevier.com/retrieve/pii/S0196064408006070\" rel=\"nofollow\"\u003eThe error of counting \"errors\"\u003c/a\u003e \u003ca href=\"https://safety177496371.wordpress.com/2023/09/20/the-error-of-counting-errors/\" rel=\"nofollow\"\u003eBH\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1007/s10111-011-0207-2\" rel=\"nofollow\"\u003eUnderground adaptations: case studies from health care\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://books.openedition.org/pressesmines/1122\" rel=\"nofollow\"\u003eFundamental On Situational Surprise: A Case Study With Implications For Resilience\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.458.7283\u0026amp;rep=rep1\u0026amp;type=pdf\" rel=\"nofollow\"\u003eReplacing Hindsight With Insight: Toward Better Understanding of Diagnostic Failures\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://dx.doi.org/10.1016%2Fj.ssci.2014.02.007\" rel=\"nofollow\"\u003eSeeing patient safety ‘Like a State’\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://books.openedition.org/pressesmines/1122?lang=en\" rel=\"nofollow\"\u003eFundamental On Situational Surprise: A Case Study With Implications For Resilience\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/232191704_The_Role_of_Automation_in_Complex_System_Failures\" rel=\"nofollow\"\u003eThe Role of Automation in Complex System Failures\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pastel.archives-ouvertes.fr/pastel-00664145/document\" rel=\"nofollow\"\u003eExploring the Dynamics of Resilient Performance\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/1423/f18530599b9de186af0eee4852bb7e619384.pdf\" rel=\"nofollow\"\u003eExtemporaneous Adaptation to Evolving Complexity: A Case Study of Resilience in Healthcare\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/55\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1016/j.ress.2006.01.009\" rel=\"nofollow\"\u003eAutomation, interaction, complexity, and failure: A case study\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/profile/Robert-Wears/publication/225108705_Resilience_is_Not_Control_Healthcare_Crisis_Management_and_ICT/links/00b49532b2c7f3ed62000000/Resilience-is-Not-Control-Healthcare-Crisis-Management-and-ICT.pdf\" rel=\"nofollow\"\u003eResilience is not control: healthcare, crisis management, and ICT\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.annemergmed.com/article/S0196-0644(17)30874-0/fulltext\" rel=\"nofollow\"\u003eThe Secret Life of Policies\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.annemergmed.com/article/S0196-0644(13)01554-0/abstract\" rel=\"nofollow\"\u003eThe tragedy of adaptability\u003c/a\u003e \u003ca href=\"https://safety177496371.wordpress.com/2021/04/19/the-tragedy-of-adaptability/\" rel=\"nofollow\"\u003eBH\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.taylorfrancis.com/chapters/edit/10.1201/9781315605722-11/relying-resilience-much-good-thing-robert-wears-charles-vincent\" rel=\"nofollow\"\u003eRelying on resilience: too much of a good thing?\u003c/a\u003e \u003ca href=\"https://safety177496371.wordpress.com/2024/03/20/relying-on-resilience-too-much-of-a-good-thing/\" rel=\"nofollow\"\u003eBH\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.458.7283\u0026amp;rep=rep1\u0026amp;type=pdf\" rel=\"nofollow\"\u003eReplacing hindsight with insight: toward better understanding of diagnostic failures\u003c/a\u003e \u003ca href=\"https://safety177496371.wordpress.com/2024/02/26/replacing-hindsight-with-insight-toward-better-understanding-of-diagnostic-failures/\" rel=\"nofollow\"\u003eBH\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://safety177496371.wordpress.com/2024/10/29/the-science-of-human-factors-separating-fact-from-fiction/\" rel=\"nofollow\"\u003eThe science of human factors: separating fact from fiction\u003c/a\u003e \u003ca href=\"https://safety177496371.wordpress.com/2024/10/29/the-science-of-human-factors-separating-fact-from-fiction/\" rel=\"nofollow\"\u003eBH\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1016/j.apergo.2016.02.012\" rel=\"nofollow\"\u003eResilience skills as emergent phenomena: A study of emergency departments in Brazil and the United States\u003c/a\u003e \u003ca href=\"https://safety177496371.wordpress.com/2023/01/20/resilience-skills-as-emergent-phenomena-a-study-of-emergency-departments-in-brazil-and-the-united-states/\" rel=\"nofollow\"\u003eBH\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://qualitysafety.bmj.com/content/26/5/381\" rel=\"nofollow\"\u003eOur current approach to root cause analysis: is it contributing to our failure to improve patient safety?\u003c/a\u003e \u003ca href=\"https://safety177496371.wordpress.com/2021/03/18/our-current-approach-to-root-cause-analysis-is-it-contributing-to-our-failure-to-improve-patient-safety/\" rel=\"nofollow\"\u003eBH\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pmc.ncbi.nlm.nih.gov/articles/PMC1464040/\" rel=\"nofollow\"\u003eError Reduction and Performance Improvement in the Emergency Department through Formal Teamwork Training: Evaluation Results of the MedTeams Project\u003c/a\u003e \u003ca href=\"https://safety177496371.wordpress.com/2021/03/18/our-current-approach-to-root-cause-analysis-is-it-contributing-to-our-failure-to-improve-patient-safety/\" rel=\"nofollow\"\u003eBH\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.academia.edu/download/85660593/468.full.pdf\" rel=\"nofollow\"\u003eIn situ simulation: detection of safety threats and teamwork training in a high risk emergency department\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://europepmc.org/article/nbk/nbk43774\" rel=\"nofollow\"\u003e“Safeware”: Safety-Critical Computing and Health Care Information Technology\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://onlinelibrary.wiley.com/doi/pdf/10.1197/j.aem.2004.07.001\" rel=\"nofollow\"\u003eThe Illusion of Explanation\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.annemergmed.com/article/S0196-0644(07)01451-5/fulltext\" rel=\"nofollow\"\u003eThick Versus Thin: Description Versus Classification in Learning From Case Reviews\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.resilience-engineering-association.org/download/resources/symposium/symposium_2015/Wears_R.-Sutcliffe_K.-Safety-error-and-resilience-a-meta-narrative-review-Paper.pdf\" rel=\"nofollow\"\u003eSafety, Error, and Resilience: a Meta-narrative Review\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.taylorfrancis.com/chapters/edit/10.1201/9781315366838-18/resilient-procedures-oxymoron-innovation-robert-wears-garth-hunte\" rel=\"nofollow\"\u003eResilient Procedures: Oxymoron or Innovation?\u003c/a\u003e (\u003ca href=\"https://safetyinsights.org/2025/02/24/resilient-procedures-oxymoron-or-innovation/\" rel=\"nofollow\"\u003eBH\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.annemergmed.com/article/S0196-0644(15)01376-1/abstract\" rel=\"nofollow\"\u003eDesign Trumps Training\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected talks\u003c/h3\u003e\u003ca id=\"user-content-selected-talks-10\" class=\"anchor\" aria-label=\"Permalink: Selected talks\" href=\"#selected-talks-10\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=nV52yh6GDMg\" rel=\"nofollow\"\u003eDesign of resilient systems\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eDavid Woods\u003c/h2\u003e\u003ca id=\"user-content-david-woods\" class=\"anchor\" aria-label=\"Permalink: David Woods\" href=\"#david-woods\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e\u003ca href=\"https://u.osu.edu/csel/member-directory/david-woods/\" rel=\"nofollow\"\u003eWoods\u003c/a\u003e has a research background in cognitive systems engineering and did work\nresearching NASA accidents. He is one of the founders \u003ca href=\"http://www.adaptivecapacitylabs.com/\" rel=\"nofollow\"\u003eAdaptive Capacity\nLabs\u003c/a\u003e, a resilience engineering\nconsultancy.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eWoods tweets as \u003ca href=\"https://twitter.com/ddwoods2\" rel=\"nofollow\"\u003e@ddwoods2\u003c/a\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eContributions\u003c/h3\u003e\u003ca id=\"user-content-contributions-6\" class=\"anchor\" aria-label=\"Permalink: Contributions\" href=\"#contributions-6\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eWoods has contributed an enormous number of concepts.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eThe adaptive universe\u003c/h4\u003e\u003ca id=\"user-content-the-adaptive-universe\" class=\"anchor\" aria-label=\"Permalink: The adaptive universe\" href=\"#the-adaptive-universe\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eWoods uses \u003cem\u003ethe adaptive universe\u003c/em\u003e as a lens for understanding the behavior of\nall different kinds of systems.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eAll systems exist in a dynamic environment, and must adapt to change.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eA successful system will need to adapt by virtue of its success.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eSystems can be viewed as units of adaptive behavior (UAB) that interact. UABs\nexist at different scales (e.g., cell, organ, individual, group, organization).\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eAll systems have competence envelopes, which are constrained by boundaries.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eThe resilience of a system is determined by how it behaves when it comes near\nto a boundary.\u003c/p\u003e\n\u003cp dir=\"auto\"\u003eSee \u003ca href=\"https://www.youtube.com/playlist?list=PLvlZBj1NU_ikTy1ot30EbEbYMAoBf9eAt\" rel=\"nofollow\"\u003eResilience Engineering Short Course\u003c/a\u003e for more details.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch4 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eCharting adaptive cycles\u003c/h4\u003e\u003ca id=\"user-content-charting-adaptive-cycles\" class=\"anchor\" aria-label=\"Permalink: Charting adaptive cycles\" href=\"#charting-adaptive-cycles\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eTrigger\u003c/li\u003e\n\u003cli\u003eUnits of adaptive behavior\u003c/li\u003e\n\u003cli\u003eGoals and goal conflicts\u003c/li\u003e\n\u003cli\u003ePressure points\u003c/li\u003e\n\u003cli\u003eSubcycles\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eGraceful extensibility\u003c/h3\u003e\u003ca id=\"user-content-graceful-extensibility\" class=\"anchor\" aria-label=\"Permalink: Graceful extensibility\" href=\"#graceful-extensibility\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eFrom \u003ca href=\"https://www.researchgate.net/publication/327427067_The_Theory_of_Graceful_Extensibility_Basic_rules_that_govern_adaptive_systems\" rel=\"nofollow\"\u003eThe theory of graceful extensibility: basic rules that govern adaptive systems\u003c/a\u003e:\u003c/p\u003e\n\u003cp dir=\"auto\"\u003e(Longer wording)\u003c/p\u003e\n\u003col dir=\"auto\"\u003e\n\u003cli\u003eAdaptive capacity is finite\u003c/li\u003e\n\u003cli\u003eEvents will produce demands that challenge boundaries on the adaptive\ncapacity of any UAB\u003c/li\u003e\n\u003cli\u003eAdaptive capacities are regulated to manage the risk of saturating CfM\u003c/li\u003e\n\u003cli\u003eNo UAB can have sufficient ability to regulate CfM to manage the risk of saturation alone\u003c/li\u003e\n\u003cli\u003eSome UABs monitor and regulate the CfM of other UABs in response to changes\nin the risk of saturation\u003c/li\u003e\n\u003cli\u003eAdaptive capacity is the potential for adjusting patterns of action to\nhandle future situations, events, opportunities and disruptions\u003c/li\u003e\n\u003cli\u003ePerformance of a UAB as it approaches saturation is different from the\nperformance of that UAB when it operates far from saturation\u003c/li\u003e\n\u003cli\u003eAll UABs are local\u003c/li\u003e\n\u003cli\u003eThere are bounds on the perspective any UAB, but these limits are overcome\nby shifts and contrasts over multiple perspectives.\u003c/li\u003e\n\u003cli\u003eReflective systems risk mis-calibration\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp dir=\"auto\"\u003e(Shorter wording)\u003c/p\u003e\n\u003col dir=\"auto\"\u003e\n\u003cli\u003eBoundaries are universal\u003c/li\u003e\n\u003cli\u003eSurprise occurs, continuously\u003c/li\u003e\n\u003cli\u003eRisk of saturation is monitored and regulated\u003c/li\u003e\n\u003cli\u003eSynchronization across multiple units of adaptive behavior in a network is necessary\u003c/li\u003e\n\u003cli\u003eRisk of saturation can be shared\u003c/li\u003e\n\u003cli\u003ePressure changes what is sacrificed when\u003c/li\u003e\n\u003cli\u003ePressure for optimality undermines graceful extensibility\u003c/li\u003e\n\u003cli\u003eAll adaptive units are local\u003c/li\u003e\n\u003cli\u003ePerspective contrast overcomes bounds\u003c/li\u003e\n\u003cli\u003eMis-calibration is the norm\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp dir=\"auto\"\u003eFor more details, see \u003ca href=\"/lorin/resilience-engineering/blob/master/graceful-extensibility.md\"\u003esummary of graceful extensibility theorems\u003c/a\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSCAD (Systemic Contributors Analysis and Diagram)\u003c/h3\u003e\u003ca id=\"user-content-scad-systemic-contributors-analysis-and-diagram\" class=\"anchor\" aria-label=\"Permalink: SCAD (Systemic Contributors Analysis and Diagram)\" href=\"#scad-systemic-contributors-analysis-and-diagram\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003e(tbd)\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eConcepts\u003c/h3\u003e\u003ca id=\"user-content-concepts-24\" class=\"anchor\" aria-label=\"Permalink: Concepts\" href=\"#concepts-24\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eMany of these are mentioned in Woods's \u003ca href=\"https://www.youtube.com/playlist?list=PLvlZBj1NU_ikTy1ot30EbEbYMAoBf9eAt\" rel=\"nofollow\"\u003eshort course\u003c/a\u003e.\u003c/p\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eadaptive capacity\u003c/li\u003e\n\u003cli\u003eadaptive universe\u003c/li\u003e\n\u003cli\u003eunit of adaptive behavior (UAB), adaptive unit\u003c/li\u003e\n\u003cli\u003econtinuous adaptation\u003c/li\u003e\n\u003cli\u003egraceful extensibility\u003c/li\u003e\n\u003cli\u003esustained adaptability\u003c/li\u003e\n\u003cli\u003eTangled, layered networks (TLN)\u003c/li\u003e\n\u003cli\u003ecompetence envelope\u003c/li\u003e\n\u003cli\u003eadaptive cycles/histories\u003c/li\u003e\n\u003cli\u003eprecarious present (unease)\u003c/li\u003e\n\u003cli\u003eresilient future\u003c/li\u003e\n\u003cli\u003etradeoffs, five fundamental\u003c/li\u003e\n\u003cli\u003eefflorescence: the degree that changes in one area tend to recruit or open up\nbeneficial changes in many other aspects of the network - which opens new\nopportunities across the network ...\u003c/li\u003e\n\u003cli\u003ereverberation\u003c/li\u003e\n\u003cli\u003eadaptive stalls\u003c/li\u003e\n\u003cli\u003eborderlands\u003c/li\u003e\n\u003cli\u003eanticipate\u003c/li\u003e\n\u003cli\u003esynchronize\u003c/li\u003e\n\u003cli\u003eproactive learning\u003c/li\u003e\n\u003cli\u003einitiative\u003c/li\u003e\n\u003cli\u003ereciprocity\u003c/li\u003e\n\u003cli\u003eSNAFUs\u003c/li\u003e\n\u003cli\u003erobustness\u003c/li\u003e\n\u003cli\u003esurprise\u003c/li\u003e\n\u003cli\u003edynamic fault management\u003c/li\u003e\n\u003cli\u003esoftware systems as \"team players\"\u003c/li\u003e\n\u003cli\u003emulti-scale\u003c/li\u003e\n\u003cli\u003ebrittleness\u003c/li\u003e\n\u003cli\u003ehow adaptive systems fail (see: \u003ca href=\"https://www.researchgate.net/publication/286581322_How_do_systems_manage_their_adaptive_capacity_to_successfully_handle_disruptions_A_resilience_engineering_perspective\" rel=\"nofollow\"\u003eHow do systems manage their adaptive capacity to successfully handle disruptions? A resilience engineering perspective\u003c/a\u003e)\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003edecompensation\u003c/li\u003e\n\u003cli\u003eworking at cross-purposes\u003c/li\u003e\n\u003cli\u003egetting stuck in outdated behaviors\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/li\u003e\n\u003cli\u003eproactive learning vs getting stuck\u003c/li\u003e\n\u003cli\u003eoversimplification\u003c/li\u003e\n\u003cli\u003efixation\u003c/li\u003e\n\u003cli\u003efluency law, veil of fluency\u003c/li\u003e\n\u003cli\u003ecapacity for manoeuvre (CfM)\u003c/li\u003e\n\u003cli\u003ecrunches\u003c/li\u003e\n\u003cli\u003eturnaround test\u003c/li\u003e\n\u003cli\u003esharp end, blunt end\u003c/li\u003e\n\u003cli\u003eadaptive landscapes\u003c/li\u003e\n\u003cli\u003elaw of stretched systems: Every system is continuously stretched to operate at capacity.\u003c/li\u003e\n\u003cli\u003ecascades\u003c/li\u003e\n\u003cli\u003eadapt how to adapt\u003c/li\u003e\n\u003cli\u003eunit working hard to stay in control\u003c/li\u003e\n\u003cli\u003eyou can monitor how hard you're working to stay in control (monitor risk of saturation)\u003c/li\u003e\n\u003cli\u003ereality trumps algorithms\u003c/li\u003e\n\u003cli\u003estand down\u003c/li\u003e\n\u003cli\u003etime matters\u003c/li\u003e\n\u003cli\u003eProperties of resilient organizations\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003eTangible experience with surprise\u003c/li\u003e\n\u003cli\u003euneasy about the precarious present\u003c/li\u003e\n\u003cli\u003epush initiative down\u003c/li\u003e\n\u003cli\u003ereciprocity\u003c/li\u003e\n\u003cli\u003ealign goals across multiple units\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/li\u003e\n\u003cli\u003egoal conflicts, goal interactions (follow them!)\u003c/li\u003e\n\u003cli\u003eto understand system, must study it under load\u003c/li\u003e\n\u003cli\u003eadaptive races are unstable\u003c/li\u003e\n\u003cli\u003eadaptive traps\u003c/li\u003e\n\u003cli\u003eroles, nesting of\u003c/li\u003e\n\u003cli\u003ehidden interdependencies\u003c/li\u003e\n\u003cli\u003enet adaptive value\u003c/li\u003e\n\u003cli\u003ematching tempos\u003c/li\u003e\n\u003cli\u003etilt toward florescence\u003c/li\u003e\n\u003cli\u003elinear simplification\u003c/li\u003e\n\u003cli\u003ecommon ground\u003c/li\u003e\n\u003cli\u003eproblem detection\u003c/li\u003e\n\u003cli\u003ejoint cognitive systems\u003c/li\u003e\n\u003cli\u003eautomation as a \"team player\"\u003c/li\u003e\n\u003cli\u003e\"new look\"\u003c/li\u003e\n\u003cli\u003esacrifice judgment\u003c/li\u003e\n\u003cli\u003etask tailoring\u003c/li\u003e\n\u003cli\u003esubstitution myth\u003c/li\u003e\n\u003cli\u003eobservability\u003c/li\u003e\n\u003cli\u003edirectability\u003c/li\u003e\n\u003cli\u003edirected attention\u003c/li\u003e\n\u003cli\u003einter-predictability\u003c/li\u003e\n\u003cli\u003eerror of the third kind: solving the wrong problem\u003c/li\u003e\n\u003cli\u003ebuffering capacity\u003c/li\u003e\n\u003cli\u003econtext gap\u003c/li\u003e\n\u003cli\u003eNorbert's contrast\u003c/li\u003e\n\u003cli\u003eanomaly response\u003c/li\u003e\n\u003cli\u003eautomation surprises\u003c/li\u003e\n\u003cli\u003edisturbance management\u003c/li\u003e\n\u003cli\u003eDoyle's catch\u003c/li\u003e\n\u003cli\u003eCooperative advocacy\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-43\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-43\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/gp/product/B009KNDF64/ref=x_gr_w_glide_bb?ie=UTF8\u0026amp;tag=x_gr_w_glide_bb-20\u0026amp;linkCode=as2\u0026amp;camp=1789\u0026amp;creative=9325\u0026amp;creativeASIN=B009KNDF64\u0026amp;SubscriptionId=1MGPYB6YW3HWK55XCGG2\" rel=\"nofollow\"\u003eResilience Engineering: Concepts and Precepts\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://erikhollnagel.com/onewebmedia/Prologue.pdf\" rel=\"nofollow\"\u003ePrologue: Resilience Engineering Concepts\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/265074845_Epilogue_Resilience_Engineering_Precepts\" rel=\"nofollow\"\u003eEpilogue: Resilience Engineering Precepts\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/329035477_Resilience_is_a_Verb\" rel=\"nofollow\"\u003eResilience is a verb\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/276139783_Four_concepts_for_resilience_and_the_implications_for_the_future_of_resilience_engineering\" rel=\"nofollow\"\u003eFour concepts for resilience and the implications for the future of resilience engineering\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/65\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/284324002_Basic_patterns_in_how_adaptive_systems_fail\" rel=\"nofollow\"\u003eBasic patterns in how adaptive systems fail\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/34/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/285487326_Resilience_and_the_ability_to_anticipate\" rel=\"nofollow\"\u003eResilience and the ability to anticipate\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/resilience-and-the-ability-to-anticipate/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/292504703_Distancing_through_differencing_An_obstacle_to_organizational_learning_following_accidents\" rel=\"nofollow\"\u003eDistancing through differencing: An obstacle to organizational learning following accidents\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/284328979_Essential_characteristics_of_resilience\" rel=\"nofollow\"\u003eEssential characteristics of resilience\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/330116587_4_Essentials_of_resilience_revisited\" rel=\"nofollow\"\u003eEssentials of resilience, revisited\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/71/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/19980016965.pdf\" rel=\"nofollow\"\u003eLearning from Automation Surprises and \"Going Sour\" Accidents: Progress on Human-Centered Automation\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/Behind-Human-Error-David-Woods/dp/0754678342\" rel=\"nofollow\"\u003eBehind Human Error\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/gp/product/0849339332/ref=x_gr_w_bb?ie=UTF8\u0026amp;tag=x_gr_w_bb-20\u0026amp;linkCode=as2\u0026amp;camp=1789\u0026amp;creative=9325\u0026amp;creativeASIN=0849339332\u0026amp;SubscriptionId=1MGPYB6YW3HWK55XCGG2\" rel=\"nofollow\"\u003eJoint Cognitive Systems: Patterns in Cognitive Systems Engineering\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/262449980_Patterns_in_Cooperative_Cognition\" rel=\"nofollow\"\u003ePatterns in Cooperative Cognition\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/298793082_Origins_of_Cognitive_Systems_Engineering\" rel=\"nofollow\"\u003eOrigins of cognitive systems engineering\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/292504952_Incidents_-_markers_of_resilience_or_brittleness\" rel=\"nofollow\"\u003eIncidents - markers of resilience or brittleness?\u003c/a\u003e \u003ca href=\"https://safety177496371.wordpress.com/2023/12/18/incidents-markers-of-resilience-or-brittleness/\" rel=\"nofollow\"\u003eBH\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/40961767_The_Alarm_problem_and_directed_attention_in_dynamic_fault_management\" rel=\"nofollow\"\u003eThe alarm problem and directed attention in dynamic fault management\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://journals.sagepub.com/doi/abs/10.1177/1555343416637520?journalCode=edma\" rel=\"nofollow\"\u003eCan We Trust Best Practices? Six Cognitive Challenges of Evidence-Based Approaches\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/313407259_Operating_at_the_Sharp_End_The_Complexity_of_Human_Error\" rel=\"nofollow\"\u003eOperating at the Sharp End: The Complexity of Human Error\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/327427067_The_Theory_of_Graceful_Extensibility_Basic_rules_that_govern_adaptive_systems\" rel=\"nofollow\"\u003eThe theory of graceful extensibility: basic rules that govern adaptive systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/220628177_Beyond_Simon%27s_Slice_Five_Fundamental_Trade-Offs_that_Bound_the_Performance_of_Macrocognitive_Work_Systems\" rel=\"nofollow\"\u003eBeyond Simon’s Slice: Five Fundamental Trade-Offs that Bound the Performance of Macrocognitive Work Systems\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/five-fundamental-trade-offs-in-cognitive-work/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/247512351_Anticipating_the_effects_of_technological_change_A_new_era_of_dynamics_for_human_factors\" rel=\"nofollow\"\u003eAnticipating the effects of technological change: A new era of dynamics for human factors\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://jeffreymbradshaw.net/publications/Common_Ground_Single.pdf\" rel=\"nofollow\"\u003eCommon Ground and Coordination in Joint Activity\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.irgc.org/wp-content/uploads/2016/04/Woods-Resilience-as-Graceful-Extensibility-to-Overcome-Brittleness-1.pdf\" rel=\"nofollow\"\u003eResilience as Graceful Extensibility to Overcome Brittleness\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://ordvac.com/soro/library/Aviation/Aviation%20Safety/General%20Safety%20Articles/resilience%20engineering%20bulletin.pdf\" rel=\"nofollow\"\u003eResilience Engineering: Redefining the Culture of Safety and Risk Management\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/220579480_Problem_detection\" rel=\"nofollow\"\u003eProblem detection\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://ntrs.nasa.gov/search.jsp?R=19910011398\" rel=\"nofollow\"\u003eCognitive consequences of clumsy automation on high workload, high consequence human performance\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1016/S0952-8180(96)90009-4\" rel=\"nofollow\"\u003eImplications of automation surprises in aviation for the future of total intravenous anesthesia (TIVA)\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://ieeexplore.ieee.org/abstract/document/1363742\" rel=\"nofollow\"\u003eTen challenges for making automation a team player\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/66\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1109%2FTSMCA.2004.836802\" rel=\"nofollow\"\u003eThe Messy Details: Insights From the Study of Technical Work in Healthcare\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/profile/David_Woods11/publication/224649052_Nosocomial_automation_technology-induced_complexity_and_human_performance/links/59399b1da6fdcc58ae902c49/Nosocomial-automation-technology-induced-complexity-and-human-performance.pdf\" rel=\"nofollow\"\u003eNosocomial automation: technology-induced complexity and human performance\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://www.ifp.illinois.edu/nsfhcs/abstracts/woods.txt\" rel=\"nofollow\"\u003eHuman-centered software agents: Lessons from clumsy automation\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://snafucatchers.github.io/\" rel=\"nofollow\"\u003eSTELLA: Report from the SNAFUcatchers Workshop on Coping with Complexity\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/67f7/53ec089e5a8879f241e2be867dad0a2026fb.pdf\" rel=\"nofollow\"\u003eThe New Look at Error, Safety, and Failure: A Primer for Health Care\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/1bed/356b5aa67c701f5bad6d943768622095f418.pdf\" rel=\"nofollow\"\u003eGrounding explanations in evolving, diagnostic situations\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.amazon.com/gp/product/B009KNDF64/ref=x_gr_w_glide_bb?ie=UTF8\u0026amp;tag=x_gr_w_glide_bb-20\u0026amp;linkCode=as2\u0026amp;camp=1789\u0026amp;creative=9325\u0026amp;creativeASIN=B009KNDF64\u0026amp;SubscriptionId=1MGPYB6YW3HWK55XCGG2\" rel=\"nofollow\"\u003eResilience Engineering: Concepts and Precepts\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/245102691_A_Tale_of_Two_Stories_Contrasting_Views_of_Patient_Safety\" rel=\"nofollow\"\u003eA Tale of Two Stories: Contrasting Views of Patient Safety\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.semanticscholar.org/paper/Voice-Loops-as-Coordination-Aids-in-Space-Shuttle-Patterson-Watts-Perotti/068dfee1a859a63fa2ef82f008d239e6a81ed004\" rel=\"nofollow\"\u003eVoice Loops as Coordination Aids in Space Shuttle Mission Control\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://journals.sagepub.com/doi/abs/10.1177/154193129403801702\" rel=\"nofollow\"\u003eThe Critical Incident Technique: 40 Years Later\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/3657906_Functionally_distributed_coordination_during_anomaly_response_inspace_shuttle_mission_control\" rel=\"nofollow\"\u003eFunctionally distributed coordination during anomaly response in space shuttle mission control\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/225211285_Cooperative_Advocacy_An_Approach_for_Integrating_Diverse_Perspectives_in_Anomaly_Response\" rel=\"nofollow\"\u003eCooperative Advocacy: An Approach for Integrating Diverse Perspectives in Anomaly Response\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/222737388_Visual_Momentum_A_Concept_to_Improve_the_Cognitive_Coupling_of_Person_and_Computer\" rel=\"nofollow\"\u003eVisual momentum: A concept to improve the cognitive coupling of person and computer\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/262401824_Cognitive_demands_and_activities_in_dynamic_fault_management_abductive_reasoning_and_disturbance_management\" rel=\"nofollow\"\u003eCognitive demands and activities in dynamic fault management: abductive reasoning and disturbance management\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/238727732_Coping_with_Complexity_The_psychology_of_human_behavior_in_complex_systems\" rel=\"nofollow\"\u003eCoping with complexity: the psychology of human behaviour in complex systems\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/coping-with-complexity/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/profile/David_Woods11/publication/232513565_Process-tracing_methods_for_the_study_of_cognition_outside_of_the_experimental_psychology_laboratory/links/00b7d53988a2f7a7f8000000.pdf\" rel=\"nofollow\"\u003eProcess Tracing Methods for The Study of Cognition Outside of the Experimental Laboratory. In Klein GA, Orasanu J, Calderwood R, Zsambok CE, eds. Decision making in action: Models\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/239059408_Towards_a_theoretical_base_for_representation_design_in_the_computer_medium_ecological_perception_and_aiding_human_cognition\" rel=\"nofollow\"\u003eTowards a theoretical base for representation design in the computer medium: ecological perception and aiding human cognition\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.nifc.gov/PUBLICATIONS/acc_invest_march2010/speakers/Perspectives%20on%20Human%20Error.pdf\" rel=\"nofollow\"\u003ePerspectives on Human Error: Hindsight Biases and Local Rationality\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://docs.wixstatic.com/ugd/3ad081_f46dda684154447583c8a5b282b60cc2.pdf\" rel=\"nofollow\"\u003eAnomaly Response\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/303832480_The_Risks_of_Autonomy_Doyles_Catch\" rel=\"nofollow\"\u003eThe Risks of Autonomy: Doyle's Catch\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/the-risks-of-autonomy-doyles-catch/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/328149714_Mistaking_Error\" rel=\"nofollow\"\u003eMistaking Error\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/14230576_Adapting_to_New_Technology_in_the_Operating_Room\" rel=\"nofollow\"\u003eAdapting to new technology in the operating room\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/330196218_The_Strategic_Agility_Gap_How_organizations_are_slow_and_stale_to_adapt_in_turbulent_worlds\" rel=\"nofollow\"\u003eThe Strategic Agility Gap: How organizations are slow and stale to adapt in turbulent worlds\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/330222613_Resiliency_Trade_Space_Study_The_Interaction_of_Degraded_C2_Link_and_Detect_and_Avoid_Autonomy_on_Unmanned_Aircraft\" rel=\"nofollow\"\u003eResiliency Trade Space Study: The Interaction of Degraded C2 Link and Detect and Avoid Autonomy on Unmanned Aircraft\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/220604613_Cognitive_Technologies_The_Design_of_Joint_Human-Machine_Cognitive_Systems\" rel=\"nofollow\"\u003eCognitive Technologies: The Design of Joint Human-Machine Cognitive Systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.ida.liu.se/~729A15/mtrl/CSEnew.pdf?utm_campaign=Resilience%20Roundup\u0026amp;utm_medium=email\u0026amp;utm_source=Revue%20newsletter\" rel=\"nofollow\"\u003eCognitive Systems Engineering: New wine in new bottles\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/32/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/260304859_The_Seven_Deadly_Myths_of_Autonomous_Systems\" rel=\"nofollow\"\u003eThe Seven Deadly Myths of \"Autonomous Systems\"\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/285487326_Resilience_and_the_ability_to_anticipate\" rel=\"nofollow\"\u003eResilience and the ability to anticipate\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/262449980_Patterns_in_Cooperative_Cognition\" rel=\"nofollow\"\u003ePatterns in Cooperative Cognition\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/220579448_Collaborative_Cross-Checking_to_Enhance_Resilience\" rel=\"nofollow\"\u003eCollaborative Cross-Checking to Enhance Resilience\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/73/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/a0d3/9cc66adc64e297048a32b71aeee209a451af.pdf\" rel=\"nofollow\"\u003eResilience Engineering: New directions for measuring and maintaining safety in complex systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/3454029_A_rose_by_any_other_namewould_probably_be_given_an_acronym\" rel=\"nofollow\"\u003eA rose by any other name...would probably be given an acronym\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/286581322_How_do_systems_manage_their_adaptive_capacity_to_successfully_handle_disruptions_A_resilience_engineering_perspective\" rel=\"nofollow\"\u003eHow do systems manage their adaptive capacity to successfully handle disruptions? A resilience engineering perspective\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://csel.eng.ohio-state.edu/productions/laws/laws_mediapaper/2_4_escalation.pdf\" rel=\"nofollow\"\u003eHow Unexpected Events Produce An Escalation Of Cognitive And Coordinative Demands\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/how-unexpected-events-produce-an-escalation-of-cognitive-and-coordinative-demands/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/profile/David_Woods11/publication/2483863_How_to_Make_Automated_Systems_Team_Players/links/5a4f829eaca272940bf8202c/How-to-Make-Automated-Systems-Team-Players.pdf\" rel=\"nofollow\"\u003eHow to Make Automated Systems Team Players\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/3454245_Toward_a_Theory_of_Complex_and_Cognitive_Systems\" rel=\"nofollow\"\u003eToward a Theory of Complex and Cognitive Systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/308194080_Multiple_Systemic_Contributors_versus_Root_Cause_Learning_from_a_NASA_Near_Miss\" rel=\"nofollow\"\u003eMultiple systemic contributors versus root cause: learning from a NASA Near Miss\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/313737506_Bootstrapping_multiple_converging_cognitive_task_analysis_techniques_for_system_design\" rel=\"nofollow\"\u003eBootstrapping multiple converging cognitive task analysis techniques for system design\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/70\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/2484621_New_Arctic_Air_Crash_Aftermath_Role-Play_Simulation_Orchestrating_a_Fundamental_Surprise\" rel=\"nofollow\"\u003eNew Arctic Air Crash Aftermath Role-Play Simulation Orchestrating a Fundamental Surprise\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/220108174_Mapping_Cognitive_Demands_in_Complex_Problem-Solving_Worlds%3CPaste%3E\" rel=\"nofollow\"\u003eMapping Cognitive Demands in Complex Problem-Solving Worlds\u003c/a\u003e (mentions disturbance management)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/290071190_Fixation_Errors_Failures_to_Revise_Situation_Assessment_in_Dynamic_and_Risky_Systems\" rel=\"nofollow\"\u003eFixation Errors: Failures to Revise Situation Assessment in Dynamic and Risky Systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://csel.eng.ohio-state.edu/productions/pexis/readings/submod4/nine%20steps%20CTW2002.pdf\" rel=\"nofollow\"\u003eNine Steps to Move Forward From Error\u003c/a\u003e \u003ca href=\"https://safety177496371.wordpress.com/2022/11/03/nine-steps-to-move-forward-from-error/\" rel=\"nofollow\"\u003eBH\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/8648890_Handoff_strategies_in_settings_with_high_consequences_for_failure_Lessons_for_health_care_operations\" rel=\"nofollow\"\u003eHandoff strategies in settings with high consequences for failure: lessons for health care operations\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/56\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://sidneydekker.com/wp-content/uploads/2013/01/CH005.pdf\" rel=\"nofollow\"\u003eThe High Reliability Organization Perspective\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/09/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/270960170_Automation_surprises\" rel=\"nofollow\"\u003eAutomation surprises\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1016/j.ress.2019.106740\" rel=\"nofollow\"\u003eSafety II professionals: How resilience engineering can transform safety practice\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/64/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117777/\" rel=\"nofollow\"\u003eGaps in the continuity of care and progress on patient safety\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/250890631_Systems_with_Human_Monitors_A_Signal_Detection_Analysis\" rel=\"nofollow\"\u003eSystems with human monitors: a signal detection analysis\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.sciencedirect.com/science/article/abs/pii/095183209090022F\" rel=\"nofollow\"\u003eOn taking human performance seriously\u003c/a\u003e, 1990\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://doi.org/10.1016/j.burns.2018.12.003\" rel=\"nofollow\"\u003eBeyond surge: Coping with mass burn casualty in the closest hospital to the Formosa Fun Coast Dust Explosion\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/284173210_Designing_for_Expertise\" rel=\"nofollow\"\u003eDesigning for Expertise\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/334267822_Steering_the_Reverberations_of_Technology_Change_on_Fields_of_Practice_Laws_that_Govern_Cognitive_Work\" rel=\"nofollow\"\u003eSteering the Reverberations of Technology Change on Fields of Practice: Laws that Govern Cognitive Work\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/steering-the-reverberations-of-technology-change-on-fields-of-practice-laws-that-govern-cognitive-work/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/profile/David_Woods11/publication/225921479_Distant_Supervision-Local_Action_Given_the_Potential_for_Surprise/links/0a85e53baa4009ad8e000000/Distant-Supervision-Local-Action-Given-the-Potential-for-Surprise.pdf\" rel=\"nofollow\"\u003eDistant Supervision–Local Action Given the Potential for Surprise\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/75/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/335366770_Coping_With_a_Mass_Casualty_Insights_into_a_Hospital's_Emergency_Response_and_Adaptations_After_the_Formosa_Fun_Coast_Dust_Explosion\" rel=\"nofollow\"\u003eCoping With a Mass Casualty: Insights into a Hospital’s Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/76/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://aaclab.mit.edu/resources/FarjadianAnnaswamyWoods2019.pdf\" rel=\"nofollow\"\u003eA Shared Pilot-Autopilot Control Architecture for Resilient Flight\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/a-shared-pilot-autopilot-control-architecture-for-resilient-flight/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/12195752_Team_Play_with_a_Powerful_and_Independent_Agent_A_Full-Mission_Simulation_Study\" rel=\"nofollow\"\u003eTeam Play with a Powerful and Independent Agent: A Full-Mission Simulation Study\u003c/a\u003e (\u003ca href=\"https://resilienceroundup.com/issues/team-play-with-a-powerful-and-independent-agent-a-full-mission-simulation-study/\" rel=\"nofollow\"\u003eTWRR\u003c/a\u003e)\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/239030256_How_Not_to_Have_to_Navigate_Through_Too_Many_Displayjjs\" rel=\"nofollow\"\u003eHow Not to Have to Navigate Through Too Many Displays\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/251196422_Discovering_How_Distributed_Cognitive_Systems_Work\" rel=\"nofollow\"\u003eDiscovering How Distributed Cognitive Systems Work\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://dx.doi.org/10.13140/RG.2.2.29675.36648\" rel=\"nofollow\"\u003eHuman Performance in Anesthesia\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/profile/David-Woods-19/publication/jjgg255648297_Creating_Foresight_Lessons_for_Enhancing_Resilience_from_Columbia/links/542becf50cf29bbc126ac095/Creating-Foresight-Lessons-for-Enhancing-Resilience-from-Columbia.pdf\" rel=\"nofollow\"\u003eCreating Foresight: Lessons for Enhancing Resilience from Columbia\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://faculty.washington.edu/roesler/publications/design_cycle2005.pdf\" rel=\"nofollow\"\u003eInventing the Future of Cognitive Work: Navigating the \"Northwest Passage\"\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.sciencedirect.com/science/article/abs/pii/S0951832015000812\" rel=\"nofollow\"\u003eA practitioner’s experiences operationalizing Resilience Engineering\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/228809190_Understanding_rigor_in_information_analysis\" rel=\"nofollow\"\u003eUnderstanding rigor in information analysis\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/347964304_Human_Performance_in_Anesthesia_Human_Performance_in_Anesthesia_Human_Performance_in_Anesthesia\" rel=\"nofollow\"\u003eHuman Performance in Anesthesia: A Corpus of Cases\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://europepmc.org/article/NBK/nbk43670\" rel=\"nofollow\"\u003eMinding the Gaps: Creating Resilience in Health Care\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://citeseerx.ist.psu.edu/document?repid=rep1\u0026amp;type=pdf\u0026amp;doi=ffe74633027ee354ebbf0ff9a6418e75f3b7a047\" rel=\"nofollow\"\u003eFrom Counting Failures to Anticipating Risks: Possible Futures for Patient Safety\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pdfs.semanticscholar.org/a0d3/9cc66adc64e297048a32b71aeee209a451af.pdf\" rel=\"nofollow\"\u003eResilience Engineering: New directions for measuring and maintaining safety in complex systems\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://citeseerx.ist.psu.edu/document?repid=rep1\u0026amp;type=pdf\u0026amp;doi=15f31969c4e1f4f599c5c68aa63f3bf930e0406f\" rel=\"nofollow\"\u003eBehind Human Error: Taming Complexity to Improve Patient Safety\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.researchgate.net/publication/239357782_Escaping_failures_of_foresight\" rel=\"nofollow\"\u003eEscaping failures of foresight\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://thebulletin.org/2025/05/the-silicon-valley-way-move-fast-and-breakaviation-safety/\" rel=\"nofollow\"\u003eThe Silicon Valley Way: Move fast and break…aviation safety?\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected talks\u003c/h3\u003e\u003ca id=\"user-content-selected-talks-11\" class=\"anchor\" aria-label=\"Permalink: Selected talks\" href=\"#selected-talks-11\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=GnVXfgC-5Jw\u0026amp;feature=youtu.be\" rel=\"nofollow\"\u003eOverview of resilience engineering\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://vimeo.com/104759707\" rel=\"nofollow\"\u003eCreating safety by engineering resilience\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=7STcaWjJoww\" rel=\"nofollow\"\u003eThe Mystery of Sustained Adaptability\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=V2qj5gMsjrU\" rel=\"nofollow\"\u003eResilience is a verb\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=KJJ2NCjc2Wg\" rel=\"nofollow\"\u003eComplexity workshop keynote\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=QSiXEZLZ1y0\u0026amp;t=6s\" rel=\"nofollow\"\u003eDe-Confounding Reliability, Robustness, and Resilience\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.c-span.org/video/?c4531343/user-clip-david-woods-senate-hearing\" rel=\"nofollow\"\u003e2003 Senate Hearing testimony\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=ZuLUp94wki4\" rel=\"nofollow\"\u003eShock and Resilience\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=vlYtd-eUjY8\" rel=\"nofollow\"\u003eHedging bets\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://youtu.be/OwdMgEf2MsA\" rel=\"nofollow\"\u003eREA 2021\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.youtube.com/watch?v=fbwDnpuys7w\" rel=\"nofollow\"\u003eAdobe Summit Talk: Why do reliable systems fail?\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://resiliencefoundations.github.io/overview.html\" rel=\"nofollow\"\u003eResilience Foundations videos\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eOnline courses\u003c/h3\u003e\u003ca id=\"user-content-online-courses\" class=\"anchor\" aria-label=\"Permalink: Online courses\" href=\"#online-courses\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 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class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch2 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eJohn Wreathall\u003c/h2\u003e\u003ca id=\"user-content-john-wreathall\" class=\"anchor\" aria-label=\"Permalink: John Wreathall\" href=\"#john-wreathall\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cp dir=\"auto\"\u003eWreathall is an expert in human performance in safety. He works at the\n\u003ca href=\"http://www.wreathall.com/\" rel=\"nofollow\"\u003eWreathWood Group\u003c/a\u003e, a risk and safety studies\nconsultancy.\nWreathall tweets as \u003ca href=\"https://twitter.com/wreathall\" rel=\"nofollow\"\u003e@wreathall\u003c/a\u003e.\u003c/p\u003e\n\u003cdiv class=\"markdown-heading\" dir=\"auto\"\u003e\u003ch3 tabindex=\"-1\" class=\"heading-element\" dir=\"auto\"\u003eSelected publications\u003c/h3\u003e\u003ca id=\"user-content-selected-publications-44\" class=\"anchor\" aria-label=\"Permalink: Selected publications\" href=\"#selected-publications-44\"\u003e\u003csvg data-component=\"Octicon\" class=\"octicon octicon-link\" viewBox=\"0 0 16 16\" version=\"1.1\" width=\"16\" height=\"16\" aria-hidden=\"true\"\u003e\u003cpath d=\"m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z\"\u003e\u003c/path\u003e\u003c/svg\u003e\u003c/a\u003e\u003c/div\u003e\n\u003cul dir=\"auto\"\u003e\n\u003cli\u003e\u003ca href=\"https://www.crcpress.com/Resilience-Engineering-in-Practice-A-Guidebook/Paries-Wreathall-Hollnagel/p/book/9781472420749\" rel=\"nofollow\"\u003eResilience engineering in practice: a guidebook\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/article\u003e","richTextTruncated":false,"renderedFileInfo":null,"symbols":{"timed_out":false,"not_analyzed":false,"symbols":[{"name":"Resilience engineering papers","fully_qualified_name":"Resilience engineering 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Resilience engineering papers","","## Overview","","Alias: \u003chttp://resiliencepapers.club\u003e (thanks to [John Allspaw](https://twitter.com/allspaw)).","","This doc contains notes about people active in resilience engineering, as well as some influential","researchers who are no longer with us, organized alphabetically. It also includes people and papers","from related fields, such as cognitive systems engineering and naturalistic decision-making.","","If you're not sure what to read first, check out [Resilience engineering: Where do I start?](intro.md)","","## Annotations","","A [BH](https://safety177496371.wordpress.com/) link indicates Ben Hutchinson's [Safety \u0026 Performance Research Summaries](https://safety177496371.wordpress.com/) blog.","Ben writes summaries of safety papers, posting them to his blog as well as LinkedIOn.","","A [TWRR](http://resilienceroundup.com) link indicates Thai Wood's [Resilience Roundup](http://resilienceroundup.com). Thai publishes a newsletter that","summarizes resilience engineering papers.","","## Other interesting links","","[resilienceinsoftware.org](https://resilienceinsoftware.org) is the Resilience in Software Foundation, a community of software people who are interested in resilience engineering.","","","For a collection of talks, check out the [Resilience Engineering, Cognitive Systems","Engineering, and Human Factors Concepts in Software","Contexts](https://www.youtube.com/playlist?list=PLb1aZTnPf3-OMChMkrr6WsokRI6LOnuem)","YouTube playlist maintained by John Allspaw.","","You might also be interested in my [notes on David Woods's Resilience Engineering short course](https://github.com/lorin/res-eng-short-course-notes).","","The papers linked here are also in the [zotero res-eng group](https://www.zotero.org/groups/2335189/res-eng/items).","","## People","","For each person, I list concepts that they reference in their writings, along","with some publications. The publications lists aren't comprehensive:","they're ones I've read or have added to my to-read list.","","* [Colette Alexander](#colette-alexander) ","* [John Allspaw](#john-allspaw)","* [Lisanne Bainbridge](#lisanne-bainbridge)","* [Andrea Baker](#andrea-baker)","* [E. Asher Balkin](#e-asher-balkin)","* [Johan Bergström](#johan-bergström)","* [Matthieu Branlat](#matthieu-branlat)","* [Sheuwen Chuang](#sheuwen-chuang)","* [Todd Conklin](#todd-conklin)","* [Richard I. Cook](#richard-i-cook)","* [Sidney Dekker](#sidney-dekker)","* [Jessica Devita](#jessica-devita)","* [John C. Doyle](#john-c-doyle)","* [Bob Edwards](#bob-edwards)","* [Anders Ericsson](#anders-ericsson)","* [Paul Feltovich](#paul-feltovich)","* [Pedro Ferreira](http://www.resilience-engineering-association.org/user/pedro/)","* [Meir Finkel](#meir-finkel)","* [Marisa Grayson](#marisa-grayson)","* [Ivonne Andrade Herrera](#ivonne-andrade-herrera)","* [Cat Hicks](#cat-hicks)","* [Robert Hoffman](#robert-hoffman)","* [Erik Hollnagel](#erik-hollnagel)","* [Leila Johannesen](#leila-johannesen)","* [Gary Klein](#gary-klein)","* [Elizabeth Lay](#elizabeth-lay)","* [Jean-Christophe Le Coze](#jean-christophe-le-coze)","* [Nancy Leveson](#nancy-leveson)","* [Beth Adele Long](#beth-long)","* [Carl Macrae](#carl-macrae)","* [Laura Maguire](#laura-maguire)","* [Courtney Nash](#courtney-nash)","* [Christopher Nemeth](#christopher-nemeth)","* [Anne-Sophie Nyssen](#anne-sophie-nyssen)","* [Elinor Ostrom](#elinor-ostrom)","* [Jean Pariès](#jean-paries)","* [Emily Patterson](#emily-patterson)","* [Charles Perrow](#charles-perrow)","* [Shawna J. Perry](#shawna-j-perry)","* [Jens Rasmussen](#jens-rasmussen)","* [Mike Rayo](#mike-rayo)","* [James Reason](#james-reason)","* [J. Paul Reed](#j-paul-reed)","* [Emilie M. Roth](#emilie-m-roth)","* [Nadine Sarter](#nadine-sarter)","* [James C. Scott](#james-c-scott)","* [Steven Shorrock](#steven-shorrock)","* [Barry Turner](#barry-turner)","* [Diane Vaughan](#diane-vaughan)","* [Robert L. Wears](#robert-l-wears)","* [David Woods](#david-woods)","* [John Wreathall](#john-wreathall)","","## Some big ideas","","* [The adaptive universe](#the-adaptive-universe) (David Woods)","* [Dynamic safety model](#dynamic-safety-model) (Jens Rasmussen)","* [Safety-II](#safety-i-vs-safety-ii) (Erik Hollnagel)","* [Graceful extensibility](#graceful-extensibility) (David Woods)","* [ETTO: Efficiency-tradeoff principle](#etto-principle) (Erik Hollnagel)","* [Drift into failure](#drift-into-failure) (Sidney Dekker)","* Robust yet fragile (John C. Doyle)","* [STAMP: Systems-Theoretic Accident Model \u0026 Process](#stamp) (Nancy Leveson)","* Polycentric governance (Elinor Ostrom)","","Note: there are now [multiple contributors](https://github.com/lorin/resilience-engineering/graphs/contributors) to this repository.","","## Colette Alexander","[Alexander](https://www.linkedin.com/in/colette-alexander-4168267/) is a Director of Engineering and researcher who previously held roles with IBM, Spotify, Cognite, and HashiCorp. She hosts the podcast This is Fine with co-host Clint Byrum. ","She completed a Masters thesis at Lund titled [Risky Business: Quantitative Risk Assessments as Enabling Devices in Cybersecurity](https://lup.lub.lu.se/luur/download?func=downloadFile\u0026recordOId=9148570\u0026fileOId=9148571). ","","","## John Allspaw","","Allspaw is the former CTO of Etsy. He applies concepts from resilience engineering to the tech industry.","He is one of the founders [Adaptive Capacity Labs](http://www.adaptivecapacitylabs.com/), a resilience engineering consultancy.","","Allspaw tweets as [@allspaw](https://twitter.com/allspaw).","","### Selected publications","","* [STELLA: Report from the SNAFUcatchers Workshop on Coping with Complexity](https://snafucatchers.github.io/)","* [Trade-Offs Under Pressure: Heuristics and Observations Of Teams Resolving Internet Service Outages](https://www.researchgate.net/publication/295011072_Trade-Offs_Under_Pressure_Heuristics_and_Observations_Of_Teams_Resolving_Internet_Service_Outages)","* [Etsy Debrief Facilitation Guide](http://extfiles.etsy.com/DebriefingFacilitationGuide.pdf)","* [Blameless PostMortems and a Just Culture](https://codeascraft.com/2012/05/22/blameless-postmortems/) (blog)","* [Resilience engineering: learning to embrace failure](https://doi.org/10.1145/2366316.2366331)","* [Fault Injection in Production: Making the case for resiliency testing](http://queue.acm.org/detail.cfm?id=2353017)","* [Technical Debt: Challenges and Perspectives](https://doi.org/10.1109/MS.2017.99)","* [Revealing the Critical Role of Human Performance in Software](https://queue.acm.org/detail.cfm?id=3380776)","* [SRE Cognitive Work] in [Seeking SRE]","* [The infinite hows: An argument against the Five Whys and an alternative approach you can apply](https://www.oreilly.com/radar/the-infinite-hows/)","","[SRE Cognitive Work]: https://www.researchgate.net/publication/343430302_SRE_Cognitive_Work","[Seeking SRE]: https://www.oreilly.com/library/view/seeking-sre/9781491978856/","","### Selected talks","","* [Resilience Engineering: The What and How](https://devopsdays.org/events/2019-washington-dc/program/john-allspaw/)","* [Incidents as we Imagine Them Versus How They Actually Are](https://www.youtube.com/watch?v=8DtzmV1jiyQ)","* [How your systems keep running day after day](https://www.youtube.com/watch?v=xA5U85LSk0M)","* [Problem detection (papers we love)](https://www.youtube.com/watch?v=NxctiGRI2y8)"," (presentation of [Problem detection] paper)","* [Common Ground and Coordination in Joint Activity (papers we love)](https://paperswelove.org/2016/video/john-allspaw-common-ground/) (presentation of [Common Ground and Coordination in Joint Activity] paper)","* [Amplifying sources of resilience](https://www.infoq.com/presentations/resilience-thinking-paradigm/) (presentation about applying Resilience Engineering thinking \u0026 paradigms to the world of software engineering)","* [Incidents: What Is Often Missed \u0026 What Can Be Done About That](https://www.adaptivecapacitylabs.com/blog/2020/03/30/incidents-what-is-often-missed-what-can-be-done-about-that/#fvp_10,1s)","* [Incident Analysis: How *Learning* is Different Than *Fixing*](https://www.adaptivecapacitylabs.com/blog/2020/05/06/how-learning-is-different-than-fixing/)","","","## Lisanne Bainbridge","","Bainbridge is a psychology researcher. She has a website at http://www.complexcognition.co.uk/","","### Contributions","","#### Ironies of automation","","Bainbridge is famous for her 1983 [Ironies of automation] paper, which continues to","be frequently cited.","","## Concepts","* automation","* design errors","* human factors/ ergonomics","* cognitive modelling","* cognitive architecture","* mental workload","* situation awareness","* cognitive error","* skill and training","* interface design","","## Selected publications","* [Ironies of automation] ([TWRR](https://resilienceroundup.com/issues/35/))","* [Verbal reports as evidence of the process operator's knowledge](https://www.sciencedirect.com/science/article/abs/pii/S0020737379800358)","","","[Ironies of automation]: https://www.sciencedirect.com/science/article/abs/pii/0005109883900468","","## Andrea Baker","","[Baker](https://www.thehopmentor.com/) is a practitioner who provides","training services in human and organizational performance (HOP) and learning","teams.","","Baker tweets as [@thehopmentor](https://twitter.com/thehopmentor).","","### Concepts","","* Human and organizational performance (HOP)","* Learning teams","* Industrial empathy","","### Selected publications","","* [A bit about HOP](https://docs.wixstatic.com/ugd/1a0149_21bcf20f158540098d3d7987ffbf3f58.pdf) (editorial)","* [A short introduction to human and organizational performance (hop) and learning teams](http://www.safetydifferently.com/a-short-introduction-to-human-and-organizational-performance-hop-and-learning-teams/) (blog post)","","## E. Asher Balkin","","### Selected publications","","* [Resiliency Trade Space Study: The Interaction of Degraded C2 Link and Detect and Avoid Autonomy on Unmanned Aircraft](https://www.researchgate.net/publication/330222613_Resiliency_Trade_Space_Study_The_Interaction_of_Degraded_C2_Link_and_Detect_and_Avoid_Autonomy_on_Unmanned_Aircraft)","* [Developing Systemic Contributors and Adaptations Diagramming (SCAD): systemic insights, multiple pragmatic implementations]","","### Selected talks","","* [Root cause and the wrong path](https://www.youtube.com/watch?v=kK6t-gttsJw)","","## Johan Bergström","","[Bergström](http://www.jbsafety.se/p/about-me.html) is a safety research and","consultant. He runs the [Master Program of Human Factors and Systems","Safety](http://www.humanfactors.lth.se/msc-programme/) at Lund University.","","Bergström tweets as [@bergstrom_johan](https://twitter.com/bergstrom_johan).","","### Concepts","","* Analytical traps in accident investigation"," - Counterfactual reasoning"," - Normative language"," - Mechanistic reasoning","* Generic competencies","","### Selected publications","","* [Resilience engineering: Current status of the research and future challenges](https://www.sciencedirect.com/science/article/pii/S0925753516306130)","* [Rule- and role retreat: An empirical study of procedures and resilience](https://www.researchgate.net/publication/50917226_Rule-_and_role_retreat_An_empirical_study_of_procedures_and_resilience)","* [Team Coordination in Escalating Situations: An Empirical Study Using Mid-Fidelity Simulation]","","[Team Coordination in Escalating Situations: An Empirical Study Using Mid-Fidelity Simulation]: https://portal.research.lu.se/ws/files/1376441/3014838.pdf","","### Selected talks","","* [Three analytical traps in accident investigation](https://www.youtube.com/watch?v=TqaFT-0cY7U)","* [Two Views on Human Error](https://www.youtube.com/watch?v=rHeukoWWtQ8)","* [What, Where and When is Risk in System Design?](https://www.youtube.com/watch?v=BtJIumyCrtE\u0026feature=youtu.be) (Velocity 2013)","","## Matthieu Branlat","","### Selected publications","","* [Basic patterns in how adaptive systems fail](https://www.researchgate.net/publication/284324002_Basic_patterns_in_how_adaptive_systems_fail) ([TWRR](https://resilienceroundup.com/issues/34/))","* [A practitioner’s experiences operationalizing Resilience Engineering]","* [Noticing Brittleness, Designing for Resilience]","","[A practitioner’s experiences operationalizing Resilience Engineering]: https://www.sciencedirect.com/science/article/abs/pii/S0951832015000812","[Noticing Brittleness, Designing for Resilience]: https://www.taylorfrancis.com/chapters/edit/10.1201/9781315605708-18/noticing-brittleness-designing-resilience-elizabeth-lay-matthieu-branlat","","## Sheuwen Chuang","","### Selected publications","","* [Beyond surge: Coping with mass burn casualty in the closest hospital to the Formosa Fun Coast Dust Explosion]","* [Coping With a Mass Casualty: Insights into a Hospital’s Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion] ([TWRR](https://resilienceroundup.com/issues/76/))","","[Beyond surge: Coping with mass burn casualty in the closest hospital to the Formosa Fun Coast Dust Explosion]: https://doi.org/10.1016/j.burns.2018.12.003","[Coping With a Mass Casualty: Insights into a Hospital’s Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion]: https://www.researchgate.net/publication/335366770_Coping_With_a_Mass_Casualty_Insights_into_a_Hospital's_Emergency_Response_and_Adaptations_After_the_Formosa_Fun_Coast_Dust_Explosion","","","","## Todd Conklin","","Conklin's books are on my reading list, but I haven't read anything by him","yet. I have listened to his great [Preaccident investigation","podcast](https://preaccidentpodcast.podbean.com/).","","Conklin tweets as [@preaccident](https://twitter.com/preaccident).","","### Selected publications","* [Pre-accident investigations: an introduction to organizational safety](https://www.amazon.com/Pre-Accident-Investigations-Todd-Conklin/dp/1409447820)","* [Pre-accident investigations: better questions - an applied approach to"," operational learning](https://www.amazon.com/gp/product/1472486137)","* [Do Safety Differently](https://www.amazon.com/Do-Safety-Differently-Sidney-Dekker/dp/B09RM3Z17V)","","### Selected talks","","Quanta - [Risk and Safety Conf 2019](https://www.youtube.com/watch?v=5WTbeFj2kJY\u0026feature=youtu.be)","","## Richard I. Cook","","[Cook](https://en.wikipedia.org/wiki/Richard_Cook_(safety_researcher)) was an anasthesiologist who studies failures in complex systems. He is one of the founders [Adaptive Capacity Labs](http://www.adaptivecapacitylabs.com/), a resilience engineering consultancy.","He tweeted as [@ri_cook](https://twitter.com/ri_cook).","","### Concepts","* how complex systems fail","* degraded mode","* sharp end (c.f. Reason's blunt end)","* Going solid","* Cycle of error","* \"new look\"","* first vs second stories","","### Selected publications","","* [A celebration of the work of Richard Cook, MD: A pioneer in understanding accidents, safety, human factors, and resilience](https://www.researchgate.net/publication/371403498_A_celebration_of_the_work_of_Richard_Cook_MD_A_pioneer_in_understanding_accidents_safety_human_factors_and_resilience)","* [How complex systems fail](https://www.adaptivecapacitylabs.com/HowComplexSystemsFail.pdf) ([BH](https://safety177496371.wordpress.com/2022/11/04/how-complex-systems-fail-a-classic-from-richard-cook/))","* [A brief look at the New Look in complex system failure, error, safety, and resilience](https://www.adaptivecapacitylabs.com/BriefLookAtTheNewLook.pdf)","* [void \\*: Incidents as Untyped Pointers. *Where* complex systems fail](https://www.snafucatchers.com/single-post/2017/11/14/void-Incidents-as-Untyped-Pointers)","* [Distancing through differencing: An obstacle to organizational learning following accidents](https://www.researchgate.net/publication/292504703_Distancing_through_differencing_An_obstacle_to_organizational_learning_following_accidents)","* [Being bumpable](http://csel.eng.ohio-state.edu/productions/woodscta/media/beingbump.pdf) ([TWRR](https://www.getrevue.co/profile/resilience/issues/resilience-roundup-being-bumpable-issue-33-177340))","* [Behind Human Error]","* [Incidents - markers of resilience or brittleness?](https://www.researchgate.net/publication/292504952_Incidents_-_markers_of_resilience_or_brittleness)","* [“Going solid”: a model of system dynamics and consequences for patient safety](https://qualitysafety.bmj.com/content/14/2/130) ([TWRR](https://resilienceroundup.com/issues/going-solid-a-model-of-system-dynamics-and-consequences-for-patient-safety/))","* [Operating at the Sharp End: The Complexity of Human Error](https://www.researchgate.net/publication/313407259_Operating_at_the_Sharp_End_The_Complexity_of_Human_Error)","* [Patient boarding in the emergency department as a symptom of complexity-induced risks](https://www.researchgate.net/publication/312624891_Patient_boarding_in_the_emergency_department_as_a_symptom_of_complexity-induced_risks)","* [Sensemaking, Safety, and Cooperative Work in the Intensive Care Unit](https://www.researchgate.net/publication/220579381_Sensemaking_Safety_and_Cooperative_Work_in_the_Intensive_Care_Unit)","* [Medication Reconciliation Is a Window into “Ordinary” Work](https://www.taylorfrancis.com/books/e/9781317164777/chapters/10.1201/9781315572529-4)","* [Cognitive consequences of clumsy automation on high workload, high consequence human performance]","* [Implications of automation surprises in aviation for the future of total intravenous anesthesia (TIVA)]","* [The Messy Details: Insights From the Study of Technical Work in Healthcare]","* [Nosocomial automation: technology-induced complexity and human performance]","* [The New Look at Error, Safety, and Failure: A Primer for Health Care]","* [Grounding explanations in evolving, diagnostic situations]","* [A Tale of Two Stories: Contrasting Views of Patient Safety] (appendix B, starting on page 64 (numbered 52) contains the talk by Charles Billings, MD, Chief Scientist (retired), NASA Ames on the lessons learned from incident reporting in aviation. Dr. Billings designed, started, and managed the Aviation Safety REporting System)","* [\"Those found responsible have been sacked\": some observations on the usefulness of error](http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.623.5749\u0026rep=rep1\u0026type=pdf) ([BH](https://safety177496371.wordpress.com/2025/01/26/those-found-responsible-have-been-sacked-some-observations-on-the-usefulness-of-error/))","* [Perspectives on Human Error: Hindsight Biases and Local Rationality])","* [Mistaking Error]","* [Adapting to new technology in the operating room]","* [Verite, Abstraction, and Ordinateur Systems in the Evolution of Complex Process Control](https://www.researchgate.net/publication/3657912_Verite_abstraction_and_ordinateur_systems_in_the_evolution_of_complex_process_control)","* [Collaborative Cross-Checking to Enhance Resilience] ([TWRR](https://resilienceroundup.com/issues/73/))","* [Resilience Engineering: New directions for measuring and maintaining safety in complex systems]","* [The Role of Automation in Complex System Failures]","* [Thinking about accidents and systems](https://www.researchgate.net/publication/228352596_Thinking_about_accidents_and_systems)","* [The Stockholm blizzard of 2012](https://www.taylorfrancis.com/books/e/9781315605739/chapters/10.1201/9781315605739-11)","* [New Arctic Air Crash Aftermath Role-Play Simulation Orchestrating a Fundamental Surprise]","* [Dissenting Statement: Health IT Is a Class III Medical Device](https://www.nap.edu/read/13269/chapter/14)","* [Nine Steps to Move Forward From Error] ([BH](https://safety177496371.wordpress.com/2022/11/03/nine-steps-to-move-forward-from-error/))","* [Gaps in the continuity of care and progress on patient safety]","* [Above the Line, Below the Line](https://queue.acm.org/detail.cfm?id=3380777) ([TWRR](https://resilienceroundup.com/issues/68/))","* [Coping With a Mass Casualty: Insights into a Hospital’s Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion] ([TWRR](https://resilienceroundup.com/issues/76/))","* [SRE Cognitive Work] in [Seeking SRE]","* [Building and revising adaptive capacity sharing for technical incident response: A case of resilience engineering](https://www.sciencedirect.com/science/article/pii/S0003687020301903) ([TWRR](https://resilienceroundup.com/issues/building-and-revising-adaptive-capacity-sharing-for-technical-incident-response-a-case-of-resilience-engineering/))","* [Automation, interaction, complexity, and failure: A case study]","* [Human Performance in Anesthesia]","* [Two years before the mast: Learning how to learn about patient safety](https://www.researchgate.net/publication/285346573_Two_years_before_the_mast_Learning_how_to_learn_about_patient_safety)","* [Resilience is not control: healthcare, crisis management, and ICT]","* [Taking Things in One’s Stride: Cognitive Features of Two Resilient Performances]","* [Human Performance in Anesthesia: A Corpus of Cases]","* [Minding the Gaps: Creating Resilience in Health Care]","* [From Counting Failures to Anticipating Risks: Possible Futures for Patient Safety]","* [Resilience Engineering: New directions for measuring and maintaining safety in complex systems]","* [Behind Human Error: Taming Complexity to Improve Patient Safety]","* [The Illusion of Explanation]","","","[Behind Human Error]: https://www.amazon.com/Behind-Human-Error-David-Woods/dp/0754678342","[Cognitive consequences of clumsy automation on high workload, high consequence human performance]: https://ntrs.nasa.gov/search.jsp?R=19910011398","[Implications of automation surprises in aviation for the future of total intravenous anesthesia (TIVA)]: https://doi.org/10.1016/S0952-8180(96)90009-4","[The Messy Details: Insights From the Study of Technical Work in Healthcare]: https://doi.org/10.1109%2FTSMCA.2004.836802","[Nosocomial automation: technology-induced complexity and human performance]: https://www.researchgate.net/profile/David_Woods11/publication/224649052_Nosocomial_automation_technology-induced_complexity_and_human_performance/links/59399b1da6fdcc58ae902c49/Nosocomial-automation-technology-induced-complexity-and-human-performance.pdf","[The New Look at Error, Safety, and Failure: A Primer for Health Care]: https://pdfs.semanticscholar.org/67f7/53ec089e5a8879f241e2be867dad0a2026fb.pdf","[Grounding explanations in evolving, diagnostic situations]: https://pdfs.semanticscholar.org/1bed/356b5aa67c701f5bad6d943768622095f418.pdf","[A Tale of Two Stories: Contrasting Views of Patient Safety]: https://www.researchgate.net/publication/245102691_A_Tale_of_Two_Stories_Contrasting_Views_of_Patient_Safety","[Perspectives on Human Error: Hindsight Biases and Local Rationality]: https://www.nifc.gov/PUBLICATIONS/acc_invest_march2010/speakers/Perspectives%20on%20Human%20Error.pdf","[Mistaking Error]: https://www.researchgate.net/publication/328149714_Mistaking_Error","[Adapting to new technology in the operating room]: https://www.researchgate.net/publication/14230576_Adapting_to_New_Technology_in_the_Operating_Room","[Collaborative Cross-Checking to Enhance Resilience]: https://www.researchgate.net/publication/220579448_Collaborative_Cross-Checking_to_Enhance_Resilience","[Resilience Engineering: New directions for measuring and maintaining safety in complex systems]: https://pdfs.semanticscholar.org/a0d3/9cc66adc64e297048a32b71aeee209a451af.pdf","[The Role of Automation in Complex System Failures]: https://www.researchgate.net/publication/232191704_The_Role_of_Automation_in_Complex_System_Failures","[New Arctic Air Crash Aftermath Role-Play Simulation Orchestrating a Fundamental Surprise]: https://www.researchgate.net/publication/2484621_New_Arctic_Air_Crash_Aftermath_Role-Play_Simulation_Orchestrating_a_Fundamental_Surprise","[Nine Steps to Move Forward From Error]: http://csel.eng.ohio-state.edu/productions/pexis/readings/submod4/nine%20steps%20CTW2002.pdf","[Gaps in the continuity of care and progress on patient safety]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117777/","[Automation, interaction, complexity, and failure: A case study]: https://doi.org/10.1016/j.ress.2006.01.009","[Human Performance in Anesthesia]: http://dx.doi.org/10.13140/RG.2.2.29675.36648","[Resilience is not control: healthcare, crisis management, and ICT]: https://www.researchgate.net/profile/Robert-Wears/publication/225108705_Resilience_is_Not_Control_Healthcare_Crisis_Management_and_ICT/links/00b49532b2c7f3ed62000000/Resilience-is-Not-Control-Healthcare-Crisis-Management-and-ICT.pdf","[Taking Things in One’s Stride: Cognitive Features of Two Resilient Performances]: https://www.taylorfrancis.com/chapters/edit/10.1201/9781315605685-19/taking-things-one-stride-cognitive-features-two-resilient-performances-richard-cook-christopher-nemeth","[Human Performance in Anesthesia: A Corpus of Cases]: https://www.researchgate.net/publication/347964304_Human_Performance_in_Anesthesia_Human_Performance_in_Anesthesia_Human_Performance_in_Anesthesia","[Minding the Gaps: Creating Resilience in Health Care]: https://europepmc.org/article/NBK/nbk43670","[From Counting Failures to Anticipating Risks: Possible Futures for Patient Safety]: https://citeseerx.ist.psu.edu/document?repid=rep1\u0026type=pdf\u0026doi=ffe74633027ee354ebbf0ff9a6418e75f3b7a047","[Resilience Engineering: New directions for measuring and maintaining safety in complex systems]: https://www.academia.edu/download/83819345/Resilience_Engineering_New_directions_fo20220411-23835-1ipo8pk.pdf","[Behind Human Error: Taming Complexity to Improve Patient Safety]: https://citeseerx.ist.psu.edu/document?repid=rep1\u0026type=pdf\u0026doi=15f31969c4e1f4f599c5c68aa63f3bf930e0406f","[The Illusion of Explanation]: https://onlinelibrary.wiley.com/doi/pdf/10.1197/j.aem.2004.07.001","","### Selected talks","* [How Complex Systems Fail](https://www.youtube.com/watch?v=2S0k12uZR14) (Velocity 2012)","* [Resilience in Complex Adaptive Systems: Operating at the Edge of Failure](https://www.youtube.com/watch?v=PGLYEDpNu60\u0026feature=youtu.be) (Velocity 2013)","* [Lectures on the study of cognitive work](https://www.youtube.com/playlist?list=PLb1aZTnPf3-OEU1by77zZQQYckvXUGmNY) (Graduate student lecture-discussions at The Royal Institute of Technology, Huddinge, SWEDEN in 2012 )","* [Panel discussion: Safety Culture, Lean, and DevOps] (DOES 2017)","* [Working at the center of the Cyclone](https://www.youtube.com/watch?v=3ZP98stDUf0\u0026feature=youtu.be) (DOES 2018)","* [A Few Observations on the Marvelous Resilience of Bone \u0026 Resilience Engineering](https://www.youtube.com/watch?v=8LbePBiOvZ4) (REdeploy 2019)","","[Panel discussion: Safety Culture, Lean, and DevOps]: https://www.youtube.com/watch?v=gtxtb9z_4FY\u0026feature=youtu.be","","","## Jean-Christophe Le Coze","","Le Coze is research director at INERIS (National Institute for the Industrial Environment and Risks) in France.","He frequently writes on historical views of safety.","","Le Coze tweets as [@JcLeCoze](https://twitter.com/JcLeCoze).","","### Selected publications","","* [Managing the Unexpected](https://www.academia.edu/36790092/Managing_the_unexpected)","* [The 'new view' of human error. Origins, ambiguities, success and critiques](https://www.sciencedirect.com/science/article/abs/pii/S0925753522001928)","* [1984-2014. Normal Accident. Was Charles Perrow right for the wrong reasons?](https://www.academia.edu/15301538/1984_2014_Normal_Accident_Was_Charles_Perrow_right_for_the_wrong_reasons)","* [Good and bad reasons: The Swiss cheese model and its critics](https://dx.doi.org/10.1016/j.ssci.2020.104660)","* [Recurring themes in the legacy of Jens Rasmussen](https://doi.org/10.1016/j.apergo.2016.10.002)","* [Reflecting on Jens Rasmussen’s legacy. A strong program for a hard problem](https://www.sciencedirect.com/science/article/pii/S0925753514000848)","* [Reflecting on Jens Rasmussen's legacy (2) behind and beyond, a ‘constructivist turn’](https://www.sciencedirect.com/science/article/abs/pii/S0003687015300429)","","## Sidney Dekker","","Dekker is a human factors and safety researcher with a background in aviation.","His books aimed at a lay audience (Drift Into Failure, Just Culture, The Field Guide to 'Human Error' investigations)","have been enormously influential. He was a founder of the MSc programme in Human Factors \u0026 Systems Safety at Lund University.","His PhD advisor is [David Woods](#david-woods).","","Dekker tweets as [@sidneydekkercom](https://twitter.com/sidneydekkercom).","","### Contributions","","#### Drift into failure","","Dekker developed the theory of *drift*, characterized by five concepts:","","1. Scarcity and competition","1. Decrementalism, or small steps","1. Sensitive dependence on initial conditions","1. Unruly technology","1. Contribution of the protective structure","","#### Just Culture","","Dekker examines how cultural norms defining justice can be re-oriented to minimize the negative impact and maximize learning when things go wrong.","","1. Retributive justice as society's traditional idea of justice: distributing punishment to those responsible based on severity of the violation","2. Restorative justice as an improvement for both victims and practicioners: distributing obligations of rebuilding trust to those responsible based on who is hurt and what they need","3. First, second, and third victims: an incident's negative impact is felt by more than just the obvious victims","4. Learning theory: people break rules when they have learned there are no negative consequences, and there are actually positive consequences - in other words, they break rules to get things done to meet production pressure","5. Reporting culture: contributing to reports of adverse events is meant to help the organization understand what went wrong and how to prevent recurrence, but accurate reporting requires appropriate and proportionate accountability actions","6. Complex systems: normal behavior of practicioners and professionals in the context of a complex system can appear abnormal or deviant in hindsight, particularly in the eyes of non-expert juries and reviewers","7. The nature of practicioners: professionals want to do good work, and therefore want to be held accountable for their mistakes; they generally want to help similarly-situated professionals avoid the same mistake.","","### Safety Differently","","- There is a difference between the organization's prescribed processes for completing work and how work is actually completed. (work as imagined vs work as done)"," - The difference between work as imagined and work as done is the result of the expertise that exists in your workers from contact with real-life pressures, heuristics, and unexpected conditions."," - Old View: People are the problem to control with process"," - They did something wrong"," - They need more rules and enforcement"," - They need to try harder"," - We need to get rid of \"bad apples\""," - Focus on the \"sharp end\" of the organization - the people closest to the work"," - New View: Work is done adaptively in an uncertain world"," - Things go wrong all the time"," - Workers often detect and correct these problems"," - Local adaptations are a source of organizational expertise"," - \"What conditions existed that made the selected course of action seem correct to the people involved?\"","- Traditional safety interventions have diminishing yields with increasing overhead. Accumulated compliance burden and \"safety clutter\" makes it harder to get work done *and* to do so safely."," - Safety Clutter is accountable to safety bureaucracy and compliance rather than the safety of the workers or the process"," - Safety Clutter is produced by the \"blunt end\" of the organization without local expertise of what is practicable or practical in-situ"," - Safety Clutter represents a broader \"deprofessionalization\" - a removal of trust and confidence in professionals to do their job well, removing their pride, autonomy, and achievement."," - Paradoxically, Safety Clutter can result from government deregulation - organizations need to self-impose risk controls in the absence of external guidelines."," - Sadly for organizations with Safety Clutter, more internal rules do not equal better legal protection.","- When a process is relatively safe or stable, measurements of bad outcomes lack statistical significance to understand trends or tie trends to interventions."," - Fundamental Regulator Paradox: regulating a system so well that there are no useful measurements left to understand how the system is performing"," - Zero Paradox: A study of construction contractors showed more fatal accidents in firms with \"goal zero\" safety policies than in those without. Non-fatal accidents were similar."," - Risk Secrecy: \"goal zero\" commitments result in injury underreporting and hiding of incidents which prevents learning, particularly when tied to financial incentives for leadership.","- There are patterns (capacities) that help things go well"," - _Diversity of opinion_ - possibility to voice dissent"," - _Keeping the discussion on risk alive_ even when things go well"," - _Deference to expertise_ that already exists in people at the sharp end"," - _Psychological safety_ / \"stop\" ability"," - _Low barriers_ to interaction between organizational groups"," - _Sharp end improvements_ to existing systems based on local expertise"," - _Pride in work_ - process and results","- Rapid problem-solving can prevent effective problem-understanding","- Leadership buy-in and practice of New View safety is imperative to its success. It's also difficult to foster."," - Worker buy-in is rapid and fits their existing mental model"," - Leadership must abandon the mental model that has governed their past work and decision-making - difficult for anyone."," - Peer discussions are especially helpful for leadership"," - Highlighting how local adaptations helped things go well also helps","","### Concepts","* Drift into failure","* Safety differently","* New view vs old view of human performance \u0026 error","* Just culture","* complexity","* broken part","* Newton-Descartes","* diversity","* systems theory","* unruly technology","* decrementalism","* generic competencies","* work as imagined vs work as done","","### Selected publications","","* [Drift into failure](https://www.amazon.com/Drift-into-Failure-Sidney-Dekker/dp/1409422216)","* [Reconstructing human contributions to accidents: the new view on error and performance](http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.411.4985\u0026rep=rep1\u0026type=pdf)","* [The field guide to understanding 'human error'](https://www.amazon.com/Field-Guide-Understanding-Human-Error/dp/1472439058s://www.amazon.com/Field-Guide-Understanding-Human-Error/dp/1472439058)","* [Behind Human Error]","* [Rule- and role retreat: An empirical study of procedures and resilience](https://www.researchgate.net/publication/50917226_Rule-_and_role_retreat_An_empirical_study_of_procedures_and_resilience?enrichId=rgreq-23625e555a0d8e5250c74f24b5fd01ca-XXX\u0026enrichSource=Y292ZXJQYWdlOzUwOTE3MjI2O0FTOjk3MzU5NjY5MjM1NzQ1QDE0MDAyMjM3NjI5NDY%3D\u0026el=1_x_2\u0026_esc=publicationCoverPdf)","* [Anticipating the effects of technological change: A new era of dynamics for human factors](https://www.researchgate.net/publication/247512351_Anticipating_the_effects_of_technological_change_A_new_era_of_dynamics_for_human_factors)","* [Why do things go right?](http://www.safetydifferently.com/why-do-things-go-right/)","* [Six stages to the new view of human error](http://www.humanfactors.lth.se/fileadmin/lusa/Sidney_Dekker/articles/2007/SafetyScienceMonitor.pdf)","* [Employees: A Problem to Control or Solution to Harness?](http://sidneydekker.com/wp-content/uploads/2014/08/DekkerPS2014.pdf)","* [Team Coordination in Escalating Situations: An Empirical Study Using Mid-Fidelity Simulation]","* [Resilience Engineering: New directions for measuring and maintaining safety in complex systems]","* [Illusions of explanation: A critical essay on error classification](http://www.humanfactors.lth.se/fileadmin/lusa/Sidney_Dekker/articles/2003_and_before/Illusions_of_explanation.pdf)","* [Failure to adapt or adaptations that fail: contrasting models on procedures and safety](http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.606.3361\u0026rep=rep1\u0026type=pdf)","* [Human factors and folk models]","* [The High Reliability Organization Perspective] ([TWRR](https://resilienceroundup.com/issues/09/))","* [Illusions of explanation: A critical essay on error classification](http://www.humanfactors.lth.se/fileadmin/lusa/Sidney_Dekker/articles/2003_and_before/Illusions_of_explanation.pdf) ([TWRR](https://resilienceroundup.com/issues/42/))","* [Safety II professionals: How resilience engineering can transform safety practice] ([TWRR](https://resilienceroundup.com/issues/64/))","* [The complexity of failure: implications of complexity theory for safety investigation](https://static1.squarespace.com/static/53b78765e4b0949940758017/t/5722beb0d51cd4d11675a69c/1461894833950/Dekker%2C+Cilliers+and+Hofmeyr+-+The+Complexity+of+Failure.pdf)","* [The Safety Anarchist](https://www.amazon.com/Safety-Anarchist-innovation-bureaucracy-compliance/dp/1138300462))","* [Compliance Capitalism](https://www.amazon.com/Compliance-Capitalism-Overregulated-Management-Neoliberalism/dp/1032012366)","* [Resilience Engineering: New directions for measuring and maintaining safety in complex systems]","* [Drifting into failure: Complexity theory and the management of risk](https://maritimesafetyinnovationlab.org/wp-content/uploads/2021/03/DekkerDriftRiskChapter2013.pdf) ([BH 1](https://safety177496371.wordpress.com/2025/05/03/drifting-into-failure-complexity-theory-and-the-management-of-risk/) [BH 2](https://safety177496371.wordpress.com/2025/05/03/complex-systems-and-drifting-into-failure-further-extracts-from-dekker-2013/))","","[Human factors and folk models]: https://link.springer.com/article/10.1007%2Fs10111-003-0136-9","[The High Reliability Organization Perspective]: http://sidneydekker.com/wp-content/uploads/2013/01/CH005.pdf","[Safety II professionals: How resilience engineering can transform safety practice]: https://doi.org/10.1016/j.ress.2019.106740","","### Selected talks","","* [Panel discussion: Safety Culture, Lean, and DevOps]","","","## Jessica Devita","Devita is a software engineering manager and researcher in software resilience engineering. She has previously held roles at Microsoft, Netflix, and Google. Her master thesis [To Deploy, or Not to Deploy, That is the Question A qualitative study of the decision-making experiences of engineers deploying software changes in production](https://lup.lub.lu.se/student-papers/search/publication/9149521) focused on software deployments and decision making. ","","## John C. Doyle","","[Doyle](http://www.cds.caltech.edu/~doyle/wiki/index.php?title=Main_Page) is a","control systems researcher. He is seeking to identify the universal laws that capture the","behavior of resilient systems, and is concerned with the architecture of such","systems.","","### Concepts","* Robust yet fragile","* layered architectures","* constraints that deconstrain","* protocol-based architectures","* emergent constraints","* Universal laws and architectures","* conservation laws","* universal architectures","* Highly optimized tolerance","* Doyle's catch","","#### Doyle's catch","","*Doyle's catch* is a term introduced by David Woods, but attributed to John Doyle. Here's how","[Woods quotes Doyle](https://www.researchgate.net/publication/303832480_The_Risks_of_Autonomy_Doyles_Catch):","","\u003e Computer-based simulation and rapid prototyping tools are now broadly available and powerful enough that it is","\u003e relatively easy to demonstrate almost anything, provided that conditions are made sufficiently idealized.","\u003e However, the real world is typically far from idealized, and thus a system must have enough robustness in order to close","\u003e the gap between demonstration and the real thing.","","","### Selected publications","","* [Universal Laws and Architectures](http://www.cis.upenn.edu/~ngns/docs/Review_2010/Doyle%20MURI%202010.pdf) (slides)","* [Contrasting Views of Complexity and Their Implications For Network-Centric Infrastructures](http://dx.doi.org/10.1109/TSMCA.2010.2048027)","* [Architecture, constraints, and behavior](https://www.pnas.org/content/108/Supplement_3/15624)","* [The “robust yet fragile” nature of the Internet](https://doi.org/10.1073/pnas.0501426102)","* [Highly Optimized Tolerance: Robustness and Design in Complex Systems](http://dx.doi.org/10.1103/physrevlett.84.2529)","* [Robust efficiency and actuator saturation explain healthy heart rate control and variability](https://doi.org/10.1073/pnas.1401883111)","","## Bob Edwards","","[Edwards](http://hopcoach.net/) is a practitioner who provides","training services in human and organizational performance (HOP).","","Edwards tweets as [@thehopcoach](https://twitter.com/thehopcoach).","","## Anders Ericsson","","Ericsson introduced the idea of *deliberate practice* as a mechanism for","achieving high level of expertise.","","Ericsson isn't directly associated with the field of resilience engineering.","However, Gary Klein's work is informed by his, and I have a particular","interest in how people improve in expertise, so I'm including him here.","","### Concepts","","* Expertise","* Deliberate practice","* Protocol analysis","","### Selected publications","","* [Peak: secrets from the new science of expertise](https://www.amazon.com/Peak-Secrets-New-Science-Expertise/dp/1531864880/)","* [Protocol analysis: verbal reports as data](https://www.amazon.com/Protocol-Analysis-Revd-Verbal-Reports/dp/0262550237)","","## Paul Feltovich","","[Feltovich](https://www.ihmc.us/groups/pfeltovich/) is a retired Senior Research Scientist at the Florida Institute for Human \u0026 Machine Cognition (IHMC),","who has done extensive reserach in human expertise.","","### Selected publications","","* [Common Ground and Coordination in Joint Activity]","* [Issue of expert flexibility in contexts characterized by complexity and change](https://www.researchgate.net/publication/232465540_Issue_of_expert_flexibility_in_contexts_characterized_by_complexity_and_change)","* [A rose by any other name...would probably be given an acronym]","* [Learners' (mis)understanding of important and difficult concepts: a challenge to smart machines in education](https://www.researchgate.net/publication/234818797_Learners'_misunderstanding_of_important_and_difficult_concepts_a_challenge_to_smart_machines_in_education)","* [Ten challenges for making automation a team player] ([TWRR](https://resilienceroundup.com/issues/ten-challenges-for-making-automation-a-team-player-in-joint-human-agent-activity/))","* [Issue of expert flexibility in contexts characterized by complexity and change](https://www.researchgate.net/publication/232465540_Issue_of_expert_flexibility_in_contexts_characterized_by_complexity_and_change)","","[Common Ground and Coordination in Joint Activity]: http://jeffreymbradshaw.net/publications/Common_Ground_Single.pdf","[A rose by any other name...would probably be given an acronym]: https://www.researchgate.net/publication/3454029_A_rose_by_any_other_namewould_probably_be_given_an_acronym","[Ten challenges for making automation a team player]: https://ieeexplore.ieee.org/abstract/document/1363742","","## Meir Finkel","","Finkel is a Colonel in the Israeli Defense Force (IDF) and the Director of the IDF's Ground Forces Concept Development and Doctrine Department","","### Selected publications","* [On Flexibility: Recovery from Technological and Doctrinal Surprise on the Battlefield](https://www.amazon.com/Flexibility-Recovery-Technological-Doctrinal-Battlefield/dp/0804774897/ref=sr_1_3?ie=UTF8\u0026qid=1546046916\u0026sr=8-3\u0026keywords=on+flexibility)","","## Marisa Grayson","","[Grayson](https://www.linkedin.com/in/marisa-grayson/) is a cognitive systems engineer at Mile Two, LLC.","","### Selected Publications","","* [Approaching Overload: Diagnosis and Response to Anomalies in Complex and Automated Production Software Systems](https://www.researchgate.net/publication/333091997_Approaching_Overload_Diagnosis_and_Response_to_Anomalies_in_Complex_and_Automated_Production_Software_Systems)","* [Cognitive Work of Hypothesis Exploration During Anomaly Response](https://queue.acm.org/detail.cfm?id=3380778)","","## Ivonne Andrade Herrera","","[Herrera](https://www.ntnu.edu/employees/ivonne.a.herrera) is an associate professor in","the department of industrial economics and technology management at NTNU and a","senior research scientist at SINTEF. Her areas of expertise include safety management and","resilience engineering in avionics and air traffic management.","","### Selected publications","","* [Organisational accidents and resilient organisations: six perspectives](https://www.sintef.no/globalassets/upload/teknologi_og_samfunn/sikkerhet-og-palitelighet/rapporter/sintef-a17034-organisational-accidents-and-resilience-organisations-six-perspectives.-revision-2.pdf) (SINTEF A17034 report)","","See also: [list of publications](https://wo.cristin.no/as/WebObjects/cristin.woa/wa/fres?sort=ar\u0026pnr=30556\u0026action=sok)","","## Cat Hicks","[Hicks](https://www.drcathicks.com/) is a psychological scientist and researcher who creates open science to drive change for people doing technical work. She holds a PhD in Quantitative Experimental Psychology from UC San Diego and is the founder and principal scientist of Catharsis Consulting, a scientific consultancy that helps organizations transform with human-centered evidence strategies.","","### Selected Publications","* [The Psychology of Software Teams](https://www.routledge.com/The-Psychology-of-Software-Teams/Hicks/p/book/9781032963389)","* [Developer Thriving: four sociocognitive factors that create resilient productivity on software teams](https://ieeexplore.ieee.org/stamp/stamp.jsp?arnumber=10491133)","* [The New Developer: AI Skill Threat, Identity Change \u0026 Developer Thriving in the Transition to AI-Assisted Software Development](https://osf.io/preprints/psyarxiv/2gej5)","* [Google Scholar](https://scholar.google.com/citations?user=MotKyQcAAAAJ\u0026hl=en)","","## Robert Hoffman","","[Hoffman](https://www.ihmc.us/groups/rhoffman/) is a senior research scientist at Florida Institute for Human \u0026 Machine Cognition (IHMC),","who has done extensive reserach in human expertise.","","### Selected publications","","* [Measuring resilience](https://journals.sagepub.com/doi/abs/10.1177/0018720816686248)","* [Myths of automation and their implications for military procurement]","* [The Seven Deadly Myths of \"Autonomous Systems\"]","* [A rose by any other name...would probably be given an acronym]","* [Seeing the invisible: perceptual-cognitive aspects of expertise](https://cmapspublic3.ihmc.us/rid=1G9NSY15K-N7MJMZ-LC5/SeeingTheInvisible.pdf)","* [Toward a Theory of Complex and Cognitive Systems]","* [Macrocognition] ([TWRR](https://resilienceroundup.com/issues/62/))","","[Myths of automation and their implications for military procurement]:https://www.researchgate.net/publication/326000581_Myths_of_automation_and_their_implications_for_military_procurement","","[The Seven Deadly Myths of \"Autonomous Systems\"]: https://www.researchgate.net/publication/260304859_The_Seven_Deadly_Myths_of_Autonomous_Systems","","[Toward a Theory of Complex and Cognitive Systems]: https://www.researchgate.net/publication/3454245_Toward_a_Theory_of_Complex_and_Cognitive_Systems","","[Macrocognition]: https://pdfs.semanticscholar.org/df74/b2909f54b41a485cd4c0189fc4aa19d176d0.pdf","","","### Concepts","","#### Seven deadly myths of autonomous systems","","1. \"Autonomy\" is unidimensional.","2. The conceptualization of \"levels of autonomy\" is a useful scientific grounding for the development of autonomous system roadmaps.","3. Autonomy is a widget.","4. Autonomous systems are autonomous.","5. Once achieved, full autonomy obviates the need for human-machine collaboration.","6. As machines acquire more autonomy, they will work as simple sibstitutes (or multipliers) of human capability","7. \"Full autonomy\" is not only possible, but is always desireable.","","## Erik Hollnagel","","### Contributions","","#### ETTO principle","","Hollnagel proposed that there is always a fundamental tradeoff between","efficiency and thoroughness, which he called the *ETTO principle*.","","#### Safety-I vs. Safety-II","","Safety-I: avoiding things that go wrong","* looking at what goes wrong","* bimodal view of work and activities (acceptable vs unacceptable)","* find-and-fix approach","* prevent transition from 'normal' to 'abnormal'","* causality credo: believe that adverse outcomes happen because something goes"," wrong (they have causes that can be found and treated)","* it either works or it doesn't","* systems are decomposable","* functioning is bimodal","","Safety-II: performance variability rather than bimodality","* the system’s ability to succeed under varying conditions, so that the number"," of intended and acceptable outcomes (in other words, everyday activities) is"," as high as possible","* performance is always variable","* performance variation is ubiquitous","* things that go right","* focus on frequent events","* remain sensitive to possibility of failure","* be thorough as well as efficient","","#### FRAM","","Hollnagel proposed the Functional Resonance Analysis Method (FRAM) for modeling","complex socio-technical systems.","","","#### Four abilities necessary for resilient performance","* respond","* monitor","* learn","* anticipate","","### Concepts","* ETTO (efficiency thoroughness tradeoff) principle","* FRAM (functional resonance analysis method)","* Safety-I and Safety-II","* things that go wrong vs things that go right","* causality credo","* performance variability","* bimodality","* emergence","* work-as-imagined vs. work-as-done","* joint cognitive systems","* systems of the first, second, third, fourth kind","","### Selected publications","","* [The ETTO Principle: Efficiency-Thoroughness Trade-Off: Why Things That Go Right Sometimes Go Wrong](https://www.amazon.com/ETTO-Principle-Efficiency-Thoroughness-Trade-Off-Sometimes/dp/0754676781/ref=sr_1_1?s=books\u0026ie=UTF8\u0026qid=1545965837\u0026sr=1-1\u0026keywords=etto+principle)","* [From Safety-I to Safety-II: A White Paper](https://www.skybrary.aero/bookshelf/books/2437.pdf)","* [Safety-II in Practice](https://www.amazon.com/Safety-II-Practice-Developing-Resilience-Potentials/dp/1138708925)","* [Safety-I and Safety-II: The past and future of safety management](https://www.amazon.com/gp/product/1472423089/ref=dbs_a_def_rwt_bibl_vppi_i0)","* [FRAM: The Functional Resonance Analysis Method: Modelling Complex Socio-technical System](https://www.amazon.com/gp/product/B010WIDYE8/ref=dbs_a_def_rwt_bibl_vppi_i15)","* [Joint Cognitive Systems: Patterns in Cognitive Systems Engineering](https://www.amazon.com/gp/product/0849339332/ref=x_gr_w_bb?ie=UTF8\u0026tag=x_gr_w_bb-20\u0026linkCode=as2\u0026camp=1789\u0026creative=9325\u0026creativeASIN=0849339332\u0026SubscriptionId=1MGPYB6YW3HWK55XCGG2)","* [Resilience Engineering: Concepts and Precepts]","* [I want to believe: some myths about the management of industrial safety](http://dx.doi.org/10.1007/s10111-012-0237-4)","* [Resilience engineering – Building a Culture of Resilience](http://www.ptil.no/getfile.php/1325150/PDF/Seminar%202013/Integrerte%20operasjoner/Hollnagel_RIO_presentation.pdf) (slides)","* [Anomaly Response]","* [Cognitive Systems Engineering: New wine in new bottles] ([TWRR](https://www.getrevue.co/profile/resilience/issues/resilience-roundup-cognitive-systems-engineering-new-wine-in-new-bottles-issue-32-175912))","* [Epilogue: Resilience Engineering Precepts](https://www.researchgate.net/publication/265074845_Epilogue_Resilience_Engineering_Precepts)","* [Resilience Engineering: New directions for measuring and maintaining safety in complex systems]","* [Resilience Engineering](https://erikhollnagel.com/ideas/resilience-engineering.html) (web essay)","* [RAG - Resilience Analysis Grid](http://erikhollnagel.com/onewebmedia/RAG%20Outline%20V2.pdf)","* [Resilience engineering in practice: a guidebook]","* [Mapping Cognitive Demands in Complex Problem-Solving Worlds] (mentions disturbance management)","* [Human factors and folk models]","* [Designing for joint cognitive systems](https://www.researchgate.net/publication/4213914_Designing_for_joint_cognitive_systems)","* [Macrocognition] ([TWRR](https://resilienceroundup.com/issues/62/))","* [A day when (Almost) nothing happened](https://www.sciencedirect.com/science/article/abs/pii/S0925753521004719)","* [Minding the Gaps: Creating Resilience in Health Care]","* [Resilience Engineering: New directions for measuring and maintaining safety in complex systems]","* [Understanding Accidents - From Root Causes to Performance Variability](https://www.researchgate.net/publication/3973687_Understanding_accidents-from_root_causes_to_performance_variability) ([BH](https://safety177496371.wordpress.com/2025/03/12/understanding-accidents-from-root-causes-to-performance-variability/))","* [Human error: trick or treat](https://onlinelibrary.wiley.com/doi/abs/10.1002/9780470713181.ch9)","* [THe 5th paradox of safety](https://incrementalsafety.com/onewebmedia/fifth%20paradox%20oct%2031.pdf) ([BH](https://safetyinsights.org/2026/01/09/the-fifth-paradox-of-safety-new-article-from-erik-hollnagel/))","","","[Resilience Engineering: Concepts and Precepts]: https://www.amazon.com/gp/product/B009KNDF64/ref=x_gr_w_glide_bb?ie=UTF8\u0026tag=x_gr_w_glide_bb-20\u0026linkCode=as2\u0026camp=1789\u0026creative=9325\u0026creativeASIN=B009KNDF64\u0026SubscriptionId=1MGPYB6YW3HWK55XCGG2","[Anomaly Response]: https://docs.wixstatic.com/ugd/3ad081_f46dda684154447583c8a5b282b60cc2.pdf","[Cognitive Systems Engineering: New wine in new bottles]: https://www.ida.liu.se/~729A15/mtrl/CSEnew.pdf?utm_campaign=Resilience%20Roundup\u0026utm_medium=email\u0026utm_source=Revue%20newsletter","[Resilience Roundup]: https://resilienceroundup.com/","[Mapping Cognitive Demands in Complex Problem-Solving Worlds]: https://www.researchgate.net/publication/220108174_Mapping_Cognitive_Demands_in_Complex_Problem-Solving_Worlds\u003cPaste\u003e","","## Leila Johannesen","","[Johannesen](https://www.linkedin.com/in/leilajohannesen/) is currently a UX researcher and community advocate at IBM.","Her PhD dissertation work examined how humans cooperate, including studies of anesthesiologists.","","### Concepts","","* common ground","","### Selected publications","","* [Grounding explanations in evolving, diagnostic situations]","* [Maintaining common ground: an analysis of cooperative communication in the operating room](https://www.abdn.ac.uk/iprc/documents/Communication%20Book%20Chapter.pdf)","* [Behind Human Error]","","","## Gary Klein","","Klein studies how experts are able to quickly make effective decisions in high-tempo situations.","","Klein tweets as [@KleInsight](https://twitter.com/KleInsight).","","### Concepts","","* naturalistic decision making (NDM)","* intuitive expertise","* cognitive task analysis","* common ground","* problem detection","* automation as a \"team player\"","","### Selected publications","","* [Sources of power: how people make decisions](https://www.amazon.com/gp/product/0262534290/ref=dbs_a_def_rwt_bibl_vppi_i0)","* [Common Ground and Coordination in Joint Activity]","* [Working minds: a practitioner's guide to cognitive task analysis](https://www.amazon.com/gp/product/0262532816/ref=dbs_a_def_rwt_bibl_vppi_i5)","* [Patterns in Cooperative Cognition](https://www.researchgate.net/publication/262449980_Patterns_in_Cooperative_Cognition)","* [Can We Trust Best Practices? Six Cognitive Challenges of Evidence-Based Approaches]","* [Conditions for intuitive expertise: a failure to disagree](http://dx.doi.org/10.1037/a0016755)","* [Problem detection]","* [Ten challenges for making automation a team player] ([TWRR](https://resilienceroundup.com/issues/66))","* [Decision making in action: models and methods](http://www.macrocognition.com/documents/Decision-Making-in-Action-Models-and-Methods-0316.pdf)","* [Critical decision method for eliciting knowledge](https://ieeexplore.ieee.org/document/31053)","* [A recognition-primed decision (RPD) model of rapid decision making](https://pdfs.semanticscholar.org/0672/092ecc507fb41d81e82d2986cf86c4bff14f.pdf)","* [Seeing the invisible: perceptual-cognitive aspects of expertise](https://cmapspublic3.ihmc.us/rid=1G9NSY15K-N7MJMZ-LC5/SeeingTheInvisible.pdf)","* [Patterns in Cooperative Cognition]","* [The strengths and limitations of teams for detecting problems](https://link.springer.com/article/10.1007/s10111-005-0024-6)","* [Macrocognition] ([TWRR](https://resilienceroundup.com/issues/62/))","","[Problem detection]: https://www.researchgate.net/publication/220579480_Problem_detection","[Patterns in Cooperative Cognition]: https://www.researchgate.net/publication/262449980_Patterns_in_Cooperative_Cognition","[Can We Trust Best Practices? Six Cognitive Challenges of Evidence-Based Approaches]: https://journals.sagepub.com/doi/abs/10.1177/1555343416637520?journalCode=edma","","### Selected talks","","* [Problem detection](https://www.youtube.com/watch?v=UXx51qK4ItQ\u0026feature=emb_title)","","## Elizabeth Lay","","Elizabeth Lay is a resilience engineering practitioner. She is currently a director of safety and human performance at Lewis Tree Service.","","### Selected publications","","* [Noticing Brittleness, Designing for Resilience]","* [A practitioner’s experiences operationalizing Resilience Engineering]","","## Nancy Leveson","","Nancy Leveson is a computer science researcher with a focus in software safety.","","### Contributions","","#### STAMP","","Leveson developed the accident causality model known as STAMP: the Systems-Theoretic Accident Model and Process.","","See [STAMP](STAMP.md) for some more detailed notes of mine.","","### Concepts","","* Software safety","* STAMP (systems-theoretic accident model and processes)","* STPA (system-theoretic process analysis) hazard analysis technique","* CAST (causal analysis based on STAMP) accident analysis technique","* Systems thinking","* hazard","* interactive complexity","* system accident","* dysfunctional interactions","* safety constraints","* control structure","* dead time","* time constants","* feedback delays","","### Selected publications","* [A New Accident Model for Engineering Safer Systems](http://sunnyday.mit.edu/accidents/safetyscience-single.pdf)","* [Engineering a safer world](https://mitpress.mit.edu/books/engineering-safer-world)","* [STPA Handbook](http://psas.scripts.mit.edu/home/get_file.php?name=STPA_handbook.pdf)","* [Safeware](https://www.amazon.com/Safeware-Computers-Nancy-G-Leveson/dp/0201119722)","* [Resilience Engineering: Concepts and Precepts](https://www.amazon.com/gp/product/B009KNDF64/ref=x_gr_w_glide_bb?ie=UTF8\u0026tag=x_gr_w_glide_bb-20\u0026linkCode=as2\u0026camp=1789\u0026creative=9325\u0026creativeASIN=B009KNDF64\u0026SubscriptionId=1MGPYB6YW3HWK55XCGG2)","* [High-pressure steam engines and computer software](http://dx.doi.org/10.1145/143062.143076)","* [Resilience Engineering: Concepts and Precepts]","","## Beth Long","[Long](https://www.linkedin.com/in/beth-adele-long/) is a software engineer, product manager, and Principal at software incident analysis company Adaptive Capacity Labs. She previously held roles at New Relic, Jeli, and who co-authored the paper [Building and revising adaptive capacity sharing for technical incident response: A case of resilience engineering](https://www-sciencedirect-com.proxy.lib.ohio-state.edu/science/article/pii/S0003687020301903) with Dr. Richard Cook. ","","## Carl Macrae","","[Macrae](https://www.nottingham.ac.uk/business/people/lizcjm.html) is a social psychology","researcher who has done safety research in multiple domains, including aviation","and healthcare. He helped set up the new healthcare investigation agency in","England. He is currently a professor of organizational behavior and psychology","at the Notthingham University Business School.","","Macrae tweets at [@CarlMacrae](https://twitter.com/CarlMacrae).","","### Concepts","","* risk resilience","","### Selected publications","","* [Close calls](http://www.closecalls.cc/)","* [Early warnings, weak signals and learning from healthcare disasters](https://qualitysafety.bmj.com/content/23/6/440)","","## Laura Maguire","","[Maguire](https://www.linkedin.com/in/lauramaguire/) is a cognitive systems","engineer and ressearcher with a PhD from Ohio State University. Maguire has done safety work in multiple domains, including forestry, healthcare, oil \u0026 gas, wildland firefighting, mountain safety, and software services. She formerly led research \u0026 development at [jeli.io](jeli.io), is the a Director of the [Resilience \u0026 Proactive Safety Initiative(https://u.osu.edu/csel/resilienceproactivesafetyinitiative/) at The Ohio State University's Cognitive Systems Engineering Lab and is the founder of [Trace Cognitive Engineering](https://www.tracecognitive.com/) and [Cognition In The Wild](cognitioninthewild.com) translating theory into practice for software and other industries. She also supervises Masters thesis projects for the College of Engineering at Lund University for the Human Factors \u0026 Systems Safety program. She was a founding member of the [SNAFUCatchers Consortium](https://www.snafucatchers.com/) conducting focused cognitive systems and resilience engineering research on software companies. ","","Maguire (rarely) tweets as [@LauraMDMaguire](https://twitter.com/lauramdmaguire).","","### Selected publications","","* [Joint Cognitive Systems: Ideas With Impact for Designing Safer, More Resilient Automated Systems](https://ieeexplore.ieee.org/document/10493156/)","* [Cognitive Skills in Software Engineering: Operating Complex, Adaptive Systems at Speed and Scale](https://ieeexplore.ieee.org/document/10339148)","* [Automation doesn't work the way we think it does](https://ieeexplore.ieee.org/document/10372510)","* [Realizing the Benefits of Human Machine Teaming for Safe Software Operations](https://dl.acm.org/doi/abs/10.1109/MS.2024.3480768) (with Laura Nolan)","* [Navigating tradeoffs in software failures](https://www.computer.org/csdl/magazine/so/2025/03/10953345/25ICFoAidsk) (with Fred Hebert)","* [Managing the Hidden Costs of Coordination](https://queue.acm.org/detail.cfm?id=3380779)","* [Controlling the Costs of Coordination in Large-scale Distributed Software Systems](http://rave.ohiolink.edu/etdc/view?acc_num=osu1593661547087969) (PhD dissertation)","* [Howie: The Post-Incident Guide](https://www.jeli.io/howie-the-post-incident-guide/)","* [STELLA: Report from the SNAFUcatchers Workshop on Coping With Complexity](https://snafucatchers.github.io/)","* Pre-prints of many of her paywalled publications are available on [Researchgate](https://www.researchgate.net/profile/Laura-Maguire-2)","","### Selected talks","","* [Hard Choices, Tight Timelines: A Closer Look at Skip-Level Tradeoff Decisions During Incidents](https://www.usenix.org/conference/srecon24americas/presentation/maguire) (With Courtney Nash)","* [Followship: A Cognitive Systems approach to coordination in software incidents](https://www.youtube.com/watch?v=m6NlJFsfimw) ","* [How Many Is Too Much? Exploring Costs of Coordination During Outages](https://www.infoq.com/presentations/incident-command-system/)","* [Mental models – why saying “I didn’t know it worked that way” is a sign of expertise not incompetence](https://www.youtube.com/watch?v=VEprjLtHzg0)","* [Operating at the edge of the envelope](https://re-deploy.io/videos/27-maguire.html)","","## Courtney Nash ","","Nash is a researcher and founder of [The Void] (https://www.thevoid.community/), a community-contributed collection of software-related incident reports, aimed at making the internet a safer and more resilient place.","","## Christopher Nemeth","","[Nemeth](https://www.linkedin.com/in/christopher-nemeth-6651204) is a principal scientist at Applied Resesarch Associates, Inc.","","### Selected publications","","* [Replacing Hindsight With Insight: Toward Better Understanding of Diagnostic Failures]","* [Resilience is not control: healthcare, crisis management, and ICT]","* [Taking Things in One’s Stride: Cognitive Features of Two Resilient Performances]","* [Minding the Gaps: Creating Resilience in Health Care]","","","[Replacing Hindsight With Insight: Toward Better Understanding of Diagnostic Failures]: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.458.7283\u0026rep=rep1\u0026type=pdf","","## Laura Nolan","","[Nolan](https://www.linkedin.com/in/lauralifts/details/experience/) is a Principal Software Engineer and researcher who previously held roles at Google, Slack, Stanza. Her forthcoming masters thesis from Lund university studied expert troubleshooting during outages in production software environments. ","","She currently works at Reddit.","","* [Realizing the Benefits of Human Machine Teaming for Safe Software Operations](https://dl.acm.org/doi/abs/10.1109/MS.2024.3480768) (with Laura Maguire)","","## Anne-Sophie Nyssen","","[Nyssen](http://www.lecit.ulg.ac.be/equipe/anne-sophie-nyssen/) is a psychology professor at the University of Liège,","who does research on human error in complex systems, in particular in medicine.","","A list of publications can be found on her website linked above.","","","## Elinor Ostrom","","[Ostrom](http://www.elinorostrom.com/) was a Nobel-prize winning economics and","political science researcher.","","### Selected publications","* [Coping with tragedies of the commons](https://www.annualreviews.org/doi/abs/10.1146/annurev.polisci.2.1.493)","* [Governing the Commons: The Evolution of Institutions for Collective Action](https://www.amazon.com/Governing-Commons-Evolution-Institutions-Collective/dp/1107569788)","","### Concepts","","* tragedy of the commons","* polycentric governance","* social-ecological system framework","","## Jean Pariès","","Pariès is the president of [Dédale](http://www.dedale.net/dedale_en/), a safety and human factors consultancy.","","### Selected publications","* [Resilience engineering in practice: a guidebook]","","","[Resilience engineering in practice: a guidebook]: https://www.crcpress.com/Resilience-Engineering-in-Practice-A-Guidebook/Paries-Wreathall-Hollnagel/p/book/9781472420749","### Selected talks","","* [Predicting The fatal flaws: The challenge of The unpredictable...](paries-keynote-2015.pptx)","","## Emily Patterson","","[Patterson](https://hrs.osu.edu/faculty-and-staff/faculty-directory/patterson-emily)","is a researcher who applies human factors engineering to improve patient safety","in healthcare.","","### Selected publications","","* [Patient boarding in the emergency department as a symptom of complexity-induced risks](https://www.researchgate.net/publication/312624891_Patient_boarding_in_the_emergency_department_as_a_symptom_of_complexity-induced_risks)","* [Using observational study as a tool for discovery: uncovering cognitive and collaborative demands and adaptive strategies]","* [Voice Loops as Coordination Aids in Space Shuttle Mission Control]","* [Functionally distributed coordination during anomaly response in space shuttle mission control]","* [Patterns in Cooperative Cognition]","* [Collaborative Cross-Checking to Enhance Resilience] ([TWRR](https://resilienceroundup.com/issues/73/))","* [New Arctic Air Crash Aftermath Role-Play Simulation Orchestrating a Fundamental Surprise]","* [Handoff strategies in settings with high consequences for failure: lessons for health care operations] ([TWRR](https://resilienceroundup.com/issues/56))","* [How Unexpected Events Produce An Escalation Of Cognitive And Coordinative Demands] ([TWRR](https://resilienceroundup.com/issues/how-unexpected-events-produce-an-escalation-of-cognitive-and-coordinative-demands/))","* [Communication Strategies from High-reliability Organizations: Translation is Hard Work](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1876978/) ([TWRR](https://resilienceroundup.com/issues/communication-strategies-from-high-reliability-organizations-translation-is-hard-work/))","* [Understanding rigor in information analysis]","* [Behind Human Error: Taming Complexity to Improve Patient Safety]","","[Using observational study as a tool for discovery: uncovering cognitive and collaborative demands and adaptive strategies]: https://www.researchgate.net/profile/Emily_Patterson2/publication/237138704_USING_OBSERVATIONAL_STUDY_AS_A_TOOL_FOR_DISCOVERY_UNCOVERING_COGNITIVE_AND_COLLABORATIVE_DEMANDS_AND_ADAPTIVE_STRATEGIES/links/0deec52c8e310b385a000000.pdf","","[Voice Loops as Coordination Aids in Space Shuttle Mission Control]: https://www.semanticscholar.org/paper/Voice-Loops-as-Coordination-Aids-in-Space-Shuttle-Patterson-Watts-Perotti/068dfee1a859a63fa2ef82f008d239e6a81ed004","","[Functionally distributed coordination during anomaly response in space shuttle mission control]: https://www.researchgate.net/publication/3657906_Functionally_distributed_coordination_during_anomaly_response_inspace_shuttle_mission_control","","[How Unexpected Events Produce An Escalation Of Cognitive And Coordinative Demands]: http://csel.eng.ohio-state.edu/productions/laws/laws_mediapaper/2_4_escalation.pdf","","[Handoff strategies in settings with high consequences for failure: lessons for health care operations]: https://www.researchgate.net/publication/8648890_Handoff_strategies_in_settings_with_high_consequences_for_failure_Lessons_for_health_care_operations","","[Understanding rigor in information analysis]: https://www.researchgate.net/publication/228809190_Understanding_rigor_in_information_analysis","","","","## Charles Perrow","","Perrow is a sociologist who studied the Three Mile Island disaster. \"Normal Accidents\" is cited by numerous other influential systems engineering publications such as [Vaughan's](#diane-vaughan) \"The Challenger Launch Decision\".","","### Concepts","* Complex systems: A system of tightly-coupled components with common mode connections that is prone to unintended feedback loops, complex controls, low observability, and poorly-understood mechanisms. They are not always high-risk, and thus their failure is not always catastrophic.","* Normal accidents: Complex systems with many components exhibit unexpected interactions in the face of inevitable component failures. When these components are tightly-coupled, failed parts cannot be isolated from other parts, resulting in unpredictable system failures. Crucially, adding more safety devices and automated system controls often makes these coupling problems worse.","* Common-mode: The failure of one component that serves multiple purposes results in multiple associated failures, often with high interactivity and low linearity - both ingredients for unexpected behavior that is difficult to control.","* Production pressures and safety: Organizations adopt processes and devices to improve safety and efficiency, but production pressure often defeats any safety gained from the additions: the safety devices allow or encourage more risky behavior. As an unfortunate side-effect, the system is now also more complex.","","### Selected publications","* [Normal Accidents: Living With High-Risk Technologies](https://www.amazon.com/Normal-Accidents-Living-Technologies-Updated-ebook/dp/B00CHRINUI)","","## Shawna J. Perry","","Perry is a medical researcher who studies emergency medicine.","","### Concepts","* Underground adaptations","* Articulated functions vs. important functions","* Unintended effects","* Apparent success vs real success","* Exceptions","* Dynamic environments","","### Selected publications","","* [Underground adaptations: case studies from health care](https://doi.org/10.1007/s10111-011-0207-2)","* [Can We Trust Best Practices? Six Cognitive Challenges of Evidence-Based Approaches]","* [The Role of Automation in Complex System Failures]","* [Extemporaneous Adaptation to Evolving Complexity: A Case Study of Resilience in Healthcare] ([TWRR](https://resilienceroundup.com/issues/55))","* [Automation, interaction, complexity, and failure: A case study]","","### Other","","* [Interview on Naturalistic Decision Making podcast](https://open.spotify.com/episode/7lHcgt2KuDoLyvTP9wMbEn?si=nPIyk9L8QB2Iuck2fKKrNA)","","","","[Extemporaneous Adaptation to Evolving Complexity: A Case Study of Resilience in Healthcare]: https://pdfs.semanticscholar.org/1423/f18530599b9de186af0eee4852bb7e619384.pdf","","## Jens Rasmussen","","Jens Rasmussen was an enormously influential researcher in human factors and safety systems. In particular, you can see his influence in the work of Sidney Dekker, Nancy Leveson, David Woods.","","### Contributions","","#### Skill-rule-knowledge (SKR) model","","Rasmussen proposed three models of human performance.","","**Skill-based** behavior doesn't require conscious attention. The prototypical example is riding a bicycle.","","**Rule-based** behavior is based on a set of rules that we have internalized in","advance. We select which rule to use based on experience, and then carry it","out. An example would be: if threads are blocked, restart the server. You can think of rule-based behavior as a memorized runbook.","","**Knowledge-based** behavior comes into play when facing an unfamiliar","situation. The person generates a set of plans based on their understanding of","the environment, and then selects which one to use. The challenging incidents","are the ones that require knowledge-based behavior to resolve.","","He also proposed three types of information that humans process as they perform work.","","**Signals**. Example: weather vane","","**Signs**. Example: stop sign","","**Symbols**. Example: written language","","#### Abstraction hierarchy","","Rasmussen proposed a model of how operators reason about the behavior of a","system they are supervising called the *abstraction hierarchy*.","The levels in the hierarchy are","","1. functional purpose","2. abstract functions","3. general functions","4. physical funcitons","5. physical form","","The hierarchy forms a means-ends relationship: proper function is described top-down (ends), and problems are explained bottom-up (means)","","","#### Dynamic safety model","","Rasmussen proposed a state-based model of a socio-technical system as a system","that moves within a region of a state space. The region is surrounded by","different boundaries:","","* economic failure","* unacceptable work load","* functionality acceptable performance","","","","Source: [Risk management in a dynamic society: a modelling problem]","","Incentives push the system towards the boundary of acceptable performance:","accidents happen when the boundary is exceeded.","","","#### AcciMaps","","The AcciMaps approach is a technique for reasoning about the causes of an accident, using a diagram.","","","#### Risk management framework","","Rasmussen proposed a multi-layer view of socio-technical systems:","","","","Source: [Risk management in a dynamic society: a modelling problem]","","### Concepts","* Dynamic safety model","* Migration toward accidents","* Risk management framework","* Boundaries:"," - boundary of functionally acceptable performance"," - boundary to economic failure"," - boundary to unacceptable work load","* Cognitive systems engineering","* Skill-rule-knowledge (SKR) model","* AcciMaps","* Means-ends hierarchy","* Ecological interface design","* Systems approach","* Control-theoretic","* decisions, acts, and errors","* hazard source","* anatomy of accidents","* energy","* systems thinking","* trial and error experiments","* defence in depth (fallacy)","* Role of managers","\t- Information","\t- Competency","\t- Awareness","\t- Commitment","* Going solid","* observability","","### Selected publications","* [Mental procedures in real-life tasks: a case study of electronic trouble shooting](https://www.tandfonline.com/doi/abs/10.1080/00140137408931355) (1974)","* [Coping with complexity](https://orbit.dtu.dk/en/publications/coping-with-complexity)","* [Skills, rules, and knowledge; signals, signs, and symbols, and other distinctions in human performance models](https://www.iwolm.com/wp-content/downloads/SkillsRulesAndKnowledge-Rasmussen.pdf)","* [“Going solid”: a model of system dynamics and consequences for patient safety](https://qualitysafety.bmj.com/content/14/2/130)","* [Human error and the problem of causality in analysis of accidents](https://www.ida.liu.se/~729A71/Literature/Human%20Error_T/Rasmussen_1990.pdf) ([TWRR](https://resilienceroundup.com/issues/human-error-and-the-problem-of-causality-in-analysis-of-accidents/))","* [Human Errors: A Taxonomy for Describing Human Malfunction in Industrial Installations](https://backend.orbit.dtu.dk/ws/portalfiles/portal/158020073/ERTAX1.PDF)","* [Ecological interfaces: A technological imperative in high‐tech systems](https://core.ac.uk/download/pdf/13788397.pdf)","* [Information processing and human-machine interaction: an approach to cognitive engineering](https://www.amazon.com/Information-Processing-Human-Machine-Interaction-North-Holland/dp/0444009876)","* [The role of hierarchical knowledge representation in decisionmaking and system management](https://backend.orbit.dtu.dk/ws/files/158019622/HISMC.PDF)","* [A Model of Human Decision Making in Complex Systems and its Use for Design of System Control Strategies](https://core.ac.uk/download/pdf/13777954.pdf)","* [The role of error in organizing behaviour](https://qualitysafety.bmj.com/content/qhc/12/5/377.full.pdf) ([TWRR](https://resilienceroundup.com/issues/the-role-of-error-in-organizing-behaviour/))","* [Information processing and human-machine interaction](https://www.osti.gov/biblio/7011990-information-processing-human-machine-interaction)","* [Risk management in a dynamic society: a modelling problem]","* [Proactive risk management in a dynamic society](https://rib.msb.se/Filer/pdf/16252.pdf)","* [Trends in Human Reliability Analysis](https://backend.orbit.dtu.dk/ws/portalfiles/portal/137294535/TREND.PDF)","* [The role of hierarchical knowledge representation in decisionmaking and system management](https://backend.orbit.dtu.dk/ws/portalfiles/portal/158019622/HISMC.PDF)","* [The role of error in organizing behaviour](https://backend.orbit.dtu.dk/ws/portalfiles/portal/137538698/ERRROLE_1_.PDF)","* [Human error and the problem of causality in analysis of accidents](https://backend.orbit.dtu.dk/ws/portalfiles/portal/158018718/ROYSOC.PDF)","* [Coping with human errors through system design: implications for ecological interface design](https://citeseerx.ist.psu.edu/document?repid=rep1\u0026type=pdf\u0026doi=5fb7644d205b342aa52c594b7982a9e208086238)","* [Graphic representation of accident scenarios: mapping system structure and the causation of accidents](https://www.sciencedirect.com/science/article/abs/pii/S0925753500000369)","* [Diagnostic reasoning in action](https://backend.orbit.dtu.dk/ws/portalfiles/portal/158017532/DIAACT.PDF)","* [A framework for cognitive task analysis in systems design](https://orbit.dtu.dk/en/publications/a-framework-for-cognitive-task-analysis-in-systems-design)","* [Analysis of human errors in industrial incidents and accidents for mprovement of work safety](https://backend.orbit.dtu.dk/ws/portalfiles/portal/158019864/LEPRAS.PDF)","* [Why do complex organizational systems fail?](https://documents1.worldbank.org/curated/ru/535511468766200820/pdf/multi0page.pdf)","* [Notes on human error analysis and prediction](https://orbit.dtu.dk/en/publications/notes-on-human-error-analysis-and-prediction)","","(These are written but others about Rasmussen's work)","* [Recurring themes in the legacy of Jens Rasmussen](https://www.sciencedirect.com/science/article/abs/pii/S0003687016302150?via%3Dihub) - special issue of Applied Ergonomics","* [Reflecting on Jens Rasmussen’s legacy. A strong program for a hard problem](https://doi.org/10.1016/j.ssci.2014.03.015) ([my notes](https://github.com/lorin/booknotes/blob/master/papers/Reflecting-on-Jens-Rasmussens-Legacy.md))","* [Reflecting on Jens Rasmussen's legacy (2) behind and beyond, a ‘constructivist turn’](https://doi.org/10.1016/j.apergo.2015.07.013)","* [Musings on Models and the Genius of Jens Rasmussen](https://www.sciencedirect.com/science/article/abs/pii/S0003687015301009?via%3Dihub)","","[Risk management in a dynamic society: a modelling problem]: https://doi.org/10.1016/S0925-7535(97)00052-0","","## Mike Rayo","","Rayo is the Director of the Cognitive Systems Engineering Laboratory at the Ohio State University.","","### Concepts","","* SCAD (Systematic Contributors Analysis and Diagram)","","### Selected Publications","","* [Developing Systemic Contributors and Adaptations Diagramming (SCAD): systemic insights, multiple pragmatic implementations]","* [Multiple Systemic Contributors versus Root Cause: Learning from a NASA Near Miss](https://www.researchgate.net/publication/308194080_Multiple_Systemic_Contributors_versus_Root_Cause_Learning_from_a_NASA_Near_Miss)","* [The Silicon Valley Way: Move fast and break…aviation safety?]","","[Developing Systemic Contributors and Adaptations Diagramming (SCAD): systemic insights, multiple pragmatic implementations]: https://journals.sagepub.com/doi/10.1177/1071181322661334","[The Silicon Valley Way: Move fast and break…aviation safety?]: https://thebulletin.org/2025/05/the-silicon-valley-way-move-fast-and-breakaviation-safety/","","## James Reason","","Reason is a psychology researcher who did work on understanding and categorizing human error.","","### Contributions","","#### Accident causation model (Swiss cheese model)","","Reason developed an accident causation model that is sometimes known as the *swiss cheese* model of accidents.","In this model, Reason introduced the terms \"sharp end\" and \"blunt end\".","","#### Human Error model: Slips, lapses and mistakes","","Reason developed a model of the types of errors that humans make:","","* slips","* lapses","* mistakes","","### Concepts","","* Blunt end","* Human error","* Slips, lapses and mistakes","* Swiss cheese model","","### Selected publications","","* [Human error]","* [Organizational Accidents Revisited](https://www.amazon.com/Organizational-Accidents-Revisited-James-Reason/dp/1472447689)","","[Human error]: https://www.amazon.com/gp/product/0521314194/ref=dbs_a_def_rwt_bibl_vppi_i0","","## J. Paul Reed","","[Reed](https://jpaulreed.com/) is a Senior Applied Resilience engineer at Netflix and runs [REdeploy](https://re-deploy.io), a conference focused on Resilience Engineering in the software development and operations industry.","","Reed tweets as [@jpaulreed](https://twitter.com/jpaulreed).","","### Selected Publications","","* [Maps, Context, and Tribal Knowledge: On the Structure and Use of Post-Incident Analysis Artifacts in Software Development and Operations](https://lup.lub.lu.se/student-papers/search/publication/8966930j","* [Beyond the \"Fix-it\" Treadmill](https://queue.acm.org/detail.cfm?id=3380780d)","","","### Concepts","","* [Blame \"Aware\"](https://jpaulreed.com/blame-aware) (versus \"Blameless\") Culture","* Postmortem Artifact _Archetypes_","","## Emilie M. Roth","","[Roth](http://www.rothsite.com/resume.html) is a cognitive psychologist who","serves as the principal scientist at [Roth Cognitive Engineering](http://www.rothsite.com/), a small","company that conducts research and application in the areas of human factors","and applied cognitive psychology (cognitive engineering)","","### Selected publications","","* [Uncovering the Requirements of Cognitive Work](http://citeseerx.ist.psu.edu/viewdoc/summary?doi=10.1.1.564.2044) ([TWRR](https://www.getrevue.co/profile/resilience/issues/resilience-roundup-uncovering-the-requirements-of-cognitive-work-issue-30-173410))","* [Using observational study as a tool for discovery: uncovering cognitive and collaborative demands and adaptive strategies]","* [Handoff strategies in settings with high consequences for failure: lessons for health care operations] ([TWRR](https://resilienceroundup.com/issues/56))","* [Bootstrapping multiple converging cognitive task analysis techniques for system design] ([TWRR](https://resilienceroundup.com/issues/70))","","### Other","","* [Interview on Naturalistic Decision Making podcast](https://open.spotify.com/episode/3XqAhdpyrszLoB59VcRJWG)","","## Nadine Sarter","","[Sarter](https://ioe.engin.umich.edu/people/nadine-sarter/) is a researcher in industrial and operations engineering.","She is the director of the Center for Ergonomics at the University of Michigan.","","### Concepts","","* cognitive ergonomics","* organization safety","* human-automation/robot interaction","* human error / error management","* attention / interruption management","* design of decision support systems","","","### Selected publications","","* [Learning from Automation Surprises and \"Going Sour\" Accidents: Progress on Human-Centered Automation](https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/19980016965.pdf)","* [Behind Human Error]","* [Designed-Induced Error and Error-Informed Design: A Two-Way Street](https://www.amazon.com/Cognitive-Systems-Engineering-Expertise-Applications-ebook/dp/B076TDR6H9/ref=sr_1_1?keywords=cognitive+systems+engineering\u0026qid=1554075974\u0026s=gateway\u0026sr=8-1)","* [The Critical Incident Technique: A Method for Identifying System Strengths and Weaknesses Based on Observational Data](https://www.taylorfrancis.com/books/e/9780429134845)","* [Myths of automation and their implications for military procurement]","* [Automation surprises]","* [Team Play with a Powerful and Independent Agent: A Full-Mission Simulation Study] ([TWRR](https://resilienceroundup.com/issues/team-play-with-a-powerful-and-independent-agent-a-full-mission-simulation-study/))","","[Bootstrapping multiple converging cognitive task analysis techniques for system design]: https://www.researchgate.net/publication/313737506_Bootstrapping_multiple_converging_cognitive_task_analysis_techniques_for_system_design","[Automation surprises]: https://www.researchgate.net/publication/270960170_Automation_surprises","[Team Play with a Powerful and Independent Agent: A Full-Mission Simulation Study]: https://www.researchgate.net/publication/12195752_Team_Play_with_a_Powerful_and_Independent_Agent_A_Full-Mission_Simulation_Study","","## James C. Scott","","Scott is an anthropologist who also does research in political science. While","Scott is not a member of a resilience engineering community, his book *Seeing","like a state* has long been a staple of the cognitive systems engineering and","resilience engineering communities.","","### Concepts","","* authoritarian high-modernism","* legibility","* mētis","","### Selected publications","","* [Seeing like a state: how certain schemes to improve the human condition have failed](https://www.amazon.com/Seeing-like-State-Certain-Condition/dp/0300078153/ref=sr_1_1)","","","## Steven Shorrock","","Shorrock is a chartered psychologist and a chartered ergonomist and human","factors specialist. He is the editor-in-chief of EUROCONTROL","[HindSight](https://www.skybrary.aero/index.php/HindSight_-_EUROCONTROL)","magazine. He runs the excellent [Humanistic Systems](https://humanisticsystems.com/) blog.","","Shorrock tweets as [@StevenShorrock](https://twitter.com/StevenShorrock).","","### Selected publications","","* [Systems Thinking for Safety: Ten Principles A White Paper Moving towards Safety-II](https://skybrary.aero/sites/default/files/bookshelf/2882.pdf)","* [Human Factors and Ergonomics in Practice: Improving System Performance and Human Well-Being in the Real World](https://www.crcpress.com/Human-Factors-and-Ergonomics-in-Practice-Improving-System-Performance-and/Shorrock-Williams/p/book/9781472439253) (book)","* [State of science: evolving perspectives on ‘human error’](https://doi.org/10.1080/00140139.2021.1953615)","","### Selected talks","","[Life After Human Error](https://www.youtube.com/watch?v=STU3Or6ZU60) (Velocity Europe 2014 keynote)","","## Diane Vaughan","","Vaughan is a sociology researcher who did a famous study of the NASA Challenger accident, concluding that it was the result of organizational failure rather than a technical failure. Specifically, production pressure overrode the rigorous scientific safety culture in place at NASA.","","### Concepts","","* Structural Secrecy: Organizational structure, processes, and information exchange patterns can systematically undermine the ability to \"see the whole picture\" and conceal risky decisions.","* Social Construction of Risk: Out of the necessity to balance risk with the associated reward, any group of people will develop efficient heuristics to solve the problems they face. The understanding of risk that faces one subgroup may not match that of another subgroup or of the whole group. The ability of an individual to change a social construction of risk, formed over years with good intentions and often with evidence, is limited. (Though the evidence is usually accurate, the conclusion might not be, leading to an inadvertent scientific paradigm.)","* Normalization of Deviance: During operation of a complex system, inadvertent deviations from system design may occur and not result in a system failure. Because the intial construction of risk is usually conservative, the deviation is seen as showing that the system and its redundancies \"worked\", leading to a new accepted safe operating envelope.","* Signals of potential danger: Information gained through the operation of a system that may indicate the system does not work as designed. Most risk constructions are based on a comprehensive understanding of the operation of the system, so information to the contrary is a sign that the system could leave the safe operation envelope in unexpected ways - a danger.","* Weak signals, mixed signals, missed signals: signals of potential danger that have been interpreted as non-threats or acceptable risk because at the time they didn't represent a clear and present danger sufficient to overcome the Social Construction of Risk. Often, post-hoc, these are seen as causes due to cherry-picking - such signals were ignored before with no negative consequences.","* Competition for Scarce Resources: An ongoing need to justify investment to customers leads to Efficiency-Thoroughness Tradeoffs (ETTOs). In NASA's case, justifying the cost of the Space Shuttle program to taxpayers and their congressional representatives meant pressure to quickly develop payload delivery capability at the lowest cost possible.","* Belief in Redundancy: Constructing risk from a signal of potential danger such that a redundant subsystem becomes part of the normal operating strategy for a primary subsystem. In NASA's case, signals that the primary O-ring assembly did not operate as expected formed an acceptable risk because a secondary O-ring would contain a failure. Redundancy was eliminated from the design in this construction of risk - the secondary system now became part of the primary system, eliminating system redundancy.","","### Selected publications","","* [The Challenger Launch Decision: Risky Technology, Culture, and Deviance at"," NASA](https://www.amazon.com/Challenger-Launch-Decision-Technology-Deviance/dp/022634682X/ref=sr_1_1?ie=UTF8\u0026qid=1545966442\u0026sr=8-1\u0026keywords=diane+vaughan)","","## Barry Turner","","[Turner](https://www.tandfonline.com/doi/pdf/10.1080/10245289508523441) was a sociologist who greatly influenced the field of organization studies.","","### Selected publications","","* [Man-made disasters](https://www.amazon.com/Man-Made-Disasters-Second-Barry-Turner/dp/0750620870/ref=sr_1_1)","","## Robert L. Wears","","[Wears](https://en.wikipedia.org/wiki/Robert_Wears) was a medical researcher who also had a PhD in industrial safety.","","### Concepts","","* Underground adaptations","* Articulated functions vs. important functions","* Unintended effects","* Apparent success vs real success","* Exceptions","* Dynamic environments","* Systems of care are intrinsically hazardous","","### Selected publications","","* [The error of counting \"errors\"](https://linkinghub.elsevier.com/retrieve/pii/S0196064408006070) [BH](https://safety177496371.wordpress.com/2023/09/20/the-error-of-counting-errors/)","* [Underground adaptations: case studies from health care](https://doi.org/10.1007/s10111-011-0207-2)","* [Fundamental On Situational Surprise: A Case Study With Implications For Resilience](https://books.openedition.org/pressesmines/1122)","* [Replacing Hindsight With Insight: Toward Better Understanding of Diagnostic Failures]","* [Seeing patient safety ‘Like a State’](http://dx.doi.org/10.1016%2Fj.ssci.2014.02.007)","* [Fundamental On Situational Surprise: A Case Study With Implications For Resilience](https://books.openedition.org/pressesmines/1122?lang=en)","* [The Role of Automation in Complex System Failures]","* [Exploring the Dynamics of Resilient Performance](https://pastel.archives-ouvertes.fr/pastel-00664145/document)","* [Extemporaneous Adaptation to Evolving Complexity: A Case Study of Resilience in Healthcare] ([TWRR](https://resilienceroundup.com/issues/55))","* [Automation, interaction, complexity, and failure: A case study]","* [Resilience is not control: healthcare, crisis management, and ICT]","* [The Secret Life of Policies](https://www.annemergmed.com/article/S0196-0644(17)30874-0/fulltext)","* [The tragedy of adaptability](https://www.annemergmed.com/article/S0196-0644(13)01554-0/abstract) [BH](https://safety177496371.wordpress.com/2021/04/19/the-tragedy-of-adaptability/)","* [Relying on resilience: too much of a good thing?](https://www.taylorfrancis.com/chapters/edit/10.1201/9781315605722-11/relying-resilience-much-good-thing-robert-wears-charles-vincent) [BH](https://safety177496371.wordpress.com/2024/03/20/relying-on-resilience-too-much-of-a-good-thing/)","* [Replacing hindsight with insight: toward better understanding of diagnostic failures] [BH](https://safety177496371.wordpress.com/2024/02/26/replacing-hindsight-with-insight-toward-better-understanding-of-diagnostic-failures/)","* [The science of human factors: separating fact from fiction](https://safety177496371.wordpress.com/2024/10/29/the-science-of-human-factors-separating-fact-from-fiction/) [BH](https://safety177496371.wordpress.com/2024/10/29/the-science-of-human-factors-separating-fact-from-fiction/)","* [Resilience skills as emergent phenomena: A study of emergency departments in Brazil and the United States](https://doi.org/10.1016/j.apergo.2016.02.012) [BH](https://safety177496371.wordpress.com/2023/01/20/resilience-skills-as-emergent-phenomena-a-study-of-emergency-departments-in-brazil-and-the-united-states/)","* [Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?](https://qualitysafety.bmj.com/content/26/5/381) [BH](https://safety177496371.wordpress.com/2021/03/18/our-current-approach-to-root-cause-analysis-is-it-contributing-to-our-failure-to-improve-patient-safety/)","* [Error Reduction and Performance Improvement in the Emergency Department through Formal Teamwork Training: Evaluation Results of the MedTeams Project](https://pmc.ncbi.nlm.nih.gov/articles/PMC1464040/) [BH](https://safety177496371.wordpress.com/2021/03/18/our-current-approach-to-root-cause-analysis-is-it-contributing-to-our-failure-to-improve-patient-safety/)","* [In situ simulation: detection of safety threats and teamwork training in a high risk emergency department](https://www.academia.edu/download/85660593/468.full.pdf)","* [“Safeware”: Safety-Critical Computing and Health Care Information Technology](https://europepmc.org/article/nbk/nbk43774)","* [The Illusion of Explanation]","* [Thick Versus Thin: Description Versus Classification in Learning From Case Reviews](https://www.annemergmed.com/article/S0196-0644(07)01451-5/fulltext)","* [Safety, Error, and Resilience: a Meta-narrative Review](https://www.resilience-engineering-association.org/download/resources/symposium/symposium_2015/Wears_R.-Sutcliffe_K.-Safety-error-and-resilience-a-meta-narrative-review-Paper.pdf)","* [Resilient Procedures: Oxymoron or Innovation?](https://www.taylorfrancis.com/chapters/edit/10.1201/9781315366838-18/resilient-procedures-oxymoron-innovation-robert-wears-garth-hunte) ([BH](https://safetyinsights.org/2025/02/24/resilient-procedures-oxymoron-or-innovation/))","* [Design Trumps Training](https://www.annemergmed.com/article/S0196-0644(15)01376-1/abstract)","","### Selected talks","","* [Design of resilient systems](https://www.youtube.com/watch?v=nV52yh6GDMg)","","","## David Woods","","[Woods](https://u.osu.edu/csel/member-directory/david-woods/) has a research background in cognitive systems engineering and did work","researching NASA accidents. He is one of the founders [Adaptive Capacity","Labs](http://www.adaptivecapacitylabs.com/), a resilience engineering","consultancy.","","Woods tweets as [@ddwoods2](https://twitter.com/ddwoods2).","","### Contributions","","Woods has contributed an enormous number of concepts.","","#### The adaptive universe","","Woods uses *the adaptive universe* as a lens for understanding the behavior of","all different kinds of systems.","","All systems exist in a dynamic environment, and must adapt to change.","","A successful system will need to adapt by virtue of its success.","","Systems can be viewed as units of adaptive behavior (UAB) that interact. UABs","exist at different scales (e.g., cell, organ, individual, group, organization).","","All systems have competence envelopes, which are constrained by boundaries.","","The resilience of a system is determined by how it behaves when it comes near","to a boundary.","","See [Resilience Engineering Short Course](https://www.youtube.com/playlist?list=PLvlZBj1NU_ikTy1ot30EbEbYMAoBf9eAt) for more details.","","#### Charting adaptive cycles","","* Trigger","* Units of adaptive behavior","* Goals and goal conflicts","* Pressure points","* Subcycles","","### Graceful extensibility","","From [The theory of graceful extensibility: basic rules that govern adaptive systems]:","","(Longer wording)","","1. Adaptive capacity is finite","2. Events will produce demands that challenge boundaries on the adaptive"," capacity of any UAB","3. Adaptive capacities are regulated to manage the risk of saturating CfM","4. No UAB can have sufficient ability to regulate CfM to manage the risk of saturation alone","5. Some UABs monitor and regulate the CfM of other UABs in response to changes"," in the risk of saturation","6. Adaptive capacity is the potential for adjusting patterns of action to"," handle future situations, events, opportunities and disruptions","7. Performance of a UAB as it approaches saturation is different from the"," performance of that UAB when it operates far from saturation","8. All UABs are local","9. There are bounds on the perspective any UAB, but these limits are overcome"," by shifts and contrasts over multiple perspectives.","10. Reflective systems risk mis-calibration","","(Shorter wording)","","1. Boundaries are universal","2. Surprise occurs, continuously","3. Risk of saturation is monitored and regulated","4. Synchronization across multiple units of adaptive behavior in a network is necessary","5. Risk of saturation can be shared","6. Pressure changes what is sacrificed when","7. Pressure for optimality undermines graceful extensibility","8. All adaptive units are local","9. Perspective contrast overcomes bounds","10. Mis-calibration is the norm","","For more details, see [summary of graceful extensibility theorems](graceful-extensibility.md).","","### SCAD (Systemic Contributors Analysis and Diagram)","","(tbd)","","### Concepts","","Many of these are mentioned in Woods's [short course](https://www.youtube.com/playlist?list=PLvlZBj1NU_ikTy1ot30EbEbYMAoBf9eAt).","","* adaptive capacity","* adaptive universe","* unit of adaptive behavior (UAB), adaptive unit","* continuous adaptation","* graceful extensibility","* sustained adaptability","* Tangled, layered networks (TLN)","* competence envelope","* adaptive cycles/histories","* precarious present (unease)","* resilient future","* tradeoffs, five fundamental","* efflorescence: the degree that changes in one area tend to recruit or open up"," beneficial changes in many other aspects of the network - which opens new"," opportunities across the network ...","* reverberation","* adaptive stalls","* borderlands","* anticipate","* synchronize","* proactive learning","* initiative","* reciprocity","* SNAFUs","* robustness","* surprise","* dynamic fault management","* software systems as \"team players\"","* multi-scale","* brittleness","* how adaptive systems fail (see: [How do systems manage their adaptive capacity to successfully handle disruptions? A resilience engineering perspective])"," - decompensation"," - working at cross-purposes"," - getting stuck in outdated behaviors","* proactive learning vs getting stuck","* oversimplification","* fixation","* fluency law, veil of fluency","* capacity for manoeuvre (CfM)","* crunches","* turnaround test","* sharp end, blunt end","* adaptive landscapes","* law of stretched systems: Every system is continuously stretched to operate at capacity.","* cascades","* adapt how to adapt","* unit working hard to stay in control","* you can monitor how hard you're working to stay in control (monitor risk of saturation)","* reality trumps algorithms","* stand down","* time matters","* Properties of resilient organizations"," - Tangible experience with surprise"," - uneasy about the precarious present"," - push initiative down"," - reciprocity"," - align goals across multiple units","* goal conflicts, goal interactions (follow them!)","* to understand system, must study it under load","* adaptive races are unstable","* adaptive traps","* roles, nesting of","* hidden interdependencies","* net adaptive value","* matching tempos","* tilt toward florescence","* linear simplification","* common ground","* problem detection","* joint cognitive systems","* automation as a \"team player\"","* \"new look\"","* sacrifice judgment","* task tailoring","* substitution myth","* observability","* directability","* directed attention","* inter-predictability","* error of the third kind: solving the wrong problem","* buffering capacity","* context gap","* Norbert's contrast","* anomaly response","* automation surprises","* disturbance management","* Doyle's catch","* Cooperative advocacy","","### Selected publications","","* [Resilience Engineering: Concepts and Precepts](https://www.amazon.com/gp/product/B009KNDF64/ref=x_gr_w_glide_bb?ie=UTF8\u0026tag=x_gr_w_glide_bb-20\u0026linkCode=as2\u0026camp=1789\u0026creative=9325\u0026creativeASIN=B009KNDF64\u0026SubscriptionId=1MGPYB6YW3HWK55XCGG2)","* [Prologue: Resilience Engineering Concepts](http://erikhollnagel.com/onewebmedia/Prologue.pdf)","* [Epilogue: Resilience Engineering Precepts](https://www.researchgate.net/publication/265074845_Epilogue_Resilience_Engineering_Precepts)","* [Resilience is a verb](https://www.researchgate.net/publication/329035477_Resilience_is_a_Verb)","* [Four concepts for resilience and the implications for the future of resilience engineering](https://www.researchgate.net/publication/276139783_Four_concepts_for_resilience_and_the_implications_for_the_future_of_resilience_engineering) ([TWRR](https://resilienceroundup.com/issues/65))","* [Basic patterns in how adaptive systems fail](https://www.researchgate.net/publication/284324002_Basic_patterns_in_how_adaptive_systems_fail) ([TWRR](https://resilienceroundup.com/issues/34/))","* [Resilience and the ability to anticipate](https://www.researchgate.net/publication/285487326_Resilience_and_the_ability_to_anticipate) ([TWRR](https://resilienceroundup.com/issues/resilience-and-the-ability-to-anticipate/))","* [Distancing through differencing: An obstacle to organizational learning following accidents](https://www.researchgate.net/publication/292504703_Distancing_through_differencing_An_obstacle_to_organizational_learning_following_accidents)","* [Essential characteristics of resilience](https://www.researchgate.net/publication/284328979_Essential_characteristics_of_resilience)","* [Essentials of resilience, revisited](https://www.researchgate.net/publication/330116587_4_Essentials_of_resilience_revisited) ([TWRR](https://resilienceroundup.com/issues/71/))","* [Learning from Automation Surprises and \"Going Sour\" Accidents: Progress on Human-Centered Automation](https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/19980016965.pdf)","* [Behind Human Error]","* [Joint Cognitive Systems: Patterns in Cognitive Systems Engineering](https://www.amazon.com/gp/product/0849339332/ref=x_gr_w_bb?ie=UTF8\u0026tag=x_gr_w_bb-20\u0026linkCode=as2\u0026camp=1789\u0026creative=9325\u0026creativeASIN=0849339332\u0026SubscriptionId=1MGPYB6YW3HWK55XCGG2)","* [Patterns in Cooperative Cognition](https://www.researchgate.net/publication/262449980_Patterns_in_Cooperative_Cognition)","* [Origins of cognitive systems engineering](https://www.researchgate.net/publication/298793082_Origins_of_Cognitive_Systems_Engineering)","* [Incidents - markers of resilience or brittleness?](https://www.researchgate.net/publication/292504952_Incidents_-_markers_of_resilience_or_brittleness) [BH](https://safety177496371.wordpress.com/2023/12/18/incidents-markers-of-resilience-or-brittleness/)","* [The alarm problem and directed attention in dynamic fault management](https://www.researchgate.net/publication/40961767_The_Alarm_problem_and_directed_attention_in_dynamic_fault_management)","* [Can We Trust Best Practices? Six Cognitive Challenges of Evidence-Based Approaches]","* [Operating at the Sharp End: The Complexity of Human Error](https://www.researchgate.net/publication/313407259_Operating_at_the_Sharp_End_The_Complexity_of_Human_Error)","* [The theory of graceful extensibility: basic rules that govern adaptive systems]","* [Beyond Simon’s Slice: Five Fundamental Trade-Offs that Bound the Performance of Macrocognitive Work Systems](https://www.researchgate.net/publication/220628177_Beyond_Simon%27s_Slice_Five_Fundamental_Trade-Offs_that_Bound_the_Performance_of_Macrocognitive_Work_Systems) ([TWRR](https://resilienceroundup.com/issues/five-fundamental-trade-offs-in-cognitive-work/))","* [Anticipating the effects of technological change: A new era of dynamics for human factors](https://www.researchgate.net/publication/247512351_Anticipating_the_effects_of_technological_change_A_new_era_of_dynamics_for_human_factors)","* [Common Ground and Coordination in Joint Activity]","* [Resilience as Graceful Extensibility to Overcome Brittleness](https://www.irgc.org/wp-content/uploads/2016/04/Woods-Resilience-as-Graceful-Extensibility-to-Overcome-Brittleness-1.pdf)","* [Resilience Engineering: Redefining the Culture of Safety and Risk Management](http://ordvac.com/soro/library/Aviation/Aviation%20Safety/General%20Safety%20Articles/resilience%20engineering%20bulletin.pdf)","* [Problem detection]","* [Cognitive consequences of clumsy automation on high workload, high consequence human performance]","* [Implications of automation surprises in aviation for the future of total intravenous anesthesia (TIVA)]","* [Ten challenges for making automation a team player] ([TWRR](https://resilienceroundup.com/issues/66))","* [The Messy Details: Insights From the Study of Technical Work in Healthcare]","* [Nosocomial automation: technology-induced complexity and human performance]","* [Human-centered software agents: Lessons from clumsy automation](http://www.ifp.illinois.edu/nsfhcs/abstracts/woods.txt)","* [STELLA: Report from the SNAFUcatchers Workshop on Coping with Complexity](https://snafucatchers.github.io/)","* [The New Look at Error, Safety, and Failure: A Primer for Health Care]","* [Grounding explanations in evolving, diagnostic situations]","* [Resilience Engineering: Concepts and Precepts]","* [A Tale of Two Stories: Contrasting Views of Patient Safety]","* [Voice Loops as Coordination Aids in Space Shuttle Mission Control]","* [The Critical Incident Technique: 40 Years Later](https://journals.sagepub.com/doi/abs/10.1177/154193129403801702)","* [Functionally distributed coordination during anomaly response in space shuttle mission control]","* [Cooperative Advocacy: An Approach for Integrating Diverse Perspectives in Anomaly Response](https://www.researchgate.net/publication/225211285_Cooperative_Advocacy_An_Approach_for_Integrating_Diverse_Perspectives_in_Anomaly_Response)","* [Visual momentum: A concept to improve the cognitive coupling of person and computer](https://www.researchgate.net/publication/222737388_Visual_Momentum_A_Concept_to_Improve_the_Cognitive_Coupling_of_Person_and_Computer)","* [Cognitive demands and activities in dynamic fault management: abductive reasoning and disturbance management](https://www.researchgate.net/publication/262401824_Cognitive_demands_and_activities_in_dynamic_fault_management_abductive_reasoning_and_disturbance_management)","* [Coping with complexity: the psychology of human behaviour in complex systems](https://www.researchgate.net/publication/238727732_Coping_with_Complexity_The_psychology_of_human_behavior_in_complex_systems) ([TWRR](https://resilienceroundup.com/issues/coping-with-complexity/))","* [Process Tracing Methods for The Study of Cognition Outside of the Experimental Laboratory. In Klein GA, Orasanu J, Calderwood R, Zsambok CE, eds. Decision making in action: Models](https://www.researchgate.net/profile/David_Woods11/publication/232513565_Process-tracing_methods_for_the_study_of_cognition_outside_of_the_experimental_psychology_laboratory/links/00b7d53988a2f7a7f8000000.pdf)","* [Towards a theoretical base for representation design in the computer medium: ecological perception and aiding human cognition](https://www.researchgate.net/publication/239059408_Towards_a_theoretical_base_for_representation_design_in_the_computer_medium_ecological_perception_and_aiding_human_cognition)","* [Perspectives on Human Error: Hindsight Biases and Local Rationality]","* [Anomaly Response]","* [The Risks of Autonomy: Doyle's Catch](https://www.researchgate.net/publication/303832480_The_Risks_of_Autonomy_Doyles_Catch) ([TWRR](https://resilienceroundup.com/issues/the-risks-of-autonomy-doyles-catch/))","* [Mistaking Error]","* [Adapting to new technology in the operating room]","* [The Strategic Agility Gap: How organizations are slow and stale to adapt in turbulent worlds](https://www.researchgate.net/publication/330196218_The_Strategic_Agility_Gap_How_organizations_are_slow_and_stale_to_adapt_in_turbulent_worlds)","* [Resiliency Trade Space Study: The Interaction of Degraded C2 Link and Detect and Avoid Autonomy on Unmanned Aircraft](https://www.researchgate.net/publication/330222613_Resiliency_Trade_Space_Study_The_Interaction_of_Degraded_C2_Link_and_Detect_and_Avoid_Autonomy_on_Unmanned_Aircraft)","* [Cognitive Technologies: The Design of Joint Human-Machine Cognitive Systems](https://www.researchgate.net/publication/220604613_Cognitive_Technologies_The_Design_of_Joint_Human-Machine_Cognitive_Systems)","* [Cognitive Systems Engineering: New wine in new bottles] ([TWRR](https://resilienceroundup.com/issues/32/))","* [The Seven Deadly Myths of \"Autonomous Systems\"]","* [Resilience and the ability to anticipate](https://www.researchgate.net/publication/285487326_Resilience_and_the_ability_to_anticipate)","* [Patterns in Cooperative Cognition]","* [Collaborative Cross-Checking to Enhance Resilience] ([TWRR](https://resilienceroundup.com/issues/73/))","* [Resilience Engineering: New directions for measuring and maintaining safety in complex systems]","* [A rose by any other name...would probably be given an acronym]","* [How do systems manage their adaptive capacity to successfully handle disruptions? A resilience engineering perspective](https://www.researchgate.net/publication/286581322_How_do_systems_manage_their_adaptive_capacity_to_successfully_handle_disruptions_A_resilience_engineering_perspective)","* [How Unexpected Events Produce An Escalation Of Cognitive And Coordinative Demands] ([TWRR](https://resilienceroundup.com/issues/how-unexpected-events-produce-an-escalation-of-cognitive-and-coordinative-demands/))","* [How to Make Automated Systems Team Players](https://www.researchgate.net/profile/David_Woods11/publication/2483863_How_to_Make_Automated_Systems_Team_Players/links/5a4f829eaca272940bf8202c/How-to-Make-Automated-Systems-Team-Players.pdf)","* [Toward a Theory of Complex and Cognitive Systems]","* [Multiple systemic contributors versus root cause: learning from a NASA Near Miss](https://www.researchgate.net/publication/308194080_Multiple_Systemic_Contributors_versus_Root_Cause_Learning_from_a_NASA_Near_Miss)","* [Bootstrapping multiple converging cognitive task analysis techniques for system design] ([TWRR](https://resilienceroundup.com/issues/70))","* [New Arctic Air Crash Aftermath Role-Play Simulation Orchestrating a Fundamental Surprise]","* [Mapping Cognitive Demands in Complex Problem-Solving Worlds] (mentions disturbance management)","* [Fixation Errors: Failures to Revise Situation Assessment in Dynamic and Risky Systems](https://www.researchgate.net/publication/290071190_Fixation_Errors_Failures_to_Revise_Situation_Assessment_in_Dynamic_and_Risky_Systems)","* [Nine Steps to Move Forward From Error] [BH](https://safety177496371.wordpress.com/2022/11/03/nine-steps-to-move-forward-from-error/)","* [Handoff strategies in settings with high consequences for failure: lessons for health care operations] ([TWRR](https://resilienceroundup.com/issues/56))","* [The High Reliability Organization Perspective] ([TWRR](https://resilienceroundup.com/issues/09/))","* [Automation surprises]","* [Safety II professionals: How resilience engineering can transform safety practice] ([TWRR](https://resilienceroundup.com/issues/64/))","* [Gaps in the continuity of care and progress on patient safety]","* [Systems with human monitors: a signal detection analysis](https://www.researchgate.net/publication/250890631_Systems_with_Human_Monitors_A_Signal_Detection_Analysis)","* [On taking human performance seriously](https://www.sciencedirect.com/science/article/abs/pii/095183209090022F), 1990","* [Beyond surge: Coping with mass burn casualty in the closest hospital to the Formosa Fun Coast Dust Explosion]","* [Designing for Expertise](https://www.researchgate.net/publication/284173210_Designing_for_Expertise)","* [Steering the Reverberations of Technology Change on Fields of Practice: Laws that Govern Cognitive Work](https://www.researchgate.net/publication/334267822_Steering_the_Reverberations_of_Technology_Change_on_Fields_of_Practice_Laws_that_Govern_Cognitive_Work) ([TWRR](https://resilienceroundup.com/issues/steering-the-reverberations-of-technology-change-on-fields-of-practice-laws-that-govern-cognitive-work/))","* [Distant Supervision–Local Action Given the Potential for Surprise](https://www.researchgate.net/profile/David_Woods11/publication/225921479_Distant_Supervision-Local_Action_Given_the_Potential_for_Surprise/links/0a85e53baa4009ad8e000000/Distant-Supervision-Local-Action-Given-the-Potential-for-Surprise.pdf) ([TWRR](https://resilienceroundup.com/issues/75/))","* [Coping With a Mass Casualty: Insights into a Hospital’s Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion] ([TWRR](https://resilienceroundup.com/issues/76/))","* [A Shared Pilot-Autopilot Control Architecture for Resilient Flight](http://aaclab.mit.edu/resources/FarjadianAnnaswamyWoods2019.pdf) ([TWRR](https://resilienceroundup.com/issues/a-shared-pilot-autopilot-control-architecture-for-resilient-flight/))","* [Team Play with a Powerful and Independent Agent: A Full-Mission Simulation Study] ([TWRR](https://resilienceroundup.com/issues/team-play-with-a-powerful-and-independent-agent-a-full-mission-simulation-study/))","* [How Not to Have to Navigate Through Too Many Displays](https://www.researchgate.net/publication/239030256_How_Not_to_Have_to_Navigate_Through_Too_Many_Displayjjs)","* [Discovering How Distributed Cognitive Systems Work](https://www.researchgate.net/publication/251196422_Discovering_How_Distributed_Cognitive_Systems_Work)","* [Human Performance in Anesthesia]","* [Creating Foresight: Lessons for Enhancing Resilience from Columbia](https://www.researchgate.net/profile/David-Woods-19/publication/jjgg255648297_Creating_Foresight_Lessons_for_Enhancing_Resilience_from_Columbia/links/542becf50cf29bbc126ac095/Creating-Foresight-Lessons-for-Enhancing-Resilience-from-Columbia.pdf)","* [Inventing the Future of Cognitive Work: Navigating the \"Northwest Passage\"](http://faculty.washington.edu/roesler/publications/design_cycle2005.pdf)","* [A practitioner’s experiences operationalizing Resilience Engineering]","* [Understanding rigor in information analysis]","* [Human Performance in Anesthesia: A Corpus of Cases]","* [Minding the Gaps: Creating Resilience in Health Care]","* [From Counting Failures to Anticipating Risks: Possible Futures for Patient Safety]","* [Resilience Engineering: New directions for measuring and maintaining safety in complex systems]","* [Behind Human Error: Taming Complexity to Improve Patient Safety]","* [Escaping failures of foresight](https://www.researchgate.net/publication/239357782_Escaping_failures_of_foresight)","* [The Silicon Valley Way: Move fast and break…aviation safety?]","","[The theory of graceful extensibility: basic rules that govern adaptive systems]: https://www.researchgate.net/publication/327427067_The_Theory_of_Graceful_Extensibility_Basic_rules_that_govern_adaptive_systems","[How do systems manage their adaptive capacity to successfully handle disruptions? A resilience engineering perspective]: https://www.researchgate.net/publication/286581322_How_do_systems_manage_their_adaptive_capacity_to_successfully_handle_disruptions_A_resilience_engineering_perspective","","### Selected talks","","* [Overview of resilience engineering](https://www.youtube.com/watch?v=GnVXfgC-5Jw\u0026feature=youtu.be)","* [Creating safety by engineering resilience](https://vimeo.com/104759707)","* [The Mystery of Sustained Adaptability](https://www.youtube.com/watch?v=7STcaWjJoww)","* [Resilience is a verb](https://www.youtube.com/watch?v=V2qj5gMsjrU)","* [Complexity workshop keynote](https://www.youtube.com/watch?v=KJJ2NCjc2Wg)","* [De-Confounding Reliability, Robustness, and Resilience](https://www.youtube.com/watch?v=QSiXEZLZ1y0\u0026t=6s)","* [2003 Senate Hearing testimony](https://www.c-span.org/video/?c4531343/user-clip-david-woods-senate-hearing)","* [Shock and Resilience](https://www.youtube.com/watch?v=ZuLUp94wki4)","* [Hedging bets](https://www.youtube.com/watch?v=vlYtd-eUjY8)","* [REA 2021](https://youtu.be/OwdMgEf2MsA)","* [Adobe Summit Talk: Why do reliable systems fail?](https://www.youtube.com/watch?v=fbwDnpuys7w)","* [Resilience Foundations videos](https://resiliencefoundations.github.io/overview.html)","","### Online courses","","* [Cognitive Systems Engineering Laboratory's (CSEL) Resilience Engineering 101 Series](https://resiliencefoundations.github.io/video-1-introduction-pt-1-it's-all-about-viability.html)","* [Resilience Engineering: An Introductory Short Course](https://www.youtube.com/playlist?list=PLvlZBj1NU_ikTy1ot30EbEbYMAoBf9eAt)","","## John Wreathall","","Wreathall is an expert in human performance in safety. He works at the","[WreathWood Group](http://www.wreathall.com/), a risk and safety studies","consultancy.","Wreathall tweets as [@wreathall](https://twitter.com/wreathall).","","### Selected publications","* [Resilience engineering in practice: a 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class="markdown-heading" dir="auto"><h1 tabindex="-1" class="heading-element" dir="auto">Resilience engineering papers</h1><a id="user-content-resilience-engineering-papers" class="anchor" aria-label="Permalink: Resilience engineering papers" href="#resilience-engineering-papers"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
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<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Overview</h2><a id="user-content-overview" class="anchor" aria-label="Permalink: Overview" href="#overview"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
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<p dir="auto">Alias: <a href="http://resiliencepapers.club" rel="nofollow">http://resiliencepapers.club</a> (thanks to <a href="https://twitter.com/allspaw" rel="nofollow">John Allspaw</a>).</p>
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<p dir="auto">This doc contains notes about people active in resilience engineering, as well as some influential
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researchers who are no longer with us, organized alphabetically. It also includes people and papers
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from related fields, such as cognitive systems engineering and naturalistic decision-making.</p>
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<p dir="auto">If you're not sure what to read first, check out <a href="/lorin/resilience-engineering/blob/master/intro.md">Resilience engineering: Where do I start?</a></p>
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<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Annotations</h2><a id="user-content-annotations" class="anchor" aria-label="Permalink: Annotations" href="#annotations"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
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<p dir="auto">A <a href="https://safety177496371.wordpress.com/" rel="nofollow">BH</a> link indicates Ben Hutchinson's <a href="https://safety177496371.wordpress.com/" rel="nofollow">Safety & Performance Research Summaries</a> blog.
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Ben writes summaries of safety papers, posting them to his blog as well as LinkedIOn.</p>
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<p dir="auto">A <a href="http://resilienceroundup.com" rel="nofollow">TWRR</a> link indicates Thai Wood's <a href="http://resilienceroundup.com" rel="nofollow">Resilience Roundup</a>. Thai publishes a newsletter that
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summarizes resilience engineering papers.</p>
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<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Other interesting links</h2><a id="user-content-other-interesting-links" class="anchor" aria-label="Permalink: Other interesting links" href="#other-interesting-links"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
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<p dir="auto"><a href="https://resilienceinsoftware.org" rel="nofollow">resilienceinsoftware.org</a> is the Resilience in Software Foundation, a community of software people who are interested in resilience engineering.</p>
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<p dir="auto">For a collection of talks, check out the <a href="https://www.youtube.com/playlist?list=PLb1aZTnPf3-OMChMkrr6WsokRI6LOnuem" rel="nofollow">Resilience Engineering, Cognitive Systems
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Engineering, and Human Factors Concepts in Software
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Contexts</a>
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YouTube playlist maintained by John Allspaw.</p>
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<p dir="auto">You might also be interested in my <a href="https://github.com/lorin/res-eng-short-course-notes">notes on David Woods's Resilience Engineering short course</a>.</p>
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<p dir="auto">The papers linked here are also in the <a href="https://www.zotero.org/groups/2335189/res-eng/items" rel="nofollow">zotero res-eng group</a>.</p>
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||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">People</h2><a id="user-content-people" class="anchor" aria-label="Permalink: People" href="#people"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
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<p dir="auto">For each person, I list concepts that they reference in their writings, along
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||
with some publications. The publications lists aren't comprehensive:
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||
they're ones I've read or have added to my to-read list.</p>
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||
<ul dir="auto">
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||
<li><a href="#colette-alexander">Colette Alexander</a></li>
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||
<li><a href="#john-allspaw">John Allspaw</a></li>
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||
<li><a href="#lisanne-bainbridge">Lisanne Bainbridge</a></li>
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||
<li><a href="#andrea-baker">Andrea Baker</a></li>
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||
<li><a href="#e-asher-balkin">E. Asher Balkin</a></li>
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||
<li><a href="#johan-bergstr%C3%B6m">Johan Bergström</a></li>
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||
<li><a href="#matthieu-branlat">Matthieu Branlat</a></li>
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||
<li><a href="#sheuwen-chuang">Sheuwen Chuang</a></li>
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||
<li><a href="#todd-conklin">Todd Conklin</a></li>
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||
<li><a href="#richard-i-cook">Richard I. Cook</a></li>
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||
<li><a href="#sidney-dekker">Sidney Dekker</a></li>
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||
<li><a href="#jessica-devita">Jessica Devita</a></li>
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||
<li><a href="#john-c-doyle">John C. Doyle</a></li>
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<li><a href="#bob-edwards">Bob Edwards</a></li>
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||
<li><a href="#anders-ericsson">Anders Ericsson</a></li>
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<li><a href="#paul-feltovich">Paul Feltovich</a></li>
|
||
<li><a href="http://www.resilience-engineering-association.org/user/pedro/" rel="nofollow">Pedro Ferreira</a></li>
|
||
<li><a href="#meir-finkel">Meir Finkel</a></li>
|
||
<li><a href="#marisa-grayson">Marisa Grayson</a></li>
|
||
<li><a href="#ivonne-andrade-herrera">Ivonne Andrade Herrera</a></li>
|
||
<li><a href="#cat-hicks">Cat Hicks</a></li>
|
||
<li><a href="#robert-hoffman">Robert Hoffman</a></li>
|
||
<li><a href="#erik-hollnagel">Erik Hollnagel</a></li>
|
||
<li><a href="#leila-johannesen">Leila Johannesen</a></li>
|
||
<li><a href="#gary-klein">Gary Klein</a></li>
|
||
<li><a href="#elizabeth-lay">Elizabeth Lay</a></li>
|
||
<li><a href="#jean-christophe-le-coze">Jean-Christophe Le Coze</a></li>
|
||
<li><a href="#nancy-leveson">Nancy Leveson</a></li>
|
||
<li><a href="#beth-long">Beth Adele Long</a></li>
|
||
<li><a href="#carl-macrae">Carl Macrae</a></li>
|
||
<li><a href="#laura-maguire">Laura Maguire</a></li>
|
||
<li><a href="#courtney-nash">Courtney Nash</a></li>
|
||
<li><a href="#christopher-nemeth">Christopher Nemeth</a></li>
|
||
<li><a href="#anne-sophie-nyssen">Anne-Sophie Nyssen</a></li>
|
||
<li><a href="#elinor-ostrom">Elinor Ostrom</a></li>
|
||
<li><a href="#jean-paries">Jean Pariès</a></li>
|
||
<li><a href="#emily-patterson">Emily Patterson</a></li>
|
||
<li><a href="#charles-perrow">Charles Perrow</a></li>
|
||
<li><a href="#shawna-j-perry">Shawna J. Perry</a></li>
|
||
<li><a href="#jens-rasmussen">Jens Rasmussen</a></li>
|
||
<li><a href="#mike-rayo">Mike Rayo</a></li>
|
||
<li><a href="#james-reason">James Reason</a></li>
|
||
<li><a href="#j-paul-reed">J. Paul Reed</a></li>
|
||
<li><a href="#emilie-m-roth">Emilie M. Roth</a></li>
|
||
<li><a href="#nadine-sarter">Nadine Sarter</a></li>
|
||
<li><a href="#james-c-scott">James C. Scott</a></li>
|
||
<li><a href="#steven-shorrock">Steven Shorrock</a></li>
|
||
<li><a href="#barry-turner">Barry Turner</a></li>
|
||
<li><a href="#diane-vaughan">Diane Vaughan</a></li>
|
||
<li><a href="#robert-l-wears">Robert L. Wears</a></li>
|
||
<li><a href="#david-woods">David Woods</a></li>
|
||
<li><a href="#john-wreathall">John Wreathall</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Some big ideas</h2><a id="user-content-some-big-ideas" class="anchor" aria-label="Permalink: Some big ideas" href="#some-big-ideas"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="#the-adaptive-universe">The adaptive universe</a> (David Woods)</li>
|
||
<li><a href="#dynamic-safety-model">Dynamic safety model</a> (Jens Rasmussen)</li>
|
||
<li><a href="#safety-i-vs-safety-ii">Safety-II</a> (Erik Hollnagel)</li>
|
||
<li><a href="#graceful-extensibility">Graceful extensibility</a> (David Woods)</li>
|
||
<li><a href="#etto-principle">ETTO: Efficiency-tradeoff principle</a> (Erik Hollnagel)</li>
|
||
<li><a href="#drift-into-failure">Drift into failure</a> (Sidney Dekker)</li>
|
||
<li>Robust yet fragile (John C. Doyle)</li>
|
||
<li><a href="#stamp">STAMP: Systems-Theoretic Accident Model & Process</a> (Nancy Leveson)</li>
|
||
<li>Polycentric governance (Elinor Ostrom)</li>
|
||
</ul>
|
||
<p dir="auto">Note: there are now <a href="https://github.com/lorin/resilience-engineering/graphs/contributors">multiple contributors</a> to this repository.</p>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Colette Alexander</h2><a id="user-content-colette-alexander" class="anchor" aria-label="Permalink: Colette Alexander" href="#colette-alexander"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://www.linkedin.com/in/colette-alexander-4168267/" rel="nofollow">Alexander</a> is a Director of Engineering and researcher who previously held roles with IBM, Spotify, Cognite, and HashiCorp. She hosts the podcast This is Fine with co-host Clint Byrum.
|
||
She completed a Masters thesis at Lund titled <a href="https://lup.lub.lu.se/luur/download?func=downloadFile&recordOId=9148570&fileOId=9148571" rel="nofollow">Risky Business: Quantitative Risk Assessments as Enabling Devices in Cybersecurity</a>.</p>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">John Allspaw</h2><a id="user-content-john-allspaw" class="anchor" aria-label="Permalink: John Allspaw" href="#john-allspaw"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Allspaw is the former CTO of Etsy. He applies concepts from resilience engineering to the tech industry.
|
||
He is one of the founders <a href="http://www.adaptivecapacitylabs.com/" rel="nofollow">Adaptive Capacity Labs</a>, a resilience engineering consultancy.</p>
|
||
<p dir="auto">Allspaw tweets as <a href="https://twitter.com/allspaw" rel="nofollow">@allspaw</a>.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://snafucatchers.github.io/" rel="nofollow">STELLA: Report from the SNAFUcatchers Workshop on Coping with Complexity</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/295011072_Trade-Offs_Under_Pressure_Heuristics_and_Observations_Of_Teams_Resolving_Internet_Service_Outages" rel="nofollow">Trade-Offs Under Pressure: Heuristics and Observations Of Teams Resolving Internet Service Outages</a></li>
|
||
<li><a href="http://extfiles.etsy.com/DebriefingFacilitationGuide.pdf" rel="nofollow">Etsy Debrief Facilitation Guide</a></li>
|
||
<li><a href="https://codeascraft.com/2012/05/22/blameless-postmortems/" rel="nofollow">Blameless PostMortems and a Just Culture</a> (blog)</li>
|
||
<li><a href="https://doi.org/10.1145/2366316.2366331" rel="nofollow">Resilience engineering: learning to embrace failure</a></li>
|
||
<li><a href="http://queue.acm.org/detail.cfm?id=2353017" rel="nofollow">Fault Injection in Production: Making the case for resiliency testing</a></li>
|
||
<li><a href="https://doi.org/10.1109/MS.2017.99" rel="nofollow">Technical Debt: Challenges and Perspectives</a></li>
|
||
<li><a href="https://queue.acm.org/detail.cfm?id=3380776" rel="nofollow">Revealing the Critical Role of Human Performance in Software</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/343430302_SRE_Cognitive_Work" rel="nofollow">SRE Cognitive Work</a> in <a href="https://www.oreilly.com/library/view/seeking-sre/9781491978856/" rel="nofollow">Seeking SRE</a></li>
|
||
<li><a href="https://www.oreilly.com/radar/the-infinite-hows/" rel="nofollow">The infinite hows: An argument against the Five Whys and an alternative approach you can apply</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected talks</h3><a id="user-content-selected-talks" class="anchor" aria-label="Permalink: Selected talks" href="#selected-talks"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://devopsdays.org/events/2019-washington-dc/program/john-allspaw/" rel="nofollow">Resilience Engineering: The What and How</a></li>
|
||
<li><a href="https://www.youtube.com/watch?v=8DtzmV1jiyQ" rel="nofollow">Incidents as we Imagine Them Versus How They Actually Are</a></li>
|
||
<li><a href="https://www.youtube.com/watch?v=xA5U85LSk0M" rel="nofollow">How your systems keep running day after day</a></li>
|
||
<li><a href="https://www.youtube.com/watch?v=NxctiGRI2y8" rel="nofollow">Problem detection (papers we love)</a>
|
||
(presentation of <a href="https://www.researchgate.net/publication/220579480_Problem_detection" rel="nofollow">Problem detection</a> paper)</li>
|
||
<li><a href="https://paperswelove.org/2016/video/john-allspaw-common-ground/" rel="nofollow">Common Ground and Coordination in Joint Activity (papers we love)</a> (presentation of <a href="http://jeffreymbradshaw.net/publications/Common_Ground_Single.pdf" rel="nofollow">Common Ground and Coordination in Joint Activity</a> paper)</li>
|
||
<li><a href="https://www.infoq.com/presentations/resilience-thinking-paradigm/" rel="nofollow">Amplifying sources of resilience</a> (presentation about applying Resilience Engineering thinking & paradigms to the world of software engineering)</li>
|
||
<li><a href="https://www.adaptivecapacitylabs.com/blog/2020/03/30/incidents-what-is-often-missed-what-can-be-done-about-that/#fvp_10,1s" rel="nofollow">Incidents: What Is Often Missed & What Can Be Done About That</a></li>
|
||
<li><a href="https://www.adaptivecapacitylabs.com/blog/2020/05/06/how-learning-is-different-than-fixing/" rel="nofollow">Incident Analysis: How <em>Learning</em> is Different Than <em>Fixing</em></a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Lisanne Bainbridge</h2><a id="user-content-lisanne-bainbridge" class="anchor" aria-label="Permalink: Lisanne Bainbridge" href="#lisanne-bainbridge"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Bainbridge is a psychology researcher. She has a website at <a href="http://www.complexcognition.co.uk/" rel="nofollow">http://www.complexcognition.co.uk/</a></p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Contributions</h3><a id="user-content-contributions" class="anchor" aria-label="Permalink: Contributions" href="#contributions"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">Ironies of automation</h4><a id="user-content-ironies-of-automation" class="anchor" aria-label="Permalink: Ironies of automation" href="#ironies-of-automation"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Bainbridge is famous for her 1983 <a href="https://www.sciencedirect.com/science/article/abs/pii/0005109883900468" rel="nofollow">Ironies of automation</a> paper, which continues to
|
||
be frequently cited.</p>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Concepts</h2><a id="user-content-concepts" class="anchor" aria-label="Permalink: Concepts" href="#concepts"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>automation</li>
|
||
<li>design errors</li>
|
||
<li>human factors/ ergonomics</li>
|
||
<li>cognitive modelling</li>
|
||
<li>cognitive architecture</li>
|
||
<li>mental workload</li>
|
||
<li>situation awareness</li>
|
||
<li>cognitive error</li>
|
||
<li>skill and training</li>
|
||
<li>interface design</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Selected publications</h2><a id="user-content-selected-publications-1" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-1"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.sciencedirect.com/science/article/abs/pii/0005109883900468" rel="nofollow">Ironies of automation</a> (<a href="https://resilienceroundup.com/issues/35/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.sciencedirect.com/science/article/abs/pii/S0020737379800358" rel="nofollow">Verbal reports as evidence of the process operator's knowledge</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Andrea Baker</h2><a id="user-content-andrea-baker" class="anchor" aria-label="Permalink: Andrea Baker" href="#andrea-baker"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://www.thehopmentor.com/" rel="nofollow">Baker</a> is a practitioner who provides
|
||
training services in human and organizational performance (HOP) and learning
|
||
teams.</p>
|
||
<p dir="auto">Baker tweets as <a href="https://twitter.com/thehopmentor" rel="nofollow">@thehopmentor</a>.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-1" class="anchor" aria-label="Permalink: Concepts" href="#concepts-1"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>Human and organizational performance (HOP)</li>
|
||
<li>Learning teams</li>
|
||
<li>Industrial empathy</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-2" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-2"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://docs.wixstatic.com/ugd/1a0149_21bcf20f158540098d3d7987ffbf3f58.pdf" rel="nofollow">A bit about HOP</a> (editorial)</li>
|
||
<li><a href="http://www.safetydifferently.com/a-short-introduction-to-human-and-organizational-performance-hop-and-learning-teams/" rel="nofollow">A short introduction to human and organizational performance (hop) and learning teams</a> (blog post)</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">E. Asher Balkin</h2><a id="user-content-e-asher-balkin" class="anchor" aria-label="Permalink: E. Asher Balkin" href="#e-asher-balkin"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-3" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-3"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.researchgate.net/publication/330222613_Resiliency_Trade_Space_Study_The_Interaction_of_Degraded_C2_Link_and_Detect_and_Avoid_Autonomy_on_Unmanned_Aircraft" rel="nofollow">Resiliency Trade Space Study: The Interaction of Degraded C2 Link and Detect and Avoid Autonomy on Unmanned Aircraft</a></li>
|
||
<li><a href="https://journals.sagepub.com/doi/10.1177/1071181322661334" rel="nofollow">Developing Systemic Contributors and Adaptations Diagramming (SCAD): systemic insights, multiple pragmatic implementations</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected talks</h3><a id="user-content-selected-talks-1" class="anchor" aria-label="Permalink: Selected talks" href="#selected-talks-1"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.youtube.com/watch?v=kK6t-gttsJw" rel="nofollow">Root cause and the wrong path</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Johan Bergström</h2><a id="user-content-johan-bergström" class="anchor" aria-label="Permalink: Johan Bergström" href="#johan-bergström"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="http://www.jbsafety.se/p/about-me.html" rel="nofollow">Bergström</a> is a safety research and
|
||
consultant. He runs the <a href="http://www.humanfactors.lth.se/msc-programme/" rel="nofollow">Master Program of Human Factors and Systems
|
||
Safety</a> at Lund University.</p>
|
||
<p dir="auto">Bergström tweets as <a href="https://twitter.com/bergstrom_johan" rel="nofollow">@bergstrom_johan</a>.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-2" class="anchor" aria-label="Permalink: Concepts" href="#concepts-2"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>Analytical traps in accident investigation
|
||
<ul dir="auto">
|
||
<li>Counterfactual reasoning</li>
|
||
<li>Normative language</li>
|
||
<li>Mechanistic reasoning</li>
|
||
</ul>
|
||
</li>
|
||
<li>Generic competencies</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-4" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-4"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.sciencedirect.com/science/article/pii/S0925753516306130" rel="nofollow">Resilience engineering: Current status of the research and future challenges</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/50917226_Rule-_and_role_retreat_An_empirical_study_of_procedures_and_resilience" rel="nofollow">Rule- and role retreat: An empirical study of procedures and resilience</a></li>
|
||
<li><a href="https://portal.research.lu.se/ws/files/1376441/3014838.pdf" rel="nofollow">Team Coordination in Escalating Situations: An Empirical Study Using Mid-Fidelity Simulation</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected talks</h3><a id="user-content-selected-talks-2" class="anchor" aria-label="Permalink: Selected talks" href="#selected-talks-2"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.youtube.com/watch?v=TqaFT-0cY7U" rel="nofollow">Three analytical traps in accident investigation</a></li>
|
||
<li><a href="https://www.youtube.com/watch?v=rHeukoWWtQ8" rel="nofollow">Two Views on Human Error</a></li>
|
||
<li><a href="https://www.youtube.com/watch?v=BtJIumyCrtE&feature=youtu.be" rel="nofollow">What, Where and When is Risk in System Design?</a> (Velocity 2013)</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Matthieu Branlat</h2><a id="user-content-matthieu-branlat" class="anchor" aria-label="Permalink: Matthieu Branlat" href="#matthieu-branlat"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-5" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-5"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.researchgate.net/publication/284324002_Basic_patterns_in_how_adaptive_systems_fail" rel="nofollow">Basic patterns in how adaptive systems fail</a> (<a href="https://resilienceroundup.com/issues/34/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.sciencedirect.com/science/article/abs/pii/S0951832015000812" rel="nofollow">A practitioner’s experiences operationalizing Resilience Engineering</a></li>
|
||
<li><a href="https://www.taylorfrancis.com/chapters/edit/10.1201/9781315605708-18/noticing-brittleness-designing-resilience-elizabeth-lay-matthieu-branlat" rel="nofollow">Noticing Brittleness, Designing for Resilience</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Sheuwen Chuang</h2><a id="user-content-sheuwen-chuang" class="anchor" aria-label="Permalink: Sheuwen Chuang" href="#sheuwen-chuang"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-6" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-6"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://doi.org/10.1016/j.burns.2018.12.003" rel="nofollow">Beyond surge: Coping with mass burn casualty in the closest hospital to the Formosa Fun Coast Dust Explosion</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/335366770_Coping_With_a_Mass_Casualty_Insights_into_a_Hospital's_Emergency_Response_and_Adaptations_After_the_Formosa_Fun_Coast_Dust_Explosion" rel="nofollow">Coping With a Mass Casualty: Insights into a Hospital’s Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion</a> (<a href="https://resilienceroundup.com/issues/76/" rel="nofollow">TWRR</a>)</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Todd Conklin</h2><a id="user-content-todd-conklin" class="anchor" aria-label="Permalink: Todd Conklin" href="#todd-conklin"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Conklin's books are on my reading list, but I haven't read anything by him
|
||
yet. I have listened to his great <a href="https://preaccidentpodcast.podbean.com/" rel="nofollow">Preaccident investigation
|
||
podcast</a>.</p>
|
||
<p dir="auto">Conklin tweets as <a href="https://twitter.com/preaccident" rel="nofollow">@preaccident</a>.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-7" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-7"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.amazon.com/Pre-Accident-Investigations-Todd-Conklin/dp/1409447820" rel="nofollow">Pre-accident investigations: an introduction to organizational safety</a></li>
|
||
<li><a href="https://www.amazon.com/gp/product/1472486137" rel="nofollow">Pre-accident investigations: better questions - an applied approach to
|
||
operational learning</a></li>
|
||
<li><a href="https://www.amazon.com/Do-Safety-Differently-Sidney-Dekker/dp/B09RM3Z17V" rel="nofollow">Do Safety Differently</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected talks</h3><a id="user-content-selected-talks-3" class="anchor" aria-label="Permalink: Selected talks" href="#selected-talks-3"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Quanta - <a href="https://www.youtube.com/watch?v=5WTbeFj2kJY&feature=youtu.be" rel="nofollow">Risk and Safety Conf 2019</a></p>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Richard I. Cook</h2><a id="user-content-richard-i-cook" class="anchor" aria-label="Permalink: Richard I. Cook" href="#richard-i-cook"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://en.wikipedia.org/wiki/Richard_Cook_(safety_researcher)" rel="nofollow">Cook</a> was an anasthesiologist who studies failures in complex systems. He is one of the founders <a href="http://www.adaptivecapacitylabs.com/" rel="nofollow">Adaptive Capacity Labs</a>, a resilience engineering consultancy.
|
||
He tweeted as <a href="https://twitter.com/ri_cook" rel="nofollow">@ri_cook</a>.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-3" class="anchor" aria-label="Permalink: Concepts" href="#concepts-3"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>how complex systems fail</li>
|
||
<li>degraded mode</li>
|
||
<li>sharp end (c.f. Reason's blunt end)</li>
|
||
<li>Going solid</li>
|
||
<li>Cycle of error</li>
|
||
<li>"new look"</li>
|
||
<li>first vs second stories</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-8" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-8"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.researchgate.net/publication/371403498_A_celebration_of_the_work_of_Richard_Cook_MD_A_pioneer_in_understanding_accidents_safety_human_factors_and_resilience" rel="nofollow">A celebration of the work of Richard Cook, MD: A pioneer in understanding accidents, safety, human factors, and resilience</a></li>
|
||
<li><a href="https://www.adaptivecapacitylabs.com/HowComplexSystemsFail.pdf" rel="nofollow">How complex systems fail</a> (<a href="https://safety177496371.wordpress.com/2022/11/04/how-complex-systems-fail-a-classic-from-richard-cook/" rel="nofollow">BH</a>)</li>
|
||
<li><a href="https://www.adaptivecapacitylabs.com/BriefLookAtTheNewLook.pdf" rel="nofollow">A brief look at the New Look in complex system failure, error, safety, and resilience</a></li>
|
||
<li><a href="https://www.snafucatchers.com/single-post/2017/11/14/void-Incidents-as-Untyped-Pointers" rel="nofollow">void *: Incidents as Untyped Pointers. <em>Where</em> complex systems fail</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/292504703_Distancing_through_differencing_An_obstacle_to_organizational_learning_following_accidents" rel="nofollow">Distancing through differencing: An obstacle to organizational learning following accidents</a></li>
|
||
<li><a href="http://csel.eng.ohio-state.edu/productions/woodscta/media/beingbump.pdf" rel="nofollow">Being bumpable</a> (<a href="https://www.getrevue.co/profile/resilience/issues/resilience-roundup-being-bumpable-issue-33-177340" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.amazon.com/Behind-Human-Error-David-Woods/dp/0754678342" rel="nofollow">Behind Human Error</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/292504952_Incidents_-_markers_of_resilience_or_brittleness" rel="nofollow">Incidents - markers of resilience or brittleness?</a></li>
|
||
<li><a href="https://qualitysafety.bmj.com/content/14/2/130" rel="nofollow">“Going solid”: a model of system dynamics and consequences for patient safety</a> (<a href="https://resilienceroundup.com/issues/going-solid-a-model-of-system-dynamics-and-consequences-for-patient-safety/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/313407259_Operating_at_the_Sharp_End_The_Complexity_of_Human_Error" rel="nofollow">Operating at the Sharp End: The Complexity of Human Error</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/312624891_Patient_boarding_in_the_emergency_department_as_a_symptom_of_complexity-induced_risks" rel="nofollow">Patient boarding in the emergency department as a symptom of complexity-induced risks</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/220579381_Sensemaking_Safety_and_Cooperative_Work_in_the_Intensive_Care_Unit" rel="nofollow">Sensemaking, Safety, and Cooperative Work in the Intensive Care Unit</a></li>
|
||
<li><a href="https://www.taylorfrancis.com/books/e/9781317164777/chapters/10.1201/9781315572529-4" rel="nofollow">Medication Reconciliation Is a Window into “Ordinary” Work</a></li>
|
||
<li><a href="https://ntrs.nasa.gov/search.jsp?R=19910011398" rel="nofollow">Cognitive consequences of clumsy automation on high workload, high consequence human performance</a></li>
|
||
<li><a href="https://doi.org/10.1016/S0952-8180(96)90009-4" rel="nofollow">Implications of automation surprises in aviation for the future of total intravenous anesthesia (TIVA)</a></li>
|
||
<li><a href="https://doi.org/10.1109%2FTSMCA.2004.836802" rel="nofollow">The Messy Details: Insights From the Study of Technical Work in Healthcare</a></li>
|
||
<li><a href="https://www.researchgate.net/profile/David_Woods11/publication/224649052_Nosocomial_automation_technology-induced_complexity_and_human_performance/links/59399b1da6fdcc58ae902c49/Nosocomial-automation-technology-induced-complexity-and-human-performance.pdf" rel="nofollow">Nosocomial automation: technology-induced complexity and human performance</a></li>
|
||
<li><a href="https://pdfs.semanticscholar.org/67f7/53ec089e5a8879f241e2be867dad0a2026fb.pdf" rel="nofollow">The New Look at Error, Safety, and Failure: A Primer for Health Care</a></li>
|
||
<li><a href="https://pdfs.semanticscholar.org/1bed/356b5aa67c701f5bad6d943768622095f418.pdf" rel="nofollow">Grounding explanations in evolving, diagnostic situations</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/245102691_A_Tale_of_Two_Stories_Contrasting_Views_of_Patient_Safety" rel="nofollow">A Tale of Two Stories: Contrasting Views of Patient Safety</a> (appendix B, starting on page 64 (numbered 52) contains the talk by Charles Billings, MD, Chief Scientist (retired), NASA Ames on the lessons learned from incident reporting in aviation. Dr. Billings designed, started, and managed the Aviation Safety REporting System)</li>
|
||
<li><a href="http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.623.5749&rep=rep1&type=pdf" rel="nofollow">"Those found responsible have been sacked": some observations on the usefulness of error</a> (<a href="https://safety177496371.wordpress.com/2025/01/26/those-found-responsible-have-been-sacked-some-observations-on-the-usefulness-of-error/" rel="nofollow">BH</a>)</li>
|
||
<li><a href="https://www.nifc.gov/PUBLICATIONS/acc_invest_march2010/speakers/Perspectives%20on%20Human%20Error.pdf" rel="nofollow">Perspectives on Human Error: Hindsight Biases and Local Rationality</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/328149714_Mistaking_Error" rel="nofollow">Mistaking Error</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/14230576_Adapting_to_New_Technology_in_the_Operating_Room" rel="nofollow">Adapting to new technology in the operating room</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/3657912_Verite_abstraction_and_ordinateur_systems_in_the_evolution_of_complex_process_control" rel="nofollow">Verite, Abstraction, and Ordinateur Systems in the Evolution of Complex Process Control</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/220579448_Collaborative_Cross-Checking_to_Enhance_Resilience" rel="nofollow">Collaborative Cross-Checking to Enhance Resilience</a> (<a href="https://resilienceroundup.com/issues/73/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://pdfs.semanticscholar.org/a0d3/9cc66adc64e297048a32b71aeee209a451af.pdf" rel="nofollow">Resilience Engineering: New directions for measuring and maintaining safety in complex systems</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/232191704_The_Role_of_Automation_in_Complex_System_Failures" rel="nofollow">The Role of Automation in Complex System Failures</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/228352596_Thinking_about_accidents_and_systems" rel="nofollow">Thinking about accidents and systems</a></li>
|
||
<li><a href="https://www.taylorfrancis.com/books/e/9781315605739/chapters/10.1201/9781315605739-11" rel="nofollow">The Stockholm blizzard of 2012</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/2484621_New_Arctic_Air_Crash_Aftermath_Role-Play_Simulation_Orchestrating_a_Fundamental_Surprise" rel="nofollow">New Arctic Air Crash Aftermath Role-Play Simulation Orchestrating a Fundamental Surprise</a></li>
|
||
<li><a href="https://www.nap.edu/read/13269/chapter/14" rel="nofollow">Dissenting Statement: Health IT Is a Class III Medical Device</a></li>
|
||
<li><a href="http://csel.eng.ohio-state.edu/productions/pexis/readings/submod4/nine%20steps%20CTW2002.pdf" rel="nofollow">Nine Steps to Move Forward From Error</a> (<a href="https://safety177496371.wordpress.com/2022/11/03/nine-steps-to-move-forward-from-error/" rel="nofollow">BH</a>)</li>
|
||
<li><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117777/" rel="nofollow">Gaps in the continuity of care and progress on patient safety</a></li>
|
||
<li><a href="https://queue.acm.org/detail.cfm?id=3380777" rel="nofollow">Above the Line, Below the Line</a> (<a href="https://resilienceroundup.com/issues/68/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/335366770_Coping_With_a_Mass_Casualty_Insights_into_a_Hospital's_Emergency_Response_and_Adaptations_After_the_Formosa_Fun_Coast_Dust_Explosion" rel="nofollow">Coping With a Mass Casualty: Insights into a Hospital’s Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion</a> (<a href="https://resilienceroundup.com/issues/76/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/343430302_SRE_Cognitive_Work" rel="nofollow">SRE Cognitive Work</a> in <a href="https://www.oreilly.com/library/view/seeking-sre/9781491978856/" rel="nofollow">Seeking SRE</a></li>
|
||
<li><a href="https://www.sciencedirect.com/science/article/pii/S0003687020301903" rel="nofollow">Building and revising adaptive capacity sharing for technical incident response: A case of resilience engineering</a> (<a href="https://resilienceroundup.com/issues/building-and-revising-adaptive-capacity-sharing-for-technical-incident-response-a-case-of-resilience-engineering/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://doi.org/10.1016/j.ress.2006.01.009" rel="nofollow">Automation, interaction, complexity, and failure: A case study</a></li>
|
||
<li><a href="http://dx.doi.org/10.13140/RG.2.2.29675.36648" rel="nofollow">Human Performance in Anesthesia</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/285346573_Two_years_before_the_mast_Learning_how_to_learn_about_patient_safety" rel="nofollow">Two years before the mast: Learning how to learn about patient safety</a></li>
|
||
<li><a href="https://www.researchgate.net/profile/Robert-Wears/publication/225108705_Resilience_is_Not_Control_Healthcare_Crisis_Management_and_ICT/links/00b49532b2c7f3ed62000000/Resilience-is-Not-Control-Healthcare-Crisis-Management-and-ICT.pdf" rel="nofollow">Resilience is not control: healthcare, crisis management, and ICT</a></li>
|
||
<li><a href="https://www.taylorfrancis.com/chapters/edit/10.1201/9781315605685-19/taking-things-one-stride-cognitive-features-two-resilient-performances-richard-cook-christopher-nemeth" rel="nofollow">Taking Things in One’s Stride: Cognitive Features of Two Resilient Performances</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/347964304_Human_Performance_in_Anesthesia_Human_Performance_in_Anesthesia_Human_Performance_in_Anesthesia" rel="nofollow">Human Performance in Anesthesia: A Corpus of Cases</a></li>
|
||
<li><a href="https://europepmc.org/article/NBK/nbk43670" rel="nofollow">Minding the Gaps: Creating Resilience in Health Care</a></li>
|
||
<li><a href="https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=ffe74633027ee354ebbf0ff9a6418e75f3b7a047" rel="nofollow">From Counting Failures to Anticipating Risks: Possible Futures for Patient Safety</a></li>
|
||
<li><a href="https://pdfs.semanticscholar.org/a0d3/9cc66adc64e297048a32b71aeee209a451af.pdf" rel="nofollow">Resilience Engineering: New directions for measuring and maintaining safety in complex systems</a></li>
|
||
<li><a href="https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=15f31969c4e1f4f599c5c68aa63f3bf930e0406f" rel="nofollow">Behind Human Error: Taming Complexity to Improve Patient Safety</a></li>
|
||
<li><a href="https://onlinelibrary.wiley.com/doi/pdf/10.1197/j.aem.2004.07.001" rel="nofollow">The Illusion of Explanation</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected talks</h3><a id="user-content-selected-talks-4" class="anchor" aria-label="Permalink: Selected talks" href="#selected-talks-4"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.youtube.com/watch?v=2S0k12uZR14" rel="nofollow">How Complex Systems Fail</a> (Velocity 2012)</li>
|
||
<li><a href="https://www.youtube.com/watch?v=PGLYEDpNu60&feature=youtu.be" rel="nofollow">Resilience in Complex Adaptive Systems: Operating at the Edge of Failure</a> (Velocity 2013)</li>
|
||
<li><a href="https://www.youtube.com/playlist?list=PLb1aZTnPf3-OEU1by77zZQQYckvXUGmNY" rel="nofollow">Lectures on the study of cognitive work</a> (Graduate student lecture-discussions at The Royal Institute of Technology, Huddinge, SWEDEN in 2012 )</li>
|
||
<li><a href="https://www.youtube.com/watch?v=gtxtb9z_4FY&feature=youtu.be" rel="nofollow">Panel discussion: Safety Culture, Lean, and DevOps</a> (DOES 2017)</li>
|
||
<li><a href="https://www.youtube.com/watch?v=3ZP98stDUf0&feature=youtu.be" rel="nofollow">Working at the center of the Cyclone</a> (DOES 2018)</li>
|
||
<li><a href="https://www.youtube.com/watch?v=8LbePBiOvZ4" rel="nofollow">A Few Observations on the Marvelous Resilience of Bone & Resilience Engineering</a> (REdeploy 2019)</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Jean-Christophe Le Coze</h2><a id="user-content-jean-christophe-le-coze" class="anchor" aria-label="Permalink: Jean-Christophe Le Coze" href="#jean-christophe-le-coze"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Le Coze is research director at INERIS (National Institute for the Industrial Environment and Risks) in France.
|
||
He frequently writes on historical views of safety.</p>
|
||
<p dir="auto">Le Coze tweets as <a href="https://twitter.com/JcLeCoze" rel="nofollow">@JcLeCoze</a>.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-9" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-9"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.academia.edu/36790092/Managing_the_unexpected" rel="nofollow">Managing the Unexpected</a></li>
|
||
<li><a href="https://www.sciencedirect.com/science/article/abs/pii/S0925753522001928" rel="nofollow">The 'new view' of human error. Origins, ambiguities, success and critiques</a></li>
|
||
<li><a href="https://www.academia.edu/15301538/1984_2014_Normal_Accident_Was_Charles_Perrow_right_for_the_wrong_reasons" rel="nofollow">1984-2014. Normal Accident. Was Charles Perrow right for the wrong reasons?</a></li>
|
||
<li><a href="https://dx.doi.org/10.1016/j.ssci.2020.104660" rel="nofollow">Good and bad reasons: The Swiss cheese model and its critics</a></li>
|
||
<li><a href="https://doi.org/10.1016/j.apergo.2016.10.002" rel="nofollow">Recurring themes in the legacy of Jens Rasmussen</a></li>
|
||
<li><a href="https://www.sciencedirect.com/science/article/pii/S0925753514000848" rel="nofollow">Reflecting on Jens Rasmussen’s legacy. A strong program for a hard problem</a></li>
|
||
<li><a href="https://www.sciencedirect.com/science/article/abs/pii/S0003687015300429" rel="nofollow">Reflecting on Jens Rasmussen's legacy (2) behind and beyond, a ‘constructivist turn’</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Sidney Dekker</h2><a id="user-content-sidney-dekker" class="anchor" aria-label="Permalink: Sidney Dekker" href="#sidney-dekker"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Dekker is a human factors and safety researcher with a background in aviation.
|
||
His books aimed at a lay audience (Drift Into Failure, Just Culture, The Field Guide to 'Human Error' investigations)
|
||
have been enormously influential. He was a founder of the MSc programme in Human Factors & Systems Safety at Lund University.
|
||
His PhD advisor is <a href="#david-woods">David Woods</a>.</p>
|
||
<p dir="auto">Dekker tweets as <a href="https://twitter.com/sidneydekkercom" rel="nofollow">@sidneydekkercom</a>.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Contributions</h3><a id="user-content-contributions-1" class="anchor" aria-label="Permalink: Contributions" href="#contributions-1"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">Drift into failure</h4><a id="user-content-drift-into-failure" class="anchor" aria-label="Permalink: Drift into failure" href="#drift-into-failure"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Dekker developed the theory of <em>drift</em>, characterized by five concepts:</p>
|
||
<ol dir="auto">
|
||
<li>Scarcity and competition</li>
|
||
<li>Decrementalism, or small steps</li>
|
||
<li>Sensitive dependence on initial conditions</li>
|
||
<li>Unruly technology</li>
|
||
<li>Contribution of the protective structure</li>
|
||
</ol>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">Just Culture</h4><a id="user-content-just-culture" class="anchor" aria-label="Permalink: Just Culture" href="#just-culture"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Dekker examines how cultural norms defining justice can be re-oriented to minimize the negative impact and maximize learning when things go wrong.</p>
|
||
<ol dir="auto">
|
||
<li>Retributive justice as society's traditional idea of justice: distributing punishment to those responsible based on severity of the violation</li>
|
||
<li>Restorative justice as an improvement for both victims and practicioners: distributing obligations of rebuilding trust to those responsible based on who is hurt and what they need</li>
|
||
<li>First, second, and third victims: an incident's negative impact is felt by more than just the obvious victims</li>
|
||
<li>Learning theory: people break rules when they have learned there are no negative consequences, and there are actually positive consequences - in other words, they break rules to get things done to meet production pressure</li>
|
||
<li>Reporting culture: contributing to reports of adverse events is meant to help the organization understand what went wrong and how to prevent recurrence, but accurate reporting requires appropriate and proportionate accountability actions</li>
|
||
<li>Complex systems: normal behavior of practicioners and professionals in the context of a complex system can appear abnormal or deviant in hindsight, particularly in the eyes of non-expert juries and reviewers</li>
|
||
<li>The nature of practicioners: professionals want to do good work, and therefore want to be held accountable for their mistakes; they generally want to help similarly-situated professionals avoid the same mistake.</li>
|
||
</ol>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Safety Differently</h3><a id="user-content-safety-differently" class="anchor" aria-label="Permalink: Safety Differently" href="#safety-differently"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>There is a difference between the organization's prescribed processes for completing work and how work is actually completed. (work as imagined vs work as done)
|
||
<ul dir="auto">
|
||
<li>The difference between work as imagined and work as done is the result of the expertise that exists in your workers from contact with real-life pressures, heuristics, and unexpected conditions.</li>
|
||
<li>Old View: People are the problem to control with process
|
||
<ul dir="auto">
|
||
<li>They did something wrong</li>
|
||
<li>They need more rules and enforcement</li>
|
||
<li>They need to try harder</li>
|
||
<li>We need to get rid of "bad apples"</li>
|
||
<li>Focus on the "sharp end" of the organization - the people closest to the work</li>
|
||
</ul>
|
||
</li>
|
||
<li>New View: Work is done adaptively in an uncertain world
|
||
<ul dir="auto">
|
||
<li>Things go wrong all the time</li>
|
||
<li>Workers often detect and correct these problems</li>
|
||
<li>Local adaptations are a source of organizational expertise</li>
|
||
<li>"What conditions existed that made the selected course of action seem correct to the people involved?"</li>
|
||
</ul>
|
||
</li>
|
||
</ul>
|
||
</li>
|
||
<li>Traditional safety interventions have diminishing yields with increasing overhead. Accumulated compliance burden and "safety clutter" makes it harder to get work done <em>and</em> to do so safely.
|
||
<ul dir="auto">
|
||
<li>Safety Clutter is accountable to safety bureaucracy and compliance rather than the safety of the workers or the process</li>
|
||
<li>Safety Clutter is produced by the "blunt end" of the organization without local expertise of what is practicable or practical in-situ</li>
|
||
<li>Safety Clutter represents a broader "deprofessionalization" - a removal of trust and confidence in professionals to do their job well, removing their pride, autonomy, and achievement.</li>
|
||
<li>Paradoxically, Safety Clutter can result from government deregulation - organizations need to self-impose risk controls in the absence of external guidelines.</li>
|
||
<li>Sadly for organizations with Safety Clutter, more internal rules do not equal better legal protection.</li>
|
||
</ul>
|
||
</li>
|
||
<li>When a process is relatively safe or stable, measurements of bad outcomes lack statistical significance to understand trends or tie trends to interventions.
|
||
<ul dir="auto">
|
||
<li>Fundamental Regulator Paradox: regulating a system so well that there are no useful measurements left to understand how the system is performing</li>
|
||
<li>Zero Paradox: A study of construction contractors showed more fatal accidents in firms with "goal zero" safety policies than in those without. Non-fatal accidents were similar.</li>
|
||
<li>Risk Secrecy: "goal zero" commitments result in injury underreporting and hiding of incidents which prevents learning, particularly when tied to financial incentives for leadership.</li>
|
||
</ul>
|
||
</li>
|
||
<li>There are patterns (capacities) that help things go well
|
||
<ul dir="auto">
|
||
<li><em>Diversity of opinion</em> - possibility to voice dissent</li>
|
||
<li><em>Keeping the discussion on risk alive</em> even when things go well</li>
|
||
<li><em>Deference to expertise</em> that already exists in people at the sharp end</li>
|
||
<li><em>Psychological safety</em> / "stop" ability</li>
|
||
<li><em>Low barriers</em> to interaction between organizational groups</li>
|
||
<li><em>Sharp end improvements</em> to existing systems based on local expertise</li>
|
||
<li><em>Pride in work</em> - process and results</li>
|
||
</ul>
|
||
</li>
|
||
<li>Rapid problem-solving can prevent effective problem-understanding</li>
|
||
<li>Leadership buy-in and practice of New View safety is imperative to its success. It's also difficult to foster.
|
||
<ul dir="auto">
|
||
<li>Worker buy-in is rapid and fits their existing mental model</li>
|
||
<li>Leadership must abandon the mental model that has governed their past work and decision-making - difficult for anyone.</li>
|
||
<li>Peer discussions are especially helpful for leadership</li>
|
||
<li>Highlighting how local adaptations helped things go well also helps</li>
|
||
</ul>
|
||
</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-4" class="anchor" aria-label="Permalink: Concepts" href="#concepts-4"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>Drift into failure</li>
|
||
<li>Safety differently</li>
|
||
<li>New view vs old view of human performance & error</li>
|
||
<li>Just culture</li>
|
||
<li>complexity</li>
|
||
<li>broken part</li>
|
||
<li>Newton-Descartes</li>
|
||
<li>diversity</li>
|
||
<li>systems theory</li>
|
||
<li>unruly technology</li>
|
||
<li>decrementalism</li>
|
||
<li>generic competencies</li>
|
||
<li>work as imagined vs work as done</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-10" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-10"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.amazon.com/Drift-into-Failure-Sidney-Dekker/dp/1409422216" rel="nofollow">Drift into failure</a></li>
|
||
<li><a href="http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.411.4985&rep=rep1&type=pdf" rel="nofollow">Reconstructing human contributions to accidents: the new view on error and performance</a></li>
|
||
<li><a href="https://www.amazon.com/Field-Guide-Understanding-Human-Error/dp/1472439058s://www.amazon.com/Field-Guide-Understanding-Human-Error/dp/1472439058" rel="nofollow">The field guide to understanding 'human error'</a></li>
|
||
<li><a href="https://www.amazon.com/Behind-Human-Error-David-Woods/dp/0754678342" rel="nofollow">Behind Human Error</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/50917226_Rule-_and_role_retreat_An_empirical_study_of_procedures_and_resilience?enrichId=rgreq-23625e555a0d8e5250c74f24b5fd01ca-XXX&enrichSource=Y292ZXJQYWdlOzUwOTE3MjI2O0FTOjk3MzU5NjY5MjM1NzQ1QDE0MDAyMjM3NjI5NDY%3D&el=1_x_2&_esc=publicationCoverPdf" rel="nofollow">Rule- and role retreat: An empirical study of procedures and resilience</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/247512351_Anticipating_the_effects_of_technological_change_A_new_era_of_dynamics_for_human_factors" rel="nofollow">Anticipating the effects of technological change: A new era of dynamics for human factors</a></li>
|
||
<li><a href="http://www.safetydifferently.com/why-do-things-go-right/" rel="nofollow">Why do things go right?</a></li>
|
||
<li><a href="http://www.humanfactors.lth.se/fileadmin/lusa/Sidney_Dekker/articles/2007/SafetyScienceMonitor.pdf" rel="nofollow">Six stages to the new view of human error</a></li>
|
||
<li><a href="http://sidneydekker.com/wp-content/uploads/2014/08/DekkerPS2014.pdf" rel="nofollow">Employees: A Problem to Control or Solution to Harness?</a></li>
|
||
<li><a href="https://portal.research.lu.se/ws/files/1376441/3014838.pdf" rel="nofollow">Team Coordination in Escalating Situations: An Empirical Study Using Mid-Fidelity Simulation</a></li>
|
||
<li><a href="https://pdfs.semanticscholar.org/a0d3/9cc66adc64e297048a32b71aeee209a451af.pdf" rel="nofollow">Resilience Engineering: New directions for measuring and maintaining safety in complex systems</a></li>
|
||
<li><a href="http://www.humanfactors.lth.se/fileadmin/lusa/Sidney_Dekker/articles/2003_and_before/Illusions_of_explanation.pdf" rel="nofollow">Illusions of explanation: A critical essay on error classification</a></li>
|
||
<li><a href="http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.606.3361&rep=rep1&type=pdf" rel="nofollow">Failure to adapt or adaptations that fail: contrasting models on procedures and safety</a></li>
|
||
<li><a href="https://link.springer.com/article/10.1007%2Fs10111-003-0136-9" rel="nofollow">Human factors and folk models</a></li>
|
||
<li><a href="http://sidneydekker.com/wp-content/uploads/2013/01/CH005.pdf" rel="nofollow">The High Reliability Organization Perspective</a> (<a href="https://resilienceroundup.com/issues/09/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="http://www.humanfactors.lth.se/fileadmin/lusa/Sidney_Dekker/articles/2003_and_before/Illusions_of_explanation.pdf" rel="nofollow">Illusions of explanation: A critical essay on error classification</a> (<a href="https://resilienceroundup.com/issues/42/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://doi.org/10.1016/j.ress.2019.106740" rel="nofollow">Safety II professionals: How resilience engineering can transform safety practice</a> (<a href="https://resilienceroundup.com/issues/64/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://static1.squarespace.com/static/53b78765e4b0949940758017/t/5722beb0d51cd4d11675a69c/1461894833950/Dekker%2C+Cilliers+and+Hofmeyr+-+The+Complexity+of+Failure.pdf" rel="nofollow">The complexity of failure: implications of complexity theory for safety investigation</a></li>
|
||
<li><a href="https://www.amazon.com/Safety-Anarchist-innovation-bureaucracy-compliance/dp/1138300462" rel="nofollow">The Safety Anarchist</a>)</li>
|
||
<li><a href="https://www.amazon.com/Compliance-Capitalism-Overregulated-Management-Neoliberalism/dp/1032012366" rel="nofollow">Compliance Capitalism</a></li>
|
||
<li><a href="https://pdfs.semanticscholar.org/a0d3/9cc66adc64e297048a32b71aeee209a451af.pdf" rel="nofollow">Resilience Engineering: New directions for measuring and maintaining safety in complex systems</a></li>
|
||
<li><a href="https://maritimesafetyinnovationlab.org/wp-content/uploads/2021/03/DekkerDriftRiskChapter2013.pdf" rel="nofollow">Drifting into failure: Complexity theory and the management of risk</a> (<a href="https://safety177496371.wordpress.com/2025/05/03/drifting-into-failure-complexity-theory-and-the-management-of-risk/" rel="nofollow">BH 1</a> <a href="https://safety177496371.wordpress.com/2025/05/03/complex-systems-and-drifting-into-failure-further-extracts-from-dekker-2013/" rel="nofollow">BH 2</a>)</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected talks</h3><a id="user-content-selected-talks-5" class="anchor" aria-label="Permalink: Selected talks" href="#selected-talks-5"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.youtube.com/watch?v=gtxtb9z_4FY&feature=youtu.be" rel="nofollow">Panel discussion: Safety Culture, Lean, and DevOps</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Jessica Devita</h2><a id="user-content-jessica-devita" class="anchor" aria-label="Permalink: Jessica Devita" href="#jessica-devita"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Devita is a software engineering manager and researcher in software resilience engineering. She has previously held roles at Microsoft, Netflix, and Google. Her master thesis <a href="https://lup.lub.lu.se/student-papers/search/publication/9149521" rel="nofollow">To Deploy, or Not to Deploy, That is the Question A qualitative study of the decision-making experiences of engineers deploying software changes in production</a> focused on software deployments and decision making.</p>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">John C. Doyle</h2><a id="user-content-john-c-doyle" class="anchor" aria-label="Permalink: John C. Doyle" href="#john-c-doyle"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="http://www.cds.caltech.edu/~doyle/wiki/index.php?title=Main_Page" rel="nofollow">Doyle</a> is a
|
||
control systems researcher. He is seeking to identify the universal laws that capture the
|
||
behavior of resilient systems, and is concerned with the architecture of such
|
||
systems.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-5" class="anchor" aria-label="Permalink: Concepts" href="#concepts-5"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>Robust yet fragile</li>
|
||
<li>layered architectures</li>
|
||
<li>constraints that deconstrain</li>
|
||
<li>protocol-based architectures</li>
|
||
<li>emergent constraints</li>
|
||
<li>Universal laws and architectures</li>
|
||
<li>conservation laws</li>
|
||
<li>universal architectures</li>
|
||
<li>Highly optimized tolerance</li>
|
||
<li>Doyle's catch</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">Doyle's catch</h4><a id="user-content-doyles-catch" class="anchor" aria-label="Permalink: Doyle's catch" href="#doyles-catch"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><em>Doyle's catch</em> is a term introduced by David Woods, but attributed to John Doyle. Here's how
|
||
<a href="https://www.researchgate.net/publication/303832480_The_Risks_of_Autonomy_Doyles_Catch" rel="nofollow">Woods quotes Doyle</a>:</p>
|
||
<blockquote>
|
||
<p dir="auto">Computer-based simulation and rapid prototyping tools are now broadly available and powerful enough that it is
|
||
relatively easy to demonstrate almost anything, provided that conditions are made sufficiently idealized.
|
||
However, the real world is typically far from idealized, and thus a system must have enough robustness in order to close
|
||
the gap between demonstration and the real thing.</p>
|
||
</blockquote>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-11" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-11"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="http://www.cis.upenn.edu/~ngns/docs/Review_2010/Doyle%20MURI%202010.pdf" rel="nofollow">Universal Laws and Architectures</a> (slides)</li>
|
||
<li><a href="http://dx.doi.org/10.1109/TSMCA.2010.2048027" rel="nofollow">Contrasting Views of Complexity and Their Implications For Network-Centric Infrastructures</a></li>
|
||
<li><a href="https://www.pnas.org/content/108/Supplement_3/15624" rel="nofollow">Architecture, constraints, and behavior</a></li>
|
||
<li><a href="https://doi.org/10.1073/pnas.0501426102" rel="nofollow">The “robust yet fragile” nature of the Internet</a></li>
|
||
<li><a href="http://dx.doi.org/10.1103/physrevlett.84.2529" rel="nofollow">Highly Optimized Tolerance: Robustness and Design in Complex Systems</a></li>
|
||
<li><a href="https://doi.org/10.1073/pnas.1401883111" rel="nofollow">Robust efficiency and actuator saturation explain healthy heart rate control and variability</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Bob Edwards</h2><a id="user-content-bob-edwards" class="anchor" aria-label="Permalink: Bob Edwards" href="#bob-edwards"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="http://hopcoach.net/" rel="nofollow">Edwards</a> is a practitioner who provides
|
||
training services in human and organizational performance (HOP).</p>
|
||
<p dir="auto">Edwards tweets as <a href="https://twitter.com/thehopcoach" rel="nofollow">@thehopcoach</a>.</p>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Anders Ericsson</h2><a id="user-content-anders-ericsson" class="anchor" aria-label="Permalink: Anders Ericsson" href="#anders-ericsson"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Ericsson introduced the idea of <em>deliberate practice</em> as a mechanism for
|
||
achieving high level of expertise.</p>
|
||
<p dir="auto">Ericsson isn't directly associated with the field of resilience engineering.
|
||
However, Gary Klein's work is informed by his, and I have a particular
|
||
interest in how people improve in expertise, so I'm including him here.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-6" class="anchor" aria-label="Permalink: Concepts" href="#concepts-6"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>Expertise</li>
|
||
<li>Deliberate practice</li>
|
||
<li>Protocol analysis</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-12" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-12"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.amazon.com/Peak-Secrets-New-Science-Expertise/dp/1531864880/" rel="nofollow">Peak: secrets from the new science of expertise</a></li>
|
||
<li><a href="https://www.amazon.com/Protocol-Analysis-Revd-Verbal-Reports/dp/0262550237" rel="nofollow">Protocol analysis: verbal reports as data</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Paul Feltovich</h2><a id="user-content-paul-feltovich" class="anchor" aria-label="Permalink: Paul Feltovich" href="#paul-feltovich"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://www.ihmc.us/groups/pfeltovich/" rel="nofollow">Feltovich</a> is a retired Senior Research Scientist at the Florida Institute for Human & Machine Cognition (IHMC),
|
||
who has done extensive reserach in human expertise.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-13" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-13"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="http://jeffreymbradshaw.net/publications/Common_Ground_Single.pdf" rel="nofollow">Common Ground and Coordination in Joint Activity</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/232465540_Issue_of_expert_flexibility_in_contexts_characterized_by_complexity_and_change" rel="nofollow">Issue of expert flexibility in contexts characterized by complexity and change</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/3454029_A_rose_by_any_other_namewould_probably_be_given_an_acronym" rel="nofollow">A rose by any other name...would probably be given an acronym</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/234818797_Learners'_misunderstanding_of_important_and_difficult_concepts_a_challenge_to_smart_machines_in_education" rel="nofollow">Learners' (mis)understanding of important and difficult concepts: a challenge to smart machines in education</a></li>
|
||
<li><a href="https://ieeexplore.ieee.org/abstract/document/1363742" rel="nofollow">Ten challenges for making automation a team player</a> (<a href="https://resilienceroundup.com/issues/ten-challenges-for-making-automation-a-team-player-in-joint-human-agent-activity/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/232465540_Issue_of_expert_flexibility_in_contexts_characterized_by_complexity_and_change" rel="nofollow">Issue of expert flexibility in contexts characterized by complexity and change</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Meir Finkel</h2><a id="user-content-meir-finkel" class="anchor" aria-label="Permalink: Meir Finkel" href="#meir-finkel"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Finkel is a Colonel in the Israeli Defense Force (IDF) and the Director of the IDF's Ground Forces Concept Development and Doctrine Department</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-14" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-14"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.amazon.com/Flexibility-Recovery-Technological-Doctrinal-Battlefield/dp/0804774897/ref=sr_1_3?ie=UTF8&qid=1546046916&sr=8-3&keywords=on+flexibility" rel="nofollow">On Flexibility: Recovery from Technological and Doctrinal Surprise on the Battlefield</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Marisa Grayson</h2><a id="user-content-marisa-grayson" class="anchor" aria-label="Permalink: Marisa Grayson" href="#marisa-grayson"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://www.linkedin.com/in/marisa-grayson/" rel="nofollow">Grayson</a> is a cognitive systems engineer at Mile Two, LLC.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected Publications</h3><a id="user-content-selected-publications-15" class="anchor" aria-label="Permalink: Selected Publications" href="#selected-publications-15"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.researchgate.net/publication/333091997_Approaching_Overload_Diagnosis_and_Response_to_Anomalies_in_Complex_and_Automated_Production_Software_Systems" rel="nofollow">Approaching Overload: Diagnosis and Response to Anomalies in Complex and Automated Production Software Systems</a></li>
|
||
<li><a href="https://queue.acm.org/detail.cfm?id=3380778" rel="nofollow">Cognitive Work of Hypothesis Exploration During Anomaly Response</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Ivonne Andrade Herrera</h2><a id="user-content-ivonne-andrade-herrera" class="anchor" aria-label="Permalink: Ivonne Andrade Herrera" href="#ivonne-andrade-herrera"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://www.ntnu.edu/employees/ivonne.a.herrera" rel="nofollow">Herrera</a> is an associate professor in
|
||
the department of industrial economics and technology management at NTNU and a
|
||
senior research scientist at SINTEF. Her areas of expertise include safety management and
|
||
resilience engineering in avionics and air traffic management.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-16" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-16"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.sintef.no/globalassets/upload/teknologi_og_samfunn/sikkerhet-og-palitelighet/rapporter/sintef-a17034-organisational-accidents-and-resilience-organisations-six-perspectives.-revision-2.pdf" rel="nofollow">Organisational accidents and resilient organisations: six perspectives</a> (SINTEF A17034 report)</li>
|
||
</ul>
|
||
<p dir="auto">See also: <a href="https://wo.cristin.no/as/WebObjects/cristin.woa/wa/fres?sort=ar&pnr=30556&action=sok" rel="nofollow">list of publications</a></p>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Cat Hicks</h2><a id="user-content-cat-hicks" class="anchor" aria-label="Permalink: Cat Hicks" href="#cat-hicks"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://www.drcathicks.com/" rel="nofollow">Hicks</a> is a psychological scientist and researcher who creates open science to drive change for people doing technical work. She holds a PhD in Quantitative Experimental Psychology from UC San Diego and is the founder and principal scientist of Catharsis Consulting, a scientific consultancy that helps organizations transform with human-centered evidence strategies.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected Publications</h3><a id="user-content-selected-publications-17" class="anchor" aria-label="Permalink: Selected Publications" href="#selected-publications-17"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.routledge.com/The-Psychology-of-Software-Teams/Hicks/p/book/9781032963389" rel="nofollow">The Psychology of Software Teams</a></li>
|
||
<li><a href="https://ieeexplore.ieee.org/stamp/stamp.jsp?arnumber=10491133" rel="nofollow">Developer Thriving: four sociocognitive factors that create resilient productivity on software teams</a></li>
|
||
<li><a href="https://osf.io/preprints/psyarxiv/2gej5" rel="nofollow">The New Developer: AI Skill Threat, Identity Change & Developer Thriving in the Transition to AI-Assisted Software Development</a></li>
|
||
<li><a href="https://scholar.google.com/citations?user=MotKyQcAAAAJ&hl=en" rel="nofollow">Google Scholar</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Robert Hoffman</h2><a id="user-content-robert-hoffman" class="anchor" aria-label="Permalink: Robert Hoffman" href="#robert-hoffman"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://www.ihmc.us/groups/rhoffman/" rel="nofollow">Hoffman</a> is a senior research scientist at Florida Institute for Human & Machine Cognition (IHMC),
|
||
who has done extensive reserach in human expertise.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-18" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-18"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://journals.sagepub.com/doi/abs/10.1177/0018720816686248" rel="nofollow">Measuring resilience</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/326000581_Myths_of_automation_and_their_implications_for_military_procurement" rel="nofollow">Myths of automation and their implications for military procurement</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/260304859_The_Seven_Deadly_Myths_of_Autonomous_Systems" rel="nofollow">The Seven Deadly Myths of "Autonomous Systems"</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/3454029_A_rose_by_any_other_namewould_probably_be_given_an_acronym" rel="nofollow">A rose by any other name...would probably be given an acronym</a></li>
|
||
<li><a href="https://cmapspublic3.ihmc.us/rid=1G9NSY15K-N7MJMZ-LC5/SeeingTheInvisible.pdf" rel="nofollow">Seeing the invisible: perceptual-cognitive aspects of expertise</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/3454245_Toward_a_Theory_of_Complex_and_Cognitive_Systems" rel="nofollow">Toward a Theory of Complex and Cognitive Systems</a></li>
|
||
<li><a href="https://pdfs.semanticscholar.org/df74/b2909f54b41a485cd4c0189fc4aa19d176d0.pdf" rel="nofollow">Macrocognition</a> (<a href="https://resilienceroundup.com/issues/62/" rel="nofollow">TWRR</a>)</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-7" class="anchor" aria-label="Permalink: Concepts" href="#concepts-7"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">Seven deadly myths of autonomous systems</h4><a id="user-content-seven-deadly-myths-of-autonomous-systems" class="anchor" aria-label="Permalink: Seven deadly myths of autonomous systems" href="#seven-deadly-myths-of-autonomous-systems"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ol dir="auto">
|
||
<li>"Autonomy" is unidimensional.</li>
|
||
<li>The conceptualization of "levels of autonomy" is a useful scientific grounding for the development of autonomous system roadmaps.</li>
|
||
<li>Autonomy is a widget.</li>
|
||
<li>Autonomous systems are autonomous.</li>
|
||
<li>Once achieved, full autonomy obviates the need for human-machine collaboration.</li>
|
||
<li>As machines acquire more autonomy, they will work as simple sibstitutes (or multipliers) of human capability</li>
|
||
<li>"Full autonomy" is not only possible, but is always desireable.</li>
|
||
</ol>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Erik Hollnagel</h2><a id="user-content-erik-hollnagel" class="anchor" aria-label="Permalink: Erik Hollnagel" href="#erik-hollnagel"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Contributions</h3><a id="user-content-contributions-2" class="anchor" aria-label="Permalink: Contributions" href="#contributions-2"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">ETTO principle</h4><a id="user-content-etto-principle" class="anchor" aria-label="Permalink: ETTO principle" href="#etto-principle"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Hollnagel proposed that there is always a fundamental tradeoff between
|
||
efficiency and thoroughness, which he called the <em>ETTO principle</em>.</p>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">Safety-I vs. Safety-II</h4><a id="user-content-safety-i-vs-safety-ii" class="anchor" aria-label="Permalink: Safety-I vs. Safety-II" href="#safety-i-vs-safety-ii"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Safety-I: avoiding things that go wrong</p>
|
||
<ul dir="auto">
|
||
<li>looking at what goes wrong</li>
|
||
<li>bimodal view of work and activities (acceptable vs unacceptable)</li>
|
||
<li>find-and-fix approach</li>
|
||
<li>prevent transition from 'normal' to 'abnormal'</li>
|
||
<li>causality credo: believe that adverse outcomes happen because something goes
|
||
wrong (they have causes that can be found and treated)</li>
|
||
<li>it either works or it doesn't</li>
|
||
<li>systems are decomposable</li>
|
||
<li>functioning is bimodal</li>
|
||
</ul>
|
||
<p dir="auto">Safety-II: performance variability rather than bimodality</p>
|
||
<ul dir="auto">
|
||
<li>the system’s ability to succeed under varying conditions, so that the number
|
||
of intended and acceptable outcomes (in other words, everyday activities) is
|
||
as high as possible</li>
|
||
<li>performance is always variable</li>
|
||
<li>performance variation is ubiquitous</li>
|
||
<li>things that go right</li>
|
||
<li>focus on frequent events</li>
|
||
<li>remain sensitive to possibility of failure</li>
|
||
<li>be thorough as well as efficient</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">FRAM</h4><a id="user-content-fram" class="anchor" aria-label="Permalink: FRAM" href="#fram"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Hollnagel proposed the Functional Resonance Analysis Method (FRAM) for modeling
|
||
complex socio-technical systems.</p>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">Four abilities necessary for resilient performance</h4><a id="user-content-four-abilities-necessary-for-resilient-performance" class="anchor" aria-label="Permalink: Four abilities necessary for resilient performance" href="#four-abilities-necessary-for-resilient-performance"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>respond</li>
|
||
<li>monitor</li>
|
||
<li>learn</li>
|
||
<li>anticipate</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-8" class="anchor" aria-label="Permalink: Concepts" href="#concepts-8"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>ETTO (efficiency thoroughness tradeoff) principle</li>
|
||
<li>FRAM (functional resonance analysis method)</li>
|
||
<li>Safety-I and Safety-II</li>
|
||
<li>things that go wrong vs things that go right</li>
|
||
<li>causality credo</li>
|
||
<li>performance variability</li>
|
||
<li>bimodality</li>
|
||
<li>emergence</li>
|
||
<li>work-as-imagined vs. work-as-done</li>
|
||
<li>joint cognitive systems</li>
|
||
<li>systems of the first, second, third, fourth kind</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-19" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-19"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.amazon.com/ETTO-Principle-Efficiency-Thoroughness-Trade-Off-Sometimes/dp/0754676781/ref=sr_1_1?s=books&ie=UTF8&qid=1545965837&sr=1-1&keywords=etto+principle" rel="nofollow">The ETTO Principle: Efficiency-Thoroughness Trade-Off: Why Things That Go Right Sometimes Go Wrong</a></li>
|
||
<li><a href="https://www.skybrary.aero/bookshelf/books/2437.pdf" rel="nofollow">From Safety-I to Safety-II: A White Paper</a></li>
|
||
<li><a href="https://www.amazon.com/Safety-II-Practice-Developing-Resilience-Potentials/dp/1138708925" rel="nofollow">Safety-II in Practice</a></li>
|
||
<li><a href="https://www.amazon.com/gp/product/1472423089/ref=dbs_a_def_rwt_bibl_vppi_i0" rel="nofollow">Safety-I and Safety-II: The past and future of safety management</a></li>
|
||
<li><a href="https://www.amazon.com/gp/product/B010WIDYE8/ref=dbs_a_def_rwt_bibl_vppi_i15" rel="nofollow">FRAM: The Functional Resonance Analysis Method: Modelling Complex Socio-technical System</a></li>
|
||
<li><a href="https://www.amazon.com/gp/product/0849339332/ref=x_gr_w_bb?ie=UTF8&tag=x_gr_w_bb-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=0849339332&SubscriptionId=1MGPYB6YW3HWK55XCGG2" rel="nofollow">Joint Cognitive Systems: Patterns in Cognitive Systems Engineering</a></li>
|
||
<li><a href="https://www.amazon.com/gp/product/B009KNDF64/ref=x_gr_w_glide_bb?ie=UTF8&tag=x_gr_w_glide_bb-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=B009KNDF64&SubscriptionId=1MGPYB6YW3HWK55XCGG2" rel="nofollow">Resilience Engineering: Concepts and Precepts</a></li>
|
||
<li><a href="http://dx.doi.org/10.1007/s10111-012-0237-4" rel="nofollow">I want to believe: some myths about the management of industrial safety</a></li>
|
||
<li><a href="http://www.ptil.no/getfile.php/1325150/PDF/Seminar%202013/Integrerte%20operasjoner/Hollnagel_RIO_presentation.pdf" rel="nofollow">Resilience engineering – Building a Culture of Resilience</a> (slides)</li>
|
||
<li><a href="https://docs.wixstatic.com/ugd/3ad081_f46dda684154447583c8a5b282b60cc2.pdf" rel="nofollow">Anomaly Response</a></li>
|
||
<li><a href="https://www.ida.liu.se/~729A15/mtrl/CSEnew.pdf?utm_campaign=Resilience%20Roundup&utm_medium=email&utm_source=Revue%20newsletter" rel="nofollow">Cognitive Systems Engineering: New wine in new bottles</a> (<a href="https://www.getrevue.co/profile/resilience/issues/resilience-roundup-cognitive-systems-engineering-new-wine-in-new-bottles-issue-32-175912" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/265074845_Epilogue_Resilience_Engineering_Precepts" rel="nofollow">Epilogue: Resilience Engineering Precepts</a></li>
|
||
<li><a href="https://pdfs.semanticscholar.org/a0d3/9cc66adc64e297048a32b71aeee209a451af.pdf" rel="nofollow">Resilience Engineering: New directions for measuring and maintaining safety in complex systems</a></li>
|
||
<li><a href="https://erikhollnagel.com/ideas/resilience-engineering.html" rel="nofollow">Resilience Engineering</a> (web essay)</li>
|
||
<li><a href="http://erikhollnagel.com/onewebmedia/RAG%20Outline%20V2.pdf" rel="nofollow">RAG - Resilience Analysis Grid</a></li>
|
||
<li><a href="https://www.crcpress.com/Resilience-Engineering-in-Practice-A-Guidebook/Paries-Wreathall-Hollnagel/p/book/9781472420749" rel="nofollow">Resilience engineering in practice: a guidebook</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/220108174_Mapping_Cognitive_Demands_in_Complex_Problem-Solving_Worlds%3CPaste%3E" rel="nofollow">Mapping Cognitive Demands in Complex Problem-Solving Worlds</a> (mentions disturbance management)</li>
|
||
<li><a href="https://link.springer.com/article/10.1007%2Fs10111-003-0136-9" rel="nofollow">Human factors and folk models</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/4213914_Designing_for_joint_cognitive_systems" rel="nofollow">Designing for joint cognitive systems</a></li>
|
||
<li><a href="https://pdfs.semanticscholar.org/df74/b2909f54b41a485cd4c0189fc4aa19d176d0.pdf" rel="nofollow">Macrocognition</a> (<a href="https://resilienceroundup.com/issues/62/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.sciencedirect.com/science/article/abs/pii/S0925753521004719" rel="nofollow">A day when (Almost) nothing happened</a></li>
|
||
<li><a href="https://europepmc.org/article/NBK/nbk43670" rel="nofollow">Minding the Gaps: Creating Resilience in Health Care</a></li>
|
||
<li><a href="https://pdfs.semanticscholar.org/a0d3/9cc66adc64e297048a32b71aeee209a451af.pdf" rel="nofollow">Resilience Engineering: New directions for measuring and maintaining safety in complex systems</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/3973687_Understanding_accidents-from_root_causes_to_performance_variability" rel="nofollow">Understanding Accidents - From Root Causes to Performance Variability</a> (<a href="https://safety177496371.wordpress.com/2025/03/12/understanding-accidents-from-root-causes-to-performance-variability/" rel="nofollow">BH</a>)</li>
|
||
<li><a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/9780470713181.ch9" rel="nofollow">Human error: trick or treat</a></li>
|
||
<li><a href="https://incrementalsafety.com/onewebmedia/fifth%20paradox%20oct%2031.pdf" rel="nofollow">THe 5th paradox of safety</a> (<a href="https://safetyinsights.org/2026/01/09/the-fifth-paradox-of-safety-new-article-from-erik-hollnagel/" rel="nofollow">BH</a>)</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Leila Johannesen</h2><a id="user-content-leila-johannesen" class="anchor" aria-label="Permalink: Leila Johannesen" href="#leila-johannesen"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://www.linkedin.com/in/leilajohannesen/" rel="nofollow">Johannesen</a> is currently a UX researcher and community advocate at IBM.
|
||
Her PhD dissertation work examined how humans cooperate, including studies of anesthesiologists.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-9" class="anchor" aria-label="Permalink: Concepts" href="#concepts-9"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>common ground</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-20" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-20"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://pdfs.semanticscholar.org/1bed/356b5aa67c701f5bad6d943768622095f418.pdf" rel="nofollow">Grounding explanations in evolving, diagnostic situations</a></li>
|
||
<li><a href="https://www.abdn.ac.uk/iprc/documents/Communication%20Book%20Chapter.pdf" rel="nofollow">Maintaining common ground: an analysis of cooperative communication in the operating room</a></li>
|
||
<li><a href="https://www.amazon.com/Behind-Human-Error-David-Woods/dp/0754678342" rel="nofollow">Behind Human Error</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Gary Klein</h2><a id="user-content-gary-klein" class="anchor" aria-label="Permalink: Gary Klein" href="#gary-klein"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Klein studies how experts are able to quickly make effective decisions in high-tempo situations.</p>
|
||
<p dir="auto">Klein tweets as <a href="https://twitter.com/KleInsight" rel="nofollow">@KleInsight</a>.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-10" class="anchor" aria-label="Permalink: Concepts" href="#concepts-10"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>naturalistic decision making (NDM)</li>
|
||
<li>intuitive expertise</li>
|
||
<li>cognitive task analysis</li>
|
||
<li>common ground</li>
|
||
<li>problem detection</li>
|
||
<li>automation as a "team player"</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-21" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-21"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.amazon.com/gp/product/0262534290/ref=dbs_a_def_rwt_bibl_vppi_i0" rel="nofollow">Sources of power: how people make decisions</a></li>
|
||
<li><a href="http://jeffreymbradshaw.net/publications/Common_Ground_Single.pdf" rel="nofollow">Common Ground and Coordination in Joint Activity</a></li>
|
||
<li><a href="https://www.amazon.com/gp/product/0262532816/ref=dbs_a_def_rwt_bibl_vppi_i5" rel="nofollow">Working minds: a practitioner's guide to cognitive task analysis</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/262449980_Patterns_in_Cooperative_Cognition" rel="nofollow">Patterns in Cooperative Cognition</a></li>
|
||
<li><a href="https://journals.sagepub.com/doi/abs/10.1177/1555343416637520?journalCode=edma" rel="nofollow">Can We Trust Best Practices? Six Cognitive Challenges of Evidence-Based Approaches</a></li>
|
||
<li><a href="http://dx.doi.org/10.1037/a0016755" rel="nofollow">Conditions for intuitive expertise: a failure to disagree</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/220579480_Problem_detection" rel="nofollow">Problem detection</a></li>
|
||
<li><a href="https://ieeexplore.ieee.org/abstract/document/1363742" rel="nofollow">Ten challenges for making automation a team player</a> (<a href="https://resilienceroundup.com/issues/66" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="http://www.macrocognition.com/documents/Decision-Making-in-Action-Models-and-Methods-0316.pdf" rel="nofollow">Decision making in action: models and methods</a></li>
|
||
<li><a href="https://ieeexplore.ieee.org/document/31053" rel="nofollow">Critical decision method for eliciting knowledge</a></li>
|
||
<li><a href="https://pdfs.semanticscholar.org/0672/092ecc507fb41d81e82d2986cf86c4bff14f.pdf" rel="nofollow">A recognition-primed decision (RPD) model of rapid decision making</a></li>
|
||
<li><a href="https://cmapspublic3.ihmc.us/rid=1G9NSY15K-N7MJMZ-LC5/SeeingTheInvisible.pdf" rel="nofollow">Seeing the invisible: perceptual-cognitive aspects of expertise</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/262449980_Patterns_in_Cooperative_Cognition" rel="nofollow">Patterns in Cooperative Cognition</a></li>
|
||
<li><a href="https://link.springer.com/article/10.1007/s10111-005-0024-6" rel="nofollow">The strengths and limitations of teams for detecting problems</a></li>
|
||
<li><a href="https://pdfs.semanticscholar.org/df74/b2909f54b41a485cd4c0189fc4aa19d176d0.pdf" rel="nofollow">Macrocognition</a> (<a href="https://resilienceroundup.com/issues/62/" rel="nofollow">TWRR</a>)</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected talks</h3><a id="user-content-selected-talks-6" class="anchor" aria-label="Permalink: Selected talks" href="#selected-talks-6"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.youtube.com/watch?v=UXx51qK4ItQ&feature=emb_title" rel="nofollow">Problem detection</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Elizabeth Lay</h2><a id="user-content-elizabeth-lay" class="anchor" aria-label="Permalink: Elizabeth Lay" href="#elizabeth-lay"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Elizabeth Lay is a resilience engineering practitioner. She is currently a director of safety and human performance at Lewis Tree Service.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-22" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-22"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.taylorfrancis.com/chapters/edit/10.1201/9781315605708-18/noticing-brittleness-designing-resilience-elizabeth-lay-matthieu-branlat" rel="nofollow">Noticing Brittleness, Designing for Resilience</a></li>
|
||
<li><a href="https://www.sciencedirect.com/science/article/abs/pii/S0951832015000812" rel="nofollow">A practitioner’s experiences operationalizing Resilience Engineering</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Nancy Leveson</h2><a id="user-content-nancy-leveson" class="anchor" aria-label="Permalink: Nancy Leveson" href="#nancy-leveson"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Nancy Leveson is a computer science researcher with a focus in software safety.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Contributions</h3><a id="user-content-contributions-3" class="anchor" aria-label="Permalink: Contributions" href="#contributions-3"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">STAMP</h4><a id="user-content-stamp" class="anchor" aria-label="Permalink: STAMP" href="#stamp"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Leveson developed the accident causality model known as STAMP: the Systems-Theoretic Accident Model and Process.</p>
|
||
<p dir="auto">See <a href="/lorin/resilience-engineering/blob/master/STAMP.md">STAMP</a> for some more detailed notes of mine.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-11" class="anchor" aria-label="Permalink: Concepts" href="#concepts-11"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>Software safety</li>
|
||
<li>STAMP (systems-theoretic accident model and processes)</li>
|
||
<li>STPA (system-theoretic process analysis) hazard analysis technique</li>
|
||
<li>CAST (causal analysis based on STAMP) accident analysis technique</li>
|
||
<li>Systems thinking</li>
|
||
<li>hazard</li>
|
||
<li>interactive complexity</li>
|
||
<li>system accident</li>
|
||
<li>dysfunctional interactions</li>
|
||
<li>safety constraints</li>
|
||
<li>control structure</li>
|
||
<li>dead time</li>
|
||
<li>time constants</li>
|
||
<li>feedback delays</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-23" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-23"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="http://sunnyday.mit.edu/accidents/safetyscience-single.pdf" rel="nofollow">A New Accident Model for Engineering Safer Systems</a></li>
|
||
<li><a href="https://mitpress.mit.edu/books/engineering-safer-world" rel="nofollow">Engineering a safer world</a></li>
|
||
<li><a href="http://psas.scripts.mit.edu/home/get_file.php?name=STPA_handbook.pdf" rel="nofollow">STPA Handbook</a></li>
|
||
<li><a href="https://www.amazon.com/Safeware-Computers-Nancy-G-Leveson/dp/0201119722" rel="nofollow">Safeware</a></li>
|
||
<li><a href="https://www.amazon.com/gp/product/B009KNDF64/ref=x_gr_w_glide_bb?ie=UTF8&tag=x_gr_w_glide_bb-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=B009KNDF64&SubscriptionId=1MGPYB6YW3HWK55XCGG2" rel="nofollow">Resilience Engineering: Concepts and Precepts</a></li>
|
||
<li><a href="http://dx.doi.org/10.1145/143062.143076" rel="nofollow">High-pressure steam engines and computer software</a></li>
|
||
<li><a href="https://www.amazon.com/gp/product/B009KNDF64/ref=x_gr_w_glide_bb?ie=UTF8&tag=x_gr_w_glide_bb-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=B009KNDF64&SubscriptionId=1MGPYB6YW3HWK55XCGG2" rel="nofollow">Resilience Engineering: Concepts and Precepts</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Beth Long</h2><a id="user-content-beth-long" class="anchor" aria-label="Permalink: Beth Long" href="#beth-long"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://www.linkedin.com/in/beth-adele-long/" rel="nofollow">Long</a> is a software engineer, product manager, and Principal at software incident analysis company Adaptive Capacity Labs. She previously held roles at New Relic, Jeli, and who co-authored the paper <a href="https://www-sciencedirect-com.proxy.lib.ohio-state.edu/science/article/pii/S0003687020301903" rel="nofollow">Building and revising adaptive capacity sharing for technical incident response: A case of resilience engineering</a> with Dr. Richard Cook.</p>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Carl Macrae</h2><a id="user-content-carl-macrae" class="anchor" aria-label="Permalink: Carl Macrae" href="#carl-macrae"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://www.nottingham.ac.uk/business/people/lizcjm.html" rel="nofollow">Macrae</a> is a social psychology
|
||
researcher who has done safety research in multiple domains, including aviation
|
||
and healthcare. He helped set up the new healthcare investigation agency in
|
||
England. He is currently a professor of organizational behavior and psychology
|
||
at the Notthingham University Business School.</p>
|
||
<p dir="auto">Macrae tweets at <a href="https://twitter.com/CarlMacrae" rel="nofollow">@CarlMacrae</a>.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-12" class="anchor" aria-label="Permalink: Concepts" href="#concepts-12"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>risk resilience</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-24" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-24"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="http://www.closecalls.cc/" rel="nofollow">Close calls</a></li>
|
||
<li><a href="https://qualitysafety.bmj.com/content/23/6/440" rel="nofollow">Early warnings, weak signals and learning from healthcare disasters</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Laura Maguire</h2><a id="user-content-laura-maguire" class="anchor" aria-label="Permalink: Laura Maguire" href="#laura-maguire"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://www.linkedin.com/in/lauramaguire/" rel="nofollow">Maguire</a> is a cognitive systems
|
||
engineer and ressearcher with a PhD from Ohio State University. Maguire has done safety work in multiple domains, including forestry, healthcare, oil & gas, wildland firefighting, mountain safety, and software services. She formerly led research & development at <a href="/lorin/resilience-engineering/blob/master/jeli.io">jeli.io</a>, is the a Director of the [Resilience & Proactive Safety Initiative(<a href="https://u.osu.edu/csel/resilienceproactivesafetyinitiative/" rel="nofollow">https://u.osu.edu/csel/resilienceproactivesafetyinitiative/</a>) at The Ohio State University's Cognitive Systems Engineering Lab and is the founder of <a href="https://www.tracecognitive.com/" rel="nofollow">Trace Cognitive Engineering</a> and <a href="/lorin/resilience-engineering/blob/master/cognitioninthewild.com">Cognition In The Wild</a> translating theory into practice for software and other industries. She also supervises Masters thesis projects for the College of Engineering at Lund University for the Human Factors & Systems Safety program. She was a founding member of the <a href="https://www.snafucatchers.com/" rel="nofollow">SNAFUCatchers Consortium</a> conducting focused cognitive systems and resilience engineering research on software companies.</p>
|
||
<p dir="auto">Maguire (rarely) tweets as <a href="https://twitter.com/lauramdmaguire" rel="nofollow">@LauraMDMaguire</a>.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-25" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-25"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://ieeexplore.ieee.org/document/10493156/" rel="nofollow">Joint Cognitive Systems: Ideas With Impact for Designing Safer, More Resilient Automated Systems</a></li>
|
||
<li><a href="https://ieeexplore.ieee.org/document/10339148" rel="nofollow">Cognitive Skills in Software Engineering: Operating Complex, Adaptive Systems at Speed and Scale</a></li>
|
||
<li><a href="https://ieeexplore.ieee.org/document/10372510" rel="nofollow">Automation doesn't work the way we think it does</a></li>
|
||
<li><a href="https://dl.acm.org/doi/abs/10.1109/MS.2024.3480768" rel="nofollow">Realizing the Benefits of Human Machine Teaming for Safe Software Operations</a> (with Laura Nolan)</li>
|
||
<li><a href="https://www.computer.org/csdl/magazine/so/2025/03/10953345/25ICFoAidsk" rel="nofollow">Navigating tradeoffs in software failures</a> (with Fred Hebert)</li>
|
||
<li><a href="https://queue.acm.org/detail.cfm?id=3380779" rel="nofollow">Managing the Hidden Costs of Coordination</a></li>
|
||
<li><a href="http://rave.ohiolink.edu/etdc/view?acc_num=osu1593661547087969" rel="nofollow">Controlling the Costs of Coordination in Large-scale Distributed Software Systems</a> (PhD dissertation)</li>
|
||
<li><a href="https://www.jeli.io/howie-the-post-incident-guide/" rel="nofollow">Howie: The Post-Incident Guide</a></li>
|
||
<li><a href="https://snafucatchers.github.io/" rel="nofollow">STELLA: Report from the SNAFUcatchers Workshop on Coping With Complexity</a></li>
|
||
<li>Pre-prints of many of her paywalled publications are available on <a href="https://www.researchgate.net/profile/Laura-Maguire-2" rel="nofollow">Researchgate</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected talks</h3><a id="user-content-selected-talks-7" class="anchor" aria-label="Permalink: Selected talks" href="#selected-talks-7"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.usenix.org/conference/srecon24americas/presentation/maguire" rel="nofollow">Hard Choices, Tight Timelines: A Closer Look at Skip-Level Tradeoff Decisions During Incidents</a> (With Courtney Nash)</li>
|
||
<li><a href="https://www.youtube.com/watch?v=m6NlJFsfimw" rel="nofollow">Followship: A Cognitive Systems approach to coordination in software incidents</a></li>
|
||
<li><a href="https://www.infoq.com/presentations/incident-command-system/" rel="nofollow">How Many Is Too Much? Exploring Costs of Coordination During Outages</a></li>
|
||
<li><a href="https://www.youtube.com/watch?v=VEprjLtHzg0" rel="nofollow">Mental models – why saying “I didn’t know it worked that way” is a sign of expertise not incompetence</a></li>
|
||
<li><a href="https://re-deploy.io/videos/27-maguire.html" rel="nofollow">Operating at the edge of the envelope</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Courtney Nash</h2><a id="user-content-courtney-nash" class="anchor" aria-label="Permalink: Courtney Nash" href="#courtney-nash"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Nash is a researcher and founder of [The Void] (<a href="https://www.thevoid.community/" rel="nofollow">https://www.thevoid.community/</a>), a community-contributed collection of software-related incident reports, aimed at making the internet a safer and more resilient place.</p>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Christopher Nemeth</h2><a id="user-content-christopher-nemeth" class="anchor" aria-label="Permalink: Christopher Nemeth" href="#christopher-nemeth"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://www.linkedin.com/in/christopher-nemeth-6651204" rel="nofollow">Nemeth</a> is a principal scientist at Applied Resesarch Associates, Inc.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-26" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-26"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.458.7283&rep=rep1&type=pdf" rel="nofollow">Replacing Hindsight With Insight: Toward Better Understanding of Diagnostic Failures</a></li>
|
||
<li><a href="https://www.researchgate.net/profile/Robert-Wears/publication/225108705_Resilience_is_Not_Control_Healthcare_Crisis_Management_and_ICT/links/00b49532b2c7f3ed62000000/Resilience-is-Not-Control-Healthcare-Crisis-Management-and-ICT.pdf" rel="nofollow">Resilience is not control: healthcare, crisis management, and ICT</a></li>
|
||
<li><a href="https://www.taylorfrancis.com/chapters/edit/10.1201/9781315605685-19/taking-things-one-stride-cognitive-features-two-resilient-performances-richard-cook-christopher-nemeth" rel="nofollow">Taking Things in One’s Stride: Cognitive Features of Two Resilient Performances</a></li>
|
||
<li><a href="https://europepmc.org/article/NBK/nbk43670" rel="nofollow">Minding the Gaps: Creating Resilience in Health Care</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Laura Nolan</h2><a id="user-content-laura-nolan" class="anchor" aria-label="Permalink: Laura Nolan" href="#laura-nolan"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://www.linkedin.com/in/lauralifts/details/experience/" rel="nofollow">Nolan</a> is a Principal Software Engineer and researcher who previously held roles at Google, Slack, Stanza. Her forthcoming masters thesis from Lund university studied expert troubleshooting during outages in production software environments.</p>
|
||
<p dir="auto">She currently works at Reddit.</p>
|
||
<ul dir="auto">
|
||
<li><a href="https://dl.acm.org/doi/abs/10.1109/MS.2024.3480768" rel="nofollow">Realizing the Benefits of Human Machine Teaming for Safe Software Operations</a> (with Laura Maguire)</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Anne-Sophie Nyssen</h2><a id="user-content-anne-sophie-nyssen" class="anchor" aria-label="Permalink: Anne-Sophie Nyssen" href="#anne-sophie-nyssen"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="http://www.lecit.ulg.ac.be/equipe/anne-sophie-nyssen/" rel="nofollow">Nyssen</a> is a psychology professor at the University of Liège,
|
||
who does research on human error in complex systems, in particular in medicine.</p>
|
||
<p dir="auto">A list of publications can be found on her website linked above.</p>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Elinor Ostrom</h2><a id="user-content-elinor-ostrom" class="anchor" aria-label="Permalink: Elinor Ostrom" href="#elinor-ostrom"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="http://www.elinorostrom.com/" rel="nofollow">Ostrom</a> was a Nobel-prize winning economics and
|
||
political science researcher.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-27" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-27"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.annualreviews.org/doi/abs/10.1146/annurev.polisci.2.1.493" rel="nofollow">Coping with tragedies of the commons</a></li>
|
||
<li><a href="https://www.amazon.com/Governing-Commons-Evolution-Institutions-Collective/dp/1107569788" rel="nofollow">Governing the Commons: The Evolution of Institutions for Collective Action</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-13" class="anchor" aria-label="Permalink: Concepts" href="#concepts-13"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>tragedy of the commons</li>
|
||
<li>polycentric governance</li>
|
||
<li>social-ecological system framework</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Jean Pariès</h2><a id="user-content-jean-pariès" class="anchor" aria-label="Permalink: Jean Pariès" href="#jean-pariès"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Pariès is the president of <a href="http://www.dedale.net/dedale_en/" rel="nofollow">Dédale</a>, a safety and human factors consultancy.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-28" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-28"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.crcpress.com/Resilience-Engineering-in-Practice-A-Guidebook/Paries-Wreathall-Hollnagel/p/book/9781472420749" rel="nofollow">Resilience engineering in practice: a guidebook</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected talks</h3><a id="user-content-selected-talks-8" class="anchor" aria-label="Permalink: Selected talks" href="#selected-talks-8"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="/lorin/resilience-engineering/blob/master/paries-keynote-2015.pptx">Predicting The fatal flaws: The challenge of The unpredictable...</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Emily Patterson</h2><a id="user-content-emily-patterson" class="anchor" aria-label="Permalink: Emily Patterson" href="#emily-patterson"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://hrs.osu.edu/faculty-and-staff/faculty-directory/patterson-emily" rel="nofollow">Patterson</a>
|
||
is a researcher who applies human factors engineering to improve patient safety
|
||
in healthcare.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-29" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-29"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.researchgate.net/publication/312624891_Patient_boarding_in_the_emergency_department_as_a_symptom_of_complexity-induced_risks" rel="nofollow">Patient boarding in the emergency department as a symptom of complexity-induced risks</a></li>
|
||
<li><a href="https://www.researchgate.net/profile/Emily_Patterson2/publication/237138704_USING_OBSERVATIONAL_STUDY_AS_A_TOOL_FOR_DISCOVERY_UNCOVERING_COGNITIVE_AND_COLLABORATIVE_DEMANDS_AND_ADAPTIVE_STRATEGIES/links/0deec52c8e310b385a000000.pdf" rel="nofollow">Using observational study as a tool for discovery: uncovering cognitive and collaborative demands and adaptive strategies</a></li>
|
||
<li><a href="https://www.semanticscholar.org/paper/Voice-Loops-as-Coordination-Aids-in-Space-Shuttle-Patterson-Watts-Perotti/068dfee1a859a63fa2ef82f008d239e6a81ed004" rel="nofollow">Voice Loops as Coordination Aids in Space Shuttle Mission Control</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/3657906_Functionally_distributed_coordination_during_anomaly_response_inspace_shuttle_mission_control" rel="nofollow">Functionally distributed coordination during anomaly response in space shuttle mission control</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/262449980_Patterns_in_Cooperative_Cognition" rel="nofollow">Patterns in Cooperative Cognition</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/220579448_Collaborative_Cross-Checking_to_Enhance_Resilience" rel="nofollow">Collaborative Cross-Checking to Enhance Resilience</a> (<a href="https://resilienceroundup.com/issues/73/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/2484621_New_Arctic_Air_Crash_Aftermath_Role-Play_Simulation_Orchestrating_a_Fundamental_Surprise" rel="nofollow">New Arctic Air Crash Aftermath Role-Play Simulation Orchestrating a Fundamental Surprise</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/8648890_Handoff_strategies_in_settings_with_high_consequences_for_failure_Lessons_for_health_care_operations" rel="nofollow">Handoff strategies in settings with high consequences for failure: lessons for health care operations</a> (<a href="https://resilienceroundup.com/issues/56" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="http://csel.eng.ohio-state.edu/productions/laws/laws_mediapaper/2_4_escalation.pdf" rel="nofollow">How Unexpected Events Produce An Escalation Of Cognitive And Coordinative Demands</a> (<a href="https://resilienceroundup.com/issues/how-unexpected-events-produce-an-escalation-of-cognitive-and-coordinative-demands/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1876978/" rel="nofollow">Communication Strategies from High-reliability Organizations: Translation is Hard Work</a> (<a href="https://resilienceroundup.com/issues/communication-strategies-from-high-reliability-organizations-translation-is-hard-work/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/228809190_Understanding_rigor_in_information_analysis" rel="nofollow">Understanding rigor in information analysis</a></li>
|
||
<li><a href="https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=15f31969c4e1f4f599c5c68aa63f3bf930e0406f" rel="nofollow">Behind Human Error: Taming Complexity to Improve Patient Safety</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Charles Perrow</h2><a id="user-content-charles-perrow" class="anchor" aria-label="Permalink: Charles Perrow" href="#charles-perrow"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Perrow is a sociologist who studied the Three Mile Island disaster. "Normal Accidents" is cited by numerous other influential systems engineering publications such as <a href="#diane-vaughan">Vaughan's</a> "The Challenger Launch Decision".</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-14" class="anchor" aria-label="Permalink: Concepts" href="#concepts-14"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>Complex systems: A system of tightly-coupled components with common mode connections that is prone to unintended feedback loops, complex controls, low observability, and poorly-understood mechanisms. They are not always high-risk, and thus their failure is not always catastrophic.</li>
|
||
<li>Normal accidents: Complex systems with many components exhibit unexpected interactions in the face of inevitable component failures. When these components are tightly-coupled, failed parts cannot be isolated from other parts, resulting in unpredictable system failures. Crucially, adding more safety devices and automated system controls often makes these coupling problems worse.</li>
|
||
<li>Common-mode: The failure of one component that serves multiple purposes results in multiple associated failures, often with high interactivity and low linearity - both ingredients for unexpected behavior that is difficult to control.</li>
|
||
<li>Production pressures and safety: Organizations adopt processes and devices to improve safety and efficiency, but production pressure often defeats any safety gained from the additions: the safety devices allow or encourage more risky behavior. As an unfortunate side-effect, the system is now also more complex.</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-30" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-30"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.amazon.com/Normal-Accidents-Living-Technologies-Updated-ebook/dp/B00CHRINUI" rel="nofollow">Normal Accidents: Living With High-Risk Technologies</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Shawna J. Perry</h2><a id="user-content-shawna-j-perry" class="anchor" aria-label="Permalink: Shawna J. Perry" href="#shawna-j-perry"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Perry is a medical researcher who studies emergency medicine.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-15" class="anchor" aria-label="Permalink: Concepts" href="#concepts-15"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>Underground adaptations</li>
|
||
<li>Articulated functions vs. important functions</li>
|
||
<li>Unintended effects</li>
|
||
<li>Apparent success vs real success</li>
|
||
<li>Exceptions</li>
|
||
<li>Dynamic environments</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-31" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-31"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://doi.org/10.1007/s10111-011-0207-2" rel="nofollow">Underground adaptations: case studies from health care</a></li>
|
||
<li><a href="https://journals.sagepub.com/doi/abs/10.1177/1555343416637520?journalCode=edma" rel="nofollow">Can We Trust Best Practices? Six Cognitive Challenges of Evidence-Based Approaches</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/232191704_The_Role_of_Automation_in_Complex_System_Failures" rel="nofollow">The Role of Automation in Complex System Failures</a></li>
|
||
<li><a href="https://pdfs.semanticscholar.org/1423/f18530599b9de186af0eee4852bb7e619384.pdf" rel="nofollow">Extemporaneous Adaptation to Evolving Complexity: A Case Study of Resilience in Healthcare</a> (<a href="https://resilienceroundup.com/issues/55" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://doi.org/10.1016/j.ress.2006.01.009" rel="nofollow">Automation, interaction, complexity, and failure: A case study</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Other</h3><a id="user-content-other" class="anchor" aria-label="Permalink: Other" href="#other"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://open.spotify.com/episode/7lHcgt2KuDoLyvTP9wMbEn?si=nPIyk9L8QB2Iuck2fKKrNA" rel="nofollow">Interview on Naturalistic Decision Making podcast</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Jens Rasmussen</h2><a id="user-content-jens-rasmussen" class="anchor" aria-label="Permalink: Jens Rasmussen" href="#jens-rasmussen"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Jens Rasmussen was an enormously influential researcher in human factors and safety systems. In particular, you can see his influence in the work of Sidney Dekker, Nancy Leveson, David Woods.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Contributions</h3><a id="user-content-contributions-4" class="anchor" aria-label="Permalink: Contributions" href="#contributions-4"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">Skill-rule-knowledge (SKR) model</h4><a id="user-content-skill-rule-knowledge-skr-model" class="anchor" aria-label="Permalink: Skill-rule-knowledge (SKR) model" href="#skill-rule-knowledge-skr-model"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Rasmussen proposed three models of human performance.</p>
|
||
<p dir="auto"><strong>Skill-based</strong> behavior doesn't require conscious attention. The prototypical example is riding a bicycle.</p>
|
||
<p dir="auto"><strong>Rule-based</strong> behavior is based on a set of rules that we have internalized in
|
||
advance. We select which rule to use based on experience, and then carry it
|
||
out. An example would be: if threads are blocked, restart the server. You can think of rule-based behavior as a memorized runbook.</p>
|
||
<p dir="auto"><strong>Knowledge-based</strong> behavior comes into play when facing an unfamiliar
|
||
situation. The person generates a set of plans based on their understanding of
|
||
the environment, and then selects which one to use. The challenging incidents
|
||
are the ones that require knowledge-based behavior to resolve.</p>
|
||
<p dir="auto">He also proposed three types of information that humans process as they perform work.</p>
|
||
<p dir="auto"><strong>Signals</strong>. Example: weather vane</p>
|
||
<p dir="auto"><strong>Signs</strong>. Example: stop sign</p>
|
||
<p dir="auto"><strong>Symbols</strong>. Example: written language</p>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">Abstraction hierarchy</h4><a id="user-content-abstraction-hierarchy" class="anchor" aria-label="Permalink: Abstraction hierarchy" href="#abstraction-hierarchy"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Rasmussen proposed a model of how operators reason about the behavior of a
|
||
system they are supervising called the <em>abstraction hierarchy</em>.
|
||
The levels in the hierarchy are</p>
|
||
<ol dir="auto">
|
||
<li>functional purpose</li>
|
||
<li>abstract functions</li>
|
||
<li>general functions</li>
|
||
<li>physical funcitons</li>
|
||
<li>physical form</li>
|
||
</ol>
|
||
<p dir="auto">The hierarchy forms a means-ends relationship: proper function is described top-down (ends), and problems are explained bottom-up (means)</p>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">Dynamic safety model</h4><a id="user-content-dynamic-safety-model" class="anchor" aria-label="Permalink: Dynamic safety model" href="#dynamic-safety-model"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Rasmussen proposed a state-based model of a socio-technical system as a system
|
||
that moves within a region of a state space. The region is surrounded by
|
||
different boundaries:</p>
|
||
<ul dir="auto">
|
||
<li>economic failure</li>
|
||
<li>unacceptable work load</li>
|
||
<li>functionality acceptable performance</li>
|
||
</ul>
|
||
<p dir="auto"><a target="_blank" rel="noopener noreferrer" href="/lorin/resilience-engineering/blob/master/boundary.png"><img src="/lorin/resilience-engineering/raw/master/boundary.png" alt="Migration to the boundary" style="max-width: 100%;"></a></p>
|
||
<p dir="auto">Source: <a href="https://doi.org/10.1016/S0925-7535(97)00052-0" rel="nofollow">Risk management in a dynamic society: a modelling problem</a></p>
|
||
<p dir="auto">Incentives push the system towards the boundary of acceptable performance:
|
||
accidents happen when the boundary is exceeded.</p>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">AcciMaps</h4><a id="user-content-accimaps" class="anchor" aria-label="Permalink: AcciMaps" href="#accimaps"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">The AcciMaps approach is a technique for reasoning about the causes of an accident, using a diagram.</p>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">Risk management framework</h4><a id="user-content-risk-management-framework" class="anchor" aria-label="Permalink: Risk management framework" href="#risk-management-framework"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Rasmussen proposed a multi-layer view of socio-technical systems:</p>
|
||
<p dir="auto"><a target="_blank" rel="noopener noreferrer" href="/lorin/resilience-engineering/blob/master/risk-management-framework.png"><img src="/lorin/resilience-engineering/raw/master/risk-management-framework.png" alt="Risk management framework" style="max-width: 100%;"></a></p>
|
||
<p dir="auto">Source: <a href="https://doi.org/10.1016/S0925-7535(97)00052-0" rel="nofollow">Risk management in a dynamic society: a modelling problem</a></p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-16" class="anchor" aria-label="Permalink: Concepts" href="#concepts-16"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>Dynamic safety model</li>
|
||
<li>Migration toward accidents</li>
|
||
<li>Risk management framework</li>
|
||
<li>Boundaries:
|
||
<ul dir="auto">
|
||
<li>boundary of functionally acceptable performance</li>
|
||
<li>boundary to economic failure</li>
|
||
<li>boundary to unacceptable work load</li>
|
||
</ul>
|
||
</li>
|
||
<li>Cognitive systems engineering</li>
|
||
<li>Skill-rule-knowledge (SKR) model</li>
|
||
<li>AcciMaps</li>
|
||
<li>Means-ends hierarchy</li>
|
||
<li>Ecological interface design</li>
|
||
<li>Systems approach</li>
|
||
<li>Control-theoretic</li>
|
||
<li>decisions, acts, and errors</li>
|
||
<li>hazard source</li>
|
||
<li>anatomy of accidents</li>
|
||
<li>energy</li>
|
||
<li>systems thinking</li>
|
||
<li>trial and error experiments</li>
|
||
<li>defence in depth (fallacy)</li>
|
||
<li>Role of managers
|
||
<ul dir="auto">
|
||
<li>Information</li>
|
||
<li>Competency</li>
|
||
<li>Awareness</li>
|
||
<li>Commitment</li>
|
||
</ul>
|
||
</li>
|
||
<li>Going solid</li>
|
||
<li>observability</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-32" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-32"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.tandfonline.com/doi/abs/10.1080/00140137408931355" rel="nofollow">Mental procedures in real-life tasks: a case study of electronic trouble shooting</a> (1974)</li>
|
||
<li><a href="https://orbit.dtu.dk/en/publications/coping-with-complexity" rel="nofollow">Coping with complexity</a></li>
|
||
<li><a href="https://www.iwolm.com/wp-content/downloads/SkillsRulesAndKnowledge-Rasmussen.pdf" rel="nofollow">Skills, rules, and knowledge; signals, signs, and symbols, and other distinctions in human performance models</a></li>
|
||
<li><a href="https://qualitysafety.bmj.com/content/14/2/130" rel="nofollow">“Going solid”: a model of system dynamics and consequences for patient safety</a></li>
|
||
<li><a href="https://www.ida.liu.se/~729A71/Literature/Human%20Error_T/Rasmussen_1990.pdf" rel="nofollow">Human error and the problem of causality in analysis of accidents</a> (<a href="https://resilienceroundup.com/issues/human-error-and-the-problem-of-causality-in-analysis-of-accidents/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://backend.orbit.dtu.dk/ws/portalfiles/portal/158020073/ERTAX1.PDF" rel="nofollow">Human Errors: A Taxonomy for Describing Human Malfunction in Industrial Installations</a></li>
|
||
<li><a href="https://core.ac.uk/download/pdf/13788397.pdf" rel="nofollow">Ecological interfaces: A technological imperative in high‐tech systems</a></li>
|
||
<li><a href="https://www.amazon.com/Information-Processing-Human-Machine-Interaction-North-Holland/dp/0444009876" rel="nofollow">Information processing and human-machine interaction: an approach to cognitive engineering</a></li>
|
||
<li><a href="https://backend.orbit.dtu.dk/ws/files/158019622/HISMC.PDF" rel="nofollow">The role of hierarchical knowledge representation in decisionmaking and system management</a></li>
|
||
<li><a href="https://core.ac.uk/download/pdf/13777954.pdf" rel="nofollow">A Model of Human Decision Making in Complex Systems and its Use for Design of System Control Strategies</a></li>
|
||
<li><a href="https://qualitysafety.bmj.com/content/qhc/12/5/377.full.pdf" rel="nofollow">The role of error in organizing behaviour</a> (<a href="https://resilienceroundup.com/issues/the-role-of-error-in-organizing-behaviour/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.osti.gov/biblio/7011990-information-processing-human-machine-interaction" rel="nofollow">Information processing and human-machine interaction</a></li>
|
||
<li><a href="https://doi.org/10.1016/S0925-7535(97)00052-0" rel="nofollow">Risk management in a dynamic society: a modelling problem</a></li>
|
||
<li><a href="https://rib.msb.se/Filer/pdf/16252.pdf" rel="nofollow">Proactive risk management in a dynamic society</a></li>
|
||
<li><a href="https://backend.orbit.dtu.dk/ws/portalfiles/portal/137294535/TREND.PDF" rel="nofollow">Trends in Human Reliability Analysis</a></li>
|
||
<li><a href="https://backend.orbit.dtu.dk/ws/portalfiles/portal/158019622/HISMC.PDF" rel="nofollow">The role of hierarchical knowledge representation in decisionmaking and system management</a></li>
|
||
<li><a href="https://backend.orbit.dtu.dk/ws/portalfiles/portal/137538698/ERRROLE_1_.PDF" rel="nofollow">The role of error in organizing behaviour</a></li>
|
||
<li><a href="https://backend.orbit.dtu.dk/ws/portalfiles/portal/158018718/ROYSOC.PDF" rel="nofollow">Human error and the problem of causality in analysis of accidents</a></li>
|
||
<li><a href="https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=5fb7644d205b342aa52c594b7982a9e208086238" rel="nofollow">Coping with human errors through system design: implications for ecological interface design</a></li>
|
||
<li><a href="https://www.sciencedirect.com/science/article/abs/pii/S0925753500000369" rel="nofollow">Graphic representation of accident scenarios: mapping system structure and the causation of accidents</a></li>
|
||
<li><a href="https://backend.orbit.dtu.dk/ws/portalfiles/portal/158017532/DIAACT.PDF" rel="nofollow">Diagnostic reasoning in action</a></li>
|
||
<li><a href="https://orbit.dtu.dk/en/publications/a-framework-for-cognitive-task-analysis-in-systems-design" rel="nofollow">A framework for cognitive task analysis in systems design</a></li>
|
||
<li><a href="https://backend.orbit.dtu.dk/ws/portalfiles/portal/158019864/LEPRAS.PDF" rel="nofollow">Analysis of human errors in industrial incidents and accidents for mprovement of work safety</a></li>
|
||
<li><a href="https://documents1.worldbank.org/curated/ru/535511468766200820/pdf/multi0page.pdf" rel="nofollow">Why do complex organizational systems fail?</a></li>
|
||
<li><a href="https://orbit.dtu.dk/en/publications/notes-on-human-error-analysis-and-prediction" rel="nofollow">Notes on human error analysis and prediction</a></li>
|
||
</ul>
|
||
<p dir="auto">(These are written but others about Rasmussen's work)</p>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.sciencedirect.com/science/article/abs/pii/S0003687016302150?via%3Dihub" rel="nofollow">Recurring themes in the legacy of Jens Rasmussen</a> - special issue of Applied Ergonomics</li>
|
||
<li><a href="https://doi.org/10.1016/j.ssci.2014.03.015" rel="nofollow">Reflecting on Jens Rasmussen’s legacy. A strong program for a hard problem</a> (<a href="https://github.com/lorin/booknotes/blob/master/papers/Reflecting-on-Jens-Rasmussens-Legacy.md">my notes</a>)</li>
|
||
<li><a href="https://doi.org/10.1016/j.apergo.2015.07.013" rel="nofollow">Reflecting on Jens Rasmussen's legacy (2) behind and beyond, a ‘constructivist turn’</a></li>
|
||
<li><a href="https://www.sciencedirect.com/science/article/abs/pii/S0003687015301009?via%3Dihub" rel="nofollow">Musings on Models and the Genius of Jens Rasmussen</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Mike Rayo</h2><a id="user-content-mike-rayo" class="anchor" aria-label="Permalink: Mike Rayo" href="#mike-rayo"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Rayo is the Director of the Cognitive Systems Engineering Laboratory at the Ohio State University.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-17" class="anchor" aria-label="Permalink: Concepts" href="#concepts-17"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>SCAD (Systematic Contributors Analysis and Diagram)</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected Publications</h3><a id="user-content-selected-publications-33" class="anchor" aria-label="Permalink: Selected Publications" href="#selected-publications-33"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://journals.sagepub.com/doi/10.1177/1071181322661334" rel="nofollow">Developing Systemic Contributors and Adaptations Diagramming (SCAD): systemic insights, multiple pragmatic implementations</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/308194080_Multiple_Systemic_Contributors_versus_Root_Cause_Learning_from_a_NASA_Near_Miss" rel="nofollow">Multiple Systemic Contributors versus Root Cause: Learning from a NASA Near Miss</a></li>
|
||
<li><a href="https://thebulletin.org/2025/05/the-silicon-valley-way-move-fast-and-breakaviation-safety/" rel="nofollow">The Silicon Valley Way: Move fast and break…aviation safety?</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">James Reason</h2><a id="user-content-james-reason" class="anchor" aria-label="Permalink: James Reason" href="#james-reason"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Reason is a psychology researcher who did work on understanding and categorizing human error.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Contributions</h3><a id="user-content-contributions-5" class="anchor" aria-label="Permalink: Contributions" href="#contributions-5"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">Accident causation model (Swiss cheese model)</h4><a id="user-content-accident-causation-model-swiss-cheese-model" class="anchor" aria-label="Permalink: Accident causation model (Swiss cheese model)" href="#accident-causation-model-swiss-cheese-model"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Reason developed an accident causation model that is sometimes known as the <em>swiss cheese</em> model of accidents.
|
||
In this model, Reason introduced the terms "sharp end" and "blunt end".</p>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">Human Error model: Slips, lapses and mistakes</h4><a id="user-content-human-error-model-slips-lapses-and-mistakes" class="anchor" aria-label="Permalink: Human Error model: Slips, lapses and mistakes" href="#human-error-model-slips-lapses-and-mistakes"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Reason developed a model of the types of errors that humans make:</p>
|
||
<ul dir="auto">
|
||
<li>slips</li>
|
||
<li>lapses</li>
|
||
<li>mistakes</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-18" class="anchor" aria-label="Permalink: Concepts" href="#concepts-18"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>Blunt end</li>
|
||
<li>Human error</li>
|
||
<li>Slips, lapses and mistakes</li>
|
||
<li>Swiss cheese model</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-34" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-34"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.amazon.com/gp/product/0521314194/ref=dbs_a_def_rwt_bibl_vppi_i0" rel="nofollow">Human error</a></li>
|
||
<li><a href="https://www.amazon.com/Organizational-Accidents-Revisited-James-Reason/dp/1472447689" rel="nofollow">Organizational Accidents Revisited</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">J. Paul Reed</h2><a id="user-content-j-paul-reed" class="anchor" aria-label="Permalink: J. Paul Reed" href="#j-paul-reed"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://jpaulreed.com/" rel="nofollow">Reed</a> is a Senior Applied Resilience engineer at Netflix and runs <a href="https://re-deploy.io" rel="nofollow">REdeploy</a>, a conference focused on Resilience Engineering in the software development and operations industry.</p>
|
||
<p dir="auto">Reed tweets as <a href="https://twitter.com/jpaulreed" rel="nofollow">@jpaulreed</a>.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected Publications</h3><a id="user-content-selected-publications-35" class="anchor" aria-label="Permalink: Selected Publications" href="#selected-publications-35"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>[Maps, Context, and Tribal Knowledge: On the Structure and Use of Post-Incident Analysis Artifacts in Software Development and Operations](<a href="https://lup.lub.lu.se/student-papers/search/publication/8966930j" rel="nofollow">https://lup.lub.lu.se/student-papers/search/publication/8966930j</a></li>
|
||
<li><a href="https://queue.acm.org/detail.cfm?id=3380780d" rel="nofollow">Beyond the "Fix-it" Treadmill</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-19" class="anchor" aria-label="Permalink: Concepts" href="#concepts-19"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://jpaulreed.com/blame-aware" rel="nofollow">Blame "Aware"</a> (versus "Blameless") Culture</li>
|
||
<li>Postmortem Artifact <em>Archetypes</em></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Emilie M. Roth</h2><a id="user-content-emilie-m-roth" class="anchor" aria-label="Permalink: Emilie M. Roth" href="#emilie-m-roth"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="http://www.rothsite.com/resume.html" rel="nofollow">Roth</a> is a cognitive psychologist who
|
||
serves as the principal scientist at <a href="http://www.rothsite.com/" rel="nofollow">Roth Cognitive Engineering</a>, a small
|
||
company that conducts research and application in the areas of human factors
|
||
and applied cognitive psychology (cognitive engineering)</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-36" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-36"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="http://citeseerx.ist.psu.edu/viewdoc/summary?doi=10.1.1.564.2044" rel="nofollow">Uncovering the Requirements of Cognitive Work</a> (<a href="https://www.getrevue.co/profile/resilience/issues/resilience-roundup-uncovering-the-requirements-of-cognitive-work-issue-30-173410" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/profile/Emily_Patterson2/publication/237138704_USING_OBSERVATIONAL_STUDY_AS_A_TOOL_FOR_DISCOVERY_UNCOVERING_COGNITIVE_AND_COLLABORATIVE_DEMANDS_AND_ADAPTIVE_STRATEGIES/links/0deec52c8e310b385a000000.pdf" rel="nofollow">Using observational study as a tool for discovery: uncovering cognitive and collaborative demands and adaptive strategies</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/8648890_Handoff_strategies_in_settings_with_high_consequences_for_failure_Lessons_for_health_care_operations" rel="nofollow">Handoff strategies in settings with high consequences for failure: lessons for health care operations</a> (<a href="https://resilienceroundup.com/issues/56" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/313737506_Bootstrapping_multiple_converging_cognitive_task_analysis_techniques_for_system_design" rel="nofollow">Bootstrapping multiple converging cognitive task analysis techniques for system design</a> (<a href="https://resilienceroundup.com/issues/70" rel="nofollow">TWRR</a>)</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Other</h3><a id="user-content-other-1" class="anchor" aria-label="Permalink: Other" href="#other-1"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://open.spotify.com/episode/3XqAhdpyrszLoB59VcRJWG" rel="nofollow">Interview on Naturalistic Decision Making podcast</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Nadine Sarter</h2><a id="user-content-nadine-sarter" class="anchor" aria-label="Permalink: Nadine Sarter" href="#nadine-sarter"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://ioe.engin.umich.edu/people/nadine-sarter/" rel="nofollow">Sarter</a> is a researcher in industrial and operations engineering.
|
||
She is the director of the Center for Ergonomics at the University of Michigan.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-20" class="anchor" aria-label="Permalink: Concepts" href="#concepts-20"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>cognitive ergonomics</li>
|
||
<li>organization safety</li>
|
||
<li>human-automation/robot interaction</li>
|
||
<li>human error / error management</li>
|
||
<li>attention / interruption management</li>
|
||
<li>design of decision support systems</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-37" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-37"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/19980016965.pdf" rel="nofollow">Learning from Automation Surprises and "Going Sour" Accidents: Progress on Human-Centered Automation</a></li>
|
||
<li><a href="https://www.amazon.com/Behind-Human-Error-David-Woods/dp/0754678342" rel="nofollow">Behind Human Error</a></li>
|
||
<li><a href="https://www.amazon.com/Cognitive-Systems-Engineering-Expertise-Applications-ebook/dp/B076TDR6H9/ref=sr_1_1?keywords=cognitive+systems+engineering&qid=1554075974&s=gateway&sr=8-1" rel="nofollow">Designed-Induced Error and Error-Informed Design: A Two-Way Street</a></li>
|
||
<li><a href="https://www.taylorfrancis.com/books/e/9780429134845" rel="nofollow">The Critical Incident Technique: A Method for Identifying System Strengths and Weaknesses Based on Observational Data</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/326000581_Myths_of_automation_and_their_implications_for_military_procurement" rel="nofollow">Myths of automation and their implications for military procurement</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/270960170_Automation_surprises" rel="nofollow">Automation surprises</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/12195752_Team_Play_with_a_Powerful_and_Independent_Agent_A_Full-Mission_Simulation_Study" rel="nofollow">Team Play with a Powerful and Independent Agent: A Full-Mission Simulation Study</a> (<a href="https://resilienceroundup.com/issues/team-play-with-a-powerful-and-independent-agent-a-full-mission-simulation-study/" rel="nofollow">TWRR</a>)</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">James C. Scott</h2><a id="user-content-james-c-scott" class="anchor" aria-label="Permalink: James C. Scott" href="#james-c-scott"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Scott is an anthropologist who also does research in political science. While
|
||
Scott is not a member of a resilience engineering community, his book <em>Seeing
|
||
like a state</em> has long been a staple of the cognitive systems engineering and
|
||
resilience engineering communities.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-21" class="anchor" aria-label="Permalink: Concepts" href="#concepts-21"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>authoritarian high-modernism</li>
|
||
<li>legibility</li>
|
||
<li>mētis</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-38" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-38"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.amazon.com/Seeing-like-State-Certain-Condition/dp/0300078153/ref=sr_1_1" rel="nofollow">Seeing like a state: how certain schemes to improve the human condition have failed</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Steven Shorrock</h2><a id="user-content-steven-shorrock" class="anchor" aria-label="Permalink: Steven Shorrock" href="#steven-shorrock"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
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<p dir="auto">Shorrock is a chartered psychologist and a chartered ergonomist and human
|
||
factors specialist. He is the editor-in-chief of EUROCONTROL
|
||
<a href="https://www.skybrary.aero/index.php/HindSight_-_EUROCONTROL" rel="nofollow">HindSight</a>
|
||
magazine. He runs the excellent <a href="https://humanisticsystems.com/" rel="nofollow">Humanistic Systems</a> blog.</p>
|
||
<p dir="auto">Shorrock tweets as <a href="https://twitter.com/StevenShorrock" rel="nofollow">@StevenShorrock</a>.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-39" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-39"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
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<ul dir="auto">
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||
<li><a href="https://skybrary.aero/sites/default/files/bookshelf/2882.pdf" rel="nofollow">Systems Thinking for Safety: Ten Principles A White Paper Moving towards Safety-II</a></li>
|
||
<li><a href="https://www.crcpress.com/Human-Factors-and-Ergonomics-in-Practice-Improving-System-Performance-and/Shorrock-Williams/p/book/9781472439253" rel="nofollow">Human Factors and Ergonomics in Practice: Improving System Performance and Human Well-Being in the Real World</a> (book)</li>
|
||
<li><a href="https://doi.org/10.1080/00140139.2021.1953615" rel="nofollow">State of science: evolving perspectives on ‘human error’</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected talks</h3><a id="user-content-selected-talks-9" class="anchor" aria-label="Permalink: Selected talks" href="#selected-talks-9"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
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<p dir="auto"><a href="https://www.youtube.com/watch?v=STU3Or6ZU60" rel="nofollow">Life After Human Error</a> (Velocity Europe 2014 keynote)</p>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Diane Vaughan</h2><a id="user-content-diane-vaughan" class="anchor" aria-label="Permalink: Diane Vaughan" href="#diane-vaughan"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
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<p dir="auto">Vaughan is a sociology researcher who did a famous study of the NASA Challenger accident, concluding that it was the result of organizational failure rather than a technical failure. Specifically, production pressure overrode the rigorous scientific safety culture in place at NASA.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-22" class="anchor" aria-label="Permalink: Concepts" href="#concepts-22"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>Structural Secrecy: Organizational structure, processes, and information exchange patterns can systematically undermine the ability to "see the whole picture" and conceal risky decisions.</li>
|
||
<li>Social Construction of Risk: Out of the necessity to balance risk with the associated reward, any group of people will develop efficient heuristics to solve the problems they face. The understanding of risk that faces one subgroup may not match that of another subgroup or of the whole group. The ability of an individual to change a social construction of risk, formed over years with good intentions and often with evidence, is limited. (Though the evidence is usually accurate, the conclusion might not be, leading to an inadvertent scientific paradigm.)</li>
|
||
<li>Normalization of Deviance: During operation of a complex system, inadvertent deviations from system design may occur and not result in a system failure. Because the intial construction of risk is usually conservative, the deviation is seen as showing that the system and its redundancies "worked", leading to a new accepted safe operating envelope.</li>
|
||
<li>Signals of potential danger: Information gained through the operation of a system that may indicate the system does not work as designed. Most risk constructions are based on a comprehensive understanding of the operation of the system, so information to the contrary is a sign that the system could leave the safe operation envelope in unexpected ways - a danger.</li>
|
||
<li>Weak signals, mixed signals, missed signals: signals of potential danger that have been interpreted as non-threats or acceptable risk because at the time they didn't represent a clear and present danger sufficient to overcome the Social Construction of Risk. Often, post-hoc, these are seen as causes due to cherry-picking - such signals were ignored before with no negative consequences.</li>
|
||
<li>Competition for Scarce Resources: An ongoing need to justify investment to customers leads to Efficiency-Thoroughness Tradeoffs (ETTOs). In NASA's case, justifying the cost of the Space Shuttle program to taxpayers and their congressional representatives meant pressure to quickly develop payload delivery capability at the lowest cost possible.</li>
|
||
<li>Belief in Redundancy: Constructing risk from a signal of potential danger such that a redundant subsystem becomes part of the normal operating strategy for a primary subsystem. In NASA's case, signals that the primary O-ring assembly did not operate as expected formed an acceptable risk because a secondary O-ring would contain a failure. Redundancy was eliminated from the design in this construction of risk - the secondary system now became part of the primary system, eliminating system redundancy.</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-40" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-40"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.amazon.com/Challenger-Launch-Decision-Technology-Deviance/dp/022634682X/ref=sr_1_1?ie=UTF8&qid=1545966442&sr=8-1&keywords=diane+vaughan" rel="nofollow">The Challenger Launch Decision: Risky Technology, Culture, and Deviance at
|
||
NASA</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Barry Turner</h2><a id="user-content-barry-turner" class="anchor" aria-label="Permalink: Barry Turner" href="#barry-turner"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://www.tandfonline.com/doi/pdf/10.1080/10245289508523441" rel="nofollow">Turner</a> was a sociologist who greatly influenced the field of organization studies.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-41" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-41"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.amazon.com/Man-Made-Disasters-Second-Barry-Turner/dp/0750620870/ref=sr_1_1" rel="nofollow">Man-made disasters</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">Robert L. Wears</h2><a id="user-content-robert-l-wears" class="anchor" aria-label="Permalink: Robert L. Wears" href="#robert-l-wears"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://en.wikipedia.org/wiki/Robert_Wears" rel="nofollow">Wears</a> was a medical researcher who also had a PhD in industrial safety.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-23" class="anchor" aria-label="Permalink: Concepts" href="#concepts-23"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>Underground adaptations</li>
|
||
<li>Articulated functions vs. important functions</li>
|
||
<li>Unintended effects</li>
|
||
<li>Apparent success vs real success</li>
|
||
<li>Exceptions</li>
|
||
<li>Dynamic environments</li>
|
||
<li>Systems of care are intrinsically hazardous</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-42" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-42"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://linkinghub.elsevier.com/retrieve/pii/S0196064408006070" rel="nofollow">The error of counting "errors"</a> <a href="https://safety177496371.wordpress.com/2023/09/20/the-error-of-counting-errors/" rel="nofollow">BH</a></li>
|
||
<li><a href="https://doi.org/10.1007/s10111-011-0207-2" rel="nofollow">Underground adaptations: case studies from health care</a></li>
|
||
<li><a href="https://books.openedition.org/pressesmines/1122" rel="nofollow">Fundamental On Situational Surprise: A Case Study With Implications For Resilience</a></li>
|
||
<li><a href="http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.458.7283&rep=rep1&type=pdf" rel="nofollow">Replacing Hindsight With Insight: Toward Better Understanding of Diagnostic Failures</a></li>
|
||
<li><a href="http://dx.doi.org/10.1016%2Fj.ssci.2014.02.007" rel="nofollow">Seeing patient safety ‘Like a State’</a></li>
|
||
<li><a href="https://books.openedition.org/pressesmines/1122?lang=en" rel="nofollow">Fundamental On Situational Surprise: A Case Study With Implications For Resilience</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/232191704_The_Role_of_Automation_in_Complex_System_Failures" rel="nofollow">The Role of Automation in Complex System Failures</a></li>
|
||
<li><a href="https://pastel.archives-ouvertes.fr/pastel-00664145/document" rel="nofollow">Exploring the Dynamics of Resilient Performance</a></li>
|
||
<li><a href="https://pdfs.semanticscholar.org/1423/f18530599b9de186af0eee4852bb7e619384.pdf" rel="nofollow">Extemporaneous Adaptation to Evolving Complexity: A Case Study of Resilience in Healthcare</a> (<a href="https://resilienceroundup.com/issues/55" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://doi.org/10.1016/j.ress.2006.01.009" rel="nofollow">Automation, interaction, complexity, and failure: A case study</a></li>
|
||
<li><a href="https://www.researchgate.net/profile/Robert-Wears/publication/225108705_Resilience_is_Not_Control_Healthcare_Crisis_Management_and_ICT/links/00b49532b2c7f3ed62000000/Resilience-is-Not-Control-Healthcare-Crisis-Management-and-ICT.pdf" rel="nofollow">Resilience is not control: healthcare, crisis management, and ICT</a></li>
|
||
<li><a href="https://www.annemergmed.com/article/S0196-0644(17)30874-0/fulltext" rel="nofollow">The Secret Life of Policies</a></li>
|
||
<li><a href="https://www.annemergmed.com/article/S0196-0644(13)01554-0/abstract" rel="nofollow">The tragedy of adaptability</a> <a href="https://safety177496371.wordpress.com/2021/04/19/the-tragedy-of-adaptability/" rel="nofollow">BH</a></li>
|
||
<li><a href="https://www.taylorfrancis.com/chapters/edit/10.1201/9781315605722-11/relying-resilience-much-good-thing-robert-wears-charles-vincent" rel="nofollow">Relying on resilience: too much of a good thing?</a> <a href="https://safety177496371.wordpress.com/2024/03/20/relying-on-resilience-too-much-of-a-good-thing/" rel="nofollow">BH</a></li>
|
||
<li><a href="http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.458.7283&rep=rep1&type=pdf" rel="nofollow">Replacing hindsight with insight: toward better understanding of diagnostic failures</a> <a href="https://safety177496371.wordpress.com/2024/02/26/replacing-hindsight-with-insight-toward-better-understanding-of-diagnostic-failures/" rel="nofollow">BH</a></li>
|
||
<li><a href="https://safety177496371.wordpress.com/2024/10/29/the-science-of-human-factors-separating-fact-from-fiction/" rel="nofollow">The science of human factors: separating fact from fiction</a> <a href="https://safety177496371.wordpress.com/2024/10/29/the-science-of-human-factors-separating-fact-from-fiction/" rel="nofollow">BH</a></li>
|
||
<li><a href="https://doi.org/10.1016/j.apergo.2016.02.012" rel="nofollow">Resilience skills as emergent phenomena: A study of emergency departments in Brazil and the United States</a> <a href="https://safety177496371.wordpress.com/2023/01/20/resilience-skills-as-emergent-phenomena-a-study-of-emergency-departments-in-brazil-and-the-united-states/" rel="nofollow">BH</a></li>
|
||
<li><a href="https://qualitysafety.bmj.com/content/26/5/381" rel="nofollow">Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?</a> <a href="https://safety177496371.wordpress.com/2021/03/18/our-current-approach-to-root-cause-analysis-is-it-contributing-to-our-failure-to-improve-patient-safety/" rel="nofollow">BH</a></li>
|
||
<li><a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC1464040/" rel="nofollow">Error Reduction and Performance Improvement in the Emergency Department through Formal Teamwork Training: Evaluation Results of the MedTeams Project</a> <a href="https://safety177496371.wordpress.com/2021/03/18/our-current-approach-to-root-cause-analysis-is-it-contributing-to-our-failure-to-improve-patient-safety/" rel="nofollow">BH</a></li>
|
||
<li><a href="https://www.academia.edu/download/85660593/468.full.pdf" rel="nofollow">In situ simulation: detection of safety threats and teamwork training in a high risk emergency department</a></li>
|
||
<li><a href="https://europepmc.org/article/nbk/nbk43774" rel="nofollow">“Safeware”: Safety-Critical Computing and Health Care Information Technology</a></li>
|
||
<li><a href="https://onlinelibrary.wiley.com/doi/pdf/10.1197/j.aem.2004.07.001" rel="nofollow">The Illusion of Explanation</a></li>
|
||
<li><a href="https://www.annemergmed.com/article/S0196-0644(07)01451-5/fulltext" rel="nofollow">Thick Versus Thin: Description Versus Classification in Learning From Case Reviews</a></li>
|
||
<li><a href="https://www.resilience-engineering-association.org/download/resources/symposium/symposium_2015/Wears_R.-Sutcliffe_K.-Safety-error-and-resilience-a-meta-narrative-review-Paper.pdf" rel="nofollow">Safety, Error, and Resilience: a Meta-narrative Review</a></li>
|
||
<li><a href="https://www.taylorfrancis.com/chapters/edit/10.1201/9781315366838-18/resilient-procedures-oxymoron-innovation-robert-wears-garth-hunte" rel="nofollow">Resilient Procedures: Oxymoron or Innovation?</a> (<a href="https://safetyinsights.org/2025/02/24/resilient-procedures-oxymoron-or-innovation/" rel="nofollow">BH</a>)</li>
|
||
<li><a href="https://www.annemergmed.com/article/S0196-0644(15)01376-1/abstract" rel="nofollow">Design Trumps Training</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected talks</h3><a id="user-content-selected-talks-10" class="anchor" aria-label="Permalink: Selected talks" href="#selected-talks-10"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.youtube.com/watch?v=nV52yh6GDMg" rel="nofollow">Design of resilient systems</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">David Woods</h2><a id="user-content-david-woods" class="anchor" aria-label="Permalink: David Woods" href="#david-woods"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto"><a href="https://u.osu.edu/csel/member-directory/david-woods/" rel="nofollow">Woods</a> has a research background in cognitive systems engineering and did work
|
||
researching NASA accidents. He is one of the founders <a href="http://www.adaptivecapacitylabs.com/" rel="nofollow">Adaptive Capacity
|
||
Labs</a>, a resilience engineering
|
||
consultancy.</p>
|
||
<p dir="auto">Woods tweets as <a href="https://twitter.com/ddwoods2" rel="nofollow">@ddwoods2</a>.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Contributions</h3><a id="user-content-contributions-6" class="anchor" aria-label="Permalink: Contributions" href="#contributions-6"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Woods has contributed an enormous number of concepts.</p>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">The adaptive universe</h4><a id="user-content-the-adaptive-universe" class="anchor" aria-label="Permalink: The adaptive universe" href="#the-adaptive-universe"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Woods uses <em>the adaptive universe</em> as a lens for understanding the behavior of
|
||
all different kinds of systems.</p>
|
||
<p dir="auto">All systems exist in a dynamic environment, and must adapt to change.</p>
|
||
<p dir="auto">A successful system will need to adapt by virtue of its success.</p>
|
||
<p dir="auto">Systems can be viewed as units of adaptive behavior (UAB) that interact. UABs
|
||
exist at different scales (e.g., cell, organ, individual, group, organization).</p>
|
||
<p dir="auto">All systems have competence envelopes, which are constrained by boundaries.</p>
|
||
<p dir="auto">The resilience of a system is determined by how it behaves when it comes near
|
||
to a boundary.</p>
|
||
<p dir="auto">See <a href="https://www.youtube.com/playlist?list=PLvlZBj1NU_ikTy1ot30EbEbYMAoBf9eAt" rel="nofollow">Resilience Engineering Short Course</a> for more details.</p>
|
||
<div class="markdown-heading" dir="auto"><h4 tabindex="-1" class="heading-element" dir="auto">Charting adaptive cycles</h4><a id="user-content-charting-adaptive-cycles" class="anchor" aria-label="Permalink: Charting adaptive cycles" href="#charting-adaptive-cycles"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li>Trigger</li>
|
||
<li>Units of adaptive behavior</li>
|
||
<li>Goals and goal conflicts</li>
|
||
<li>Pressure points</li>
|
||
<li>Subcycles</li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Graceful extensibility</h3><a id="user-content-graceful-extensibility" class="anchor" aria-label="Permalink: Graceful extensibility" href="#graceful-extensibility"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">From <a href="https://www.researchgate.net/publication/327427067_The_Theory_of_Graceful_Extensibility_Basic_rules_that_govern_adaptive_systems" rel="nofollow">The theory of graceful extensibility: basic rules that govern adaptive systems</a>:</p>
|
||
<p dir="auto">(Longer wording)</p>
|
||
<ol dir="auto">
|
||
<li>Adaptive capacity is finite</li>
|
||
<li>Events will produce demands that challenge boundaries on the adaptive
|
||
capacity of any UAB</li>
|
||
<li>Adaptive capacities are regulated to manage the risk of saturating CfM</li>
|
||
<li>No UAB can have sufficient ability to regulate CfM to manage the risk of saturation alone</li>
|
||
<li>Some UABs monitor and regulate the CfM of other UABs in response to changes
|
||
in the risk of saturation</li>
|
||
<li>Adaptive capacity is the potential for adjusting patterns of action to
|
||
handle future situations, events, opportunities and disruptions</li>
|
||
<li>Performance of a UAB as it approaches saturation is different from the
|
||
performance of that UAB when it operates far from saturation</li>
|
||
<li>All UABs are local</li>
|
||
<li>There are bounds on the perspective any UAB, but these limits are overcome
|
||
by shifts and contrasts over multiple perspectives.</li>
|
||
<li>Reflective systems risk mis-calibration</li>
|
||
</ol>
|
||
<p dir="auto">(Shorter wording)</p>
|
||
<ol dir="auto">
|
||
<li>Boundaries are universal</li>
|
||
<li>Surprise occurs, continuously</li>
|
||
<li>Risk of saturation is monitored and regulated</li>
|
||
<li>Synchronization across multiple units of adaptive behavior in a network is necessary</li>
|
||
<li>Risk of saturation can be shared</li>
|
||
<li>Pressure changes what is sacrificed when</li>
|
||
<li>Pressure for optimality undermines graceful extensibility</li>
|
||
<li>All adaptive units are local</li>
|
||
<li>Perspective contrast overcomes bounds</li>
|
||
<li>Mis-calibration is the norm</li>
|
||
</ol>
|
||
<p dir="auto">For more details, see <a href="/lorin/resilience-engineering/blob/master/graceful-extensibility.md">summary of graceful extensibility theorems</a>.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">SCAD (Systemic Contributors Analysis and Diagram)</h3><a id="user-content-scad-systemic-contributors-analysis-and-diagram" class="anchor" aria-label="Permalink: SCAD (Systemic Contributors Analysis and Diagram)" href="#scad-systemic-contributors-analysis-and-diagram"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">(tbd)</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Concepts</h3><a id="user-content-concepts-24" class="anchor" aria-label="Permalink: Concepts" href="#concepts-24"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Many of these are mentioned in Woods's <a href="https://www.youtube.com/playlist?list=PLvlZBj1NU_ikTy1ot30EbEbYMAoBf9eAt" rel="nofollow">short course</a>.</p>
|
||
<ul dir="auto">
|
||
<li>adaptive capacity</li>
|
||
<li>adaptive universe</li>
|
||
<li>unit of adaptive behavior (UAB), adaptive unit</li>
|
||
<li>continuous adaptation</li>
|
||
<li>graceful extensibility</li>
|
||
<li>sustained adaptability</li>
|
||
<li>Tangled, layered networks (TLN)</li>
|
||
<li>competence envelope</li>
|
||
<li>adaptive cycles/histories</li>
|
||
<li>precarious present (unease)</li>
|
||
<li>resilient future</li>
|
||
<li>tradeoffs, five fundamental</li>
|
||
<li>efflorescence: the degree that changes in one area tend to recruit or open up
|
||
beneficial changes in many other aspects of the network - which opens new
|
||
opportunities across the network ...</li>
|
||
<li>reverberation</li>
|
||
<li>adaptive stalls</li>
|
||
<li>borderlands</li>
|
||
<li>anticipate</li>
|
||
<li>synchronize</li>
|
||
<li>proactive learning</li>
|
||
<li>initiative</li>
|
||
<li>reciprocity</li>
|
||
<li>SNAFUs</li>
|
||
<li>robustness</li>
|
||
<li>surprise</li>
|
||
<li>dynamic fault management</li>
|
||
<li>software systems as "team players"</li>
|
||
<li>multi-scale</li>
|
||
<li>brittleness</li>
|
||
<li>how adaptive systems fail (see: <a href="https://www.researchgate.net/publication/286581322_How_do_systems_manage_their_adaptive_capacity_to_successfully_handle_disruptions_A_resilience_engineering_perspective" rel="nofollow">How do systems manage their adaptive capacity to successfully handle disruptions? A resilience engineering perspective</a>)
|
||
<ul dir="auto">
|
||
<li>decompensation</li>
|
||
<li>working at cross-purposes</li>
|
||
<li>getting stuck in outdated behaviors</li>
|
||
</ul>
|
||
</li>
|
||
<li>proactive learning vs getting stuck</li>
|
||
<li>oversimplification</li>
|
||
<li>fixation</li>
|
||
<li>fluency law, veil of fluency</li>
|
||
<li>capacity for manoeuvre (CfM)</li>
|
||
<li>crunches</li>
|
||
<li>turnaround test</li>
|
||
<li>sharp end, blunt end</li>
|
||
<li>adaptive landscapes</li>
|
||
<li>law of stretched systems: Every system is continuously stretched to operate at capacity.</li>
|
||
<li>cascades</li>
|
||
<li>adapt how to adapt</li>
|
||
<li>unit working hard to stay in control</li>
|
||
<li>you can monitor how hard you're working to stay in control (monitor risk of saturation)</li>
|
||
<li>reality trumps algorithms</li>
|
||
<li>stand down</li>
|
||
<li>time matters</li>
|
||
<li>Properties of resilient organizations
|
||
<ul dir="auto">
|
||
<li>Tangible experience with surprise</li>
|
||
<li>uneasy about the precarious present</li>
|
||
<li>push initiative down</li>
|
||
<li>reciprocity</li>
|
||
<li>align goals across multiple units</li>
|
||
</ul>
|
||
</li>
|
||
<li>goal conflicts, goal interactions (follow them!)</li>
|
||
<li>to understand system, must study it under load</li>
|
||
<li>adaptive races are unstable</li>
|
||
<li>adaptive traps</li>
|
||
<li>roles, nesting of</li>
|
||
<li>hidden interdependencies</li>
|
||
<li>net adaptive value</li>
|
||
<li>matching tempos</li>
|
||
<li>tilt toward florescence</li>
|
||
<li>linear simplification</li>
|
||
<li>common ground</li>
|
||
<li>problem detection</li>
|
||
<li>joint cognitive systems</li>
|
||
<li>automation as a "team player"</li>
|
||
<li>"new look"</li>
|
||
<li>sacrifice judgment</li>
|
||
<li>task tailoring</li>
|
||
<li>substitution myth</li>
|
||
<li>observability</li>
|
||
<li>directability</li>
|
||
<li>directed attention</li>
|
||
<li>inter-predictability</li>
|
||
<li>error of the third kind: solving the wrong problem</li>
|
||
<li>buffering capacity</li>
|
||
<li>context gap</li>
|
||
<li>Norbert's contrast</li>
|
||
<li>anomaly response</li>
|
||
<li>automation surprises</li>
|
||
<li>disturbance management</li>
|
||
<li>Doyle's catch</li>
|
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<li>Cooperative advocacy</li>
|
||
</ul>
|
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<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-43" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-43"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
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<ul dir="auto">
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<li><a href="https://www.amazon.com/gp/product/B009KNDF64/ref=x_gr_w_glide_bb?ie=UTF8&tag=x_gr_w_glide_bb-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=B009KNDF64&SubscriptionId=1MGPYB6YW3HWK55XCGG2" rel="nofollow">Resilience Engineering: Concepts and Precepts</a></li>
|
||
<li><a href="http://erikhollnagel.com/onewebmedia/Prologue.pdf" rel="nofollow">Prologue: Resilience Engineering Concepts</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/265074845_Epilogue_Resilience_Engineering_Precepts" rel="nofollow">Epilogue: Resilience Engineering Precepts</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/329035477_Resilience_is_a_Verb" rel="nofollow">Resilience is a verb</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/276139783_Four_concepts_for_resilience_and_the_implications_for_the_future_of_resilience_engineering" rel="nofollow">Four concepts for resilience and the implications for the future of resilience engineering</a> (<a href="https://resilienceroundup.com/issues/65" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/284324002_Basic_patterns_in_how_adaptive_systems_fail" rel="nofollow">Basic patterns in how adaptive systems fail</a> (<a href="https://resilienceroundup.com/issues/34/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/285487326_Resilience_and_the_ability_to_anticipate" rel="nofollow">Resilience and the ability to anticipate</a> (<a href="https://resilienceroundup.com/issues/resilience-and-the-ability-to-anticipate/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/292504703_Distancing_through_differencing_An_obstacle_to_organizational_learning_following_accidents" rel="nofollow">Distancing through differencing: An obstacle to organizational learning following accidents</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/284328979_Essential_characteristics_of_resilience" rel="nofollow">Essential characteristics of resilience</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/330116587_4_Essentials_of_resilience_revisited" rel="nofollow">Essentials of resilience, revisited</a> (<a href="https://resilienceroundup.com/issues/71/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/19980016965.pdf" rel="nofollow">Learning from Automation Surprises and "Going Sour" Accidents: Progress on Human-Centered Automation</a></li>
|
||
<li><a href="https://www.amazon.com/Behind-Human-Error-David-Woods/dp/0754678342" rel="nofollow">Behind Human Error</a></li>
|
||
<li><a href="https://www.amazon.com/gp/product/0849339332/ref=x_gr_w_bb?ie=UTF8&tag=x_gr_w_bb-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=0849339332&SubscriptionId=1MGPYB6YW3HWK55XCGG2" rel="nofollow">Joint Cognitive Systems: Patterns in Cognitive Systems Engineering</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/262449980_Patterns_in_Cooperative_Cognition" rel="nofollow">Patterns in Cooperative Cognition</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/298793082_Origins_of_Cognitive_Systems_Engineering" rel="nofollow">Origins of cognitive systems engineering</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/292504952_Incidents_-_markers_of_resilience_or_brittleness" rel="nofollow">Incidents - markers of resilience or brittleness?</a> <a href="https://safety177496371.wordpress.com/2023/12/18/incidents-markers-of-resilience-or-brittleness/" rel="nofollow">BH</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/40961767_The_Alarm_problem_and_directed_attention_in_dynamic_fault_management" rel="nofollow">The alarm problem and directed attention in dynamic fault management</a></li>
|
||
<li><a href="https://journals.sagepub.com/doi/abs/10.1177/1555343416637520?journalCode=edma" rel="nofollow">Can We Trust Best Practices? Six Cognitive Challenges of Evidence-Based Approaches</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/313407259_Operating_at_the_Sharp_End_The_Complexity_of_Human_Error" rel="nofollow">Operating at the Sharp End: The Complexity of Human Error</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/327427067_The_Theory_of_Graceful_Extensibility_Basic_rules_that_govern_adaptive_systems" rel="nofollow">The theory of graceful extensibility: basic rules that govern adaptive systems</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/220628177_Beyond_Simon%27s_Slice_Five_Fundamental_Trade-Offs_that_Bound_the_Performance_of_Macrocognitive_Work_Systems" rel="nofollow">Beyond Simon’s Slice: Five Fundamental Trade-Offs that Bound the Performance of Macrocognitive Work Systems</a> (<a href="https://resilienceroundup.com/issues/five-fundamental-trade-offs-in-cognitive-work/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/247512351_Anticipating_the_effects_of_technological_change_A_new_era_of_dynamics_for_human_factors" rel="nofollow">Anticipating the effects of technological change: A new era of dynamics for human factors</a></li>
|
||
<li><a href="http://jeffreymbradshaw.net/publications/Common_Ground_Single.pdf" rel="nofollow">Common Ground and Coordination in Joint Activity</a></li>
|
||
<li><a href="https://www.irgc.org/wp-content/uploads/2016/04/Woods-Resilience-as-Graceful-Extensibility-to-Overcome-Brittleness-1.pdf" rel="nofollow">Resilience as Graceful Extensibility to Overcome Brittleness</a></li>
|
||
<li><a href="http://ordvac.com/soro/library/Aviation/Aviation%20Safety/General%20Safety%20Articles/resilience%20engineering%20bulletin.pdf" rel="nofollow">Resilience Engineering: Redefining the Culture of Safety and Risk Management</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/220579480_Problem_detection" rel="nofollow">Problem detection</a></li>
|
||
<li><a href="https://ntrs.nasa.gov/search.jsp?R=19910011398" rel="nofollow">Cognitive consequences of clumsy automation on high workload, high consequence human performance</a></li>
|
||
<li><a href="https://doi.org/10.1016/S0952-8180(96)90009-4" rel="nofollow">Implications of automation surprises in aviation for the future of total intravenous anesthesia (TIVA)</a></li>
|
||
<li><a href="https://ieeexplore.ieee.org/abstract/document/1363742" rel="nofollow">Ten challenges for making automation a team player</a> (<a href="https://resilienceroundup.com/issues/66" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://doi.org/10.1109%2FTSMCA.2004.836802" rel="nofollow">The Messy Details: Insights From the Study of Technical Work in Healthcare</a></li>
|
||
<li><a href="https://www.researchgate.net/profile/David_Woods11/publication/224649052_Nosocomial_automation_technology-induced_complexity_and_human_performance/links/59399b1da6fdcc58ae902c49/Nosocomial-automation-technology-induced-complexity-and-human-performance.pdf" rel="nofollow">Nosocomial automation: technology-induced complexity and human performance</a></li>
|
||
<li><a href="http://www.ifp.illinois.edu/nsfhcs/abstracts/woods.txt" rel="nofollow">Human-centered software agents: Lessons from clumsy automation</a></li>
|
||
<li><a href="https://snafucatchers.github.io/" rel="nofollow">STELLA: Report from the SNAFUcatchers Workshop on Coping with Complexity</a></li>
|
||
<li><a href="https://pdfs.semanticscholar.org/67f7/53ec089e5a8879f241e2be867dad0a2026fb.pdf" rel="nofollow">The New Look at Error, Safety, and Failure: A Primer for Health Care</a></li>
|
||
<li><a href="https://pdfs.semanticscholar.org/1bed/356b5aa67c701f5bad6d943768622095f418.pdf" rel="nofollow">Grounding explanations in evolving, diagnostic situations</a></li>
|
||
<li><a href="https://www.amazon.com/gp/product/B009KNDF64/ref=x_gr_w_glide_bb?ie=UTF8&tag=x_gr_w_glide_bb-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=B009KNDF64&SubscriptionId=1MGPYB6YW3HWK55XCGG2" rel="nofollow">Resilience Engineering: Concepts and Precepts</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/245102691_A_Tale_of_Two_Stories_Contrasting_Views_of_Patient_Safety" rel="nofollow">A Tale of Two Stories: Contrasting Views of Patient Safety</a></li>
|
||
<li><a href="https://www.semanticscholar.org/paper/Voice-Loops-as-Coordination-Aids-in-Space-Shuttle-Patterson-Watts-Perotti/068dfee1a859a63fa2ef82f008d239e6a81ed004" rel="nofollow">Voice Loops as Coordination Aids in Space Shuttle Mission Control</a></li>
|
||
<li><a href="https://journals.sagepub.com/doi/abs/10.1177/154193129403801702" rel="nofollow">The Critical Incident Technique: 40 Years Later</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/3657906_Functionally_distributed_coordination_during_anomaly_response_inspace_shuttle_mission_control" rel="nofollow">Functionally distributed coordination during anomaly response in space shuttle mission control</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/225211285_Cooperative_Advocacy_An_Approach_for_Integrating_Diverse_Perspectives_in_Anomaly_Response" rel="nofollow">Cooperative Advocacy: An Approach for Integrating Diverse Perspectives in Anomaly Response</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/222737388_Visual_Momentum_A_Concept_to_Improve_the_Cognitive_Coupling_of_Person_and_Computer" rel="nofollow">Visual momentum: A concept to improve the cognitive coupling of person and computer</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/262401824_Cognitive_demands_and_activities_in_dynamic_fault_management_abductive_reasoning_and_disturbance_management" rel="nofollow">Cognitive demands and activities in dynamic fault management: abductive reasoning and disturbance management</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/238727732_Coping_with_Complexity_The_psychology_of_human_behavior_in_complex_systems" rel="nofollow">Coping with complexity: the psychology of human behaviour in complex systems</a> (<a href="https://resilienceroundup.com/issues/coping-with-complexity/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/profile/David_Woods11/publication/232513565_Process-tracing_methods_for_the_study_of_cognition_outside_of_the_experimental_psychology_laboratory/links/00b7d53988a2f7a7f8000000.pdf" rel="nofollow">Process Tracing Methods for The Study of Cognition Outside of the Experimental Laboratory. In Klein GA, Orasanu J, Calderwood R, Zsambok CE, eds. Decision making in action: Models</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/239059408_Towards_a_theoretical_base_for_representation_design_in_the_computer_medium_ecological_perception_and_aiding_human_cognition" rel="nofollow">Towards a theoretical base for representation design in the computer medium: ecological perception and aiding human cognition</a></li>
|
||
<li><a href="https://www.nifc.gov/PUBLICATIONS/acc_invest_march2010/speakers/Perspectives%20on%20Human%20Error.pdf" rel="nofollow">Perspectives on Human Error: Hindsight Biases and Local Rationality</a></li>
|
||
<li><a href="https://docs.wixstatic.com/ugd/3ad081_f46dda684154447583c8a5b282b60cc2.pdf" rel="nofollow">Anomaly Response</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/303832480_The_Risks_of_Autonomy_Doyles_Catch" rel="nofollow">The Risks of Autonomy: Doyle's Catch</a> (<a href="https://resilienceroundup.com/issues/the-risks-of-autonomy-doyles-catch/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/328149714_Mistaking_Error" rel="nofollow">Mistaking Error</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/14230576_Adapting_to_New_Technology_in_the_Operating_Room" rel="nofollow">Adapting to new technology in the operating room</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/330196218_The_Strategic_Agility_Gap_How_organizations_are_slow_and_stale_to_adapt_in_turbulent_worlds" rel="nofollow">The Strategic Agility Gap: How organizations are slow and stale to adapt in turbulent worlds</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/330222613_Resiliency_Trade_Space_Study_The_Interaction_of_Degraded_C2_Link_and_Detect_and_Avoid_Autonomy_on_Unmanned_Aircraft" rel="nofollow">Resiliency Trade Space Study: The Interaction of Degraded C2 Link and Detect and Avoid Autonomy on Unmanned Aircraft</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/220604613_Cognitive_Technologies_The_Design_of_Joint_Human-Machine_Cognitive_Systems" rel="nofollow">Cognitive Technologies: The Design of Joint Human-Machine Cognitive Systems</a></li>
|
||
<li><a href="https://www.ida.liu.se/~729A15/mtrl/CSEnew.pdf?utm_campaign=Resilience%20Roundup&utm_medium=email&utm_source=Revue%20newsletter" rel="nofollow">Cognitive Systems Engineering: New wine in new bottles</a> (<a href="https://resilienceroundup.com/issues/32/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/260304859_The_Seven_Deadly_Myths_of_Autonomous_Systems" rel="nofollow">The Seven Deadly Myths of "Autonomous Systems"</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/285487326_Resilience_and_the_ability_to_anticipate" rel="nofollow">Resilience and the ability to anticipate</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/262449980_Patterns_in_Cooperative_Cognition" rel="nofollow">Patterns in Cooperative Cognition</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/220579448_Collaborative_Cross-Checking_to_Enhance_Resilience" rel="nofollow">Collaborative Cross-Checking to Enhance Resilience</a> (<a href="https://resilienceroundup.com/issues/73/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://pdfs.semanticscholar.org/a0d3/9cc66adc64e297048a32b71aeee209a451af.pdf" rel="nofollow">Resilience Engineering: New directions for measuring and maintaining safety in complex systems</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/3454029_A_rose_by_any_other_namewould_probably_be_given_an_acronym" rel="nofollow">A rose by any other name...would probably be given an acronym</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/286581322_How_do_systems_manage_their_adaptive_capacity_to_successfully_handle_disruptions_A_resilience_engineering_perspective" rel="nofollow">How do systems manage their adaptive capacity to successfully handle disruptions? A resilience engineering perspective</a></li>
|
||
<li><a href="http://csel.eng.ohio-state.edu/productions/laws/laws_mediapaper/2_4_escalation.pdf" rel="nofollow">How Unexpected Events Produce An Escalation Of Cognitive And Coordinative Demands</a> (<a href="https://resilienceroundup.com/issues/how-unexpected-events-produce-an-escalation-of-cognitive-and-coordinative-demands/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/profile/David_Woods11/publication/2483863_How_to_Make_Automated_Systems_Team_Players/links/5a4f829eaca272940bf8202c/How-to-Make-Automated-Systems-Team-Players.pdf" rel="nofollow">How to Make Automated Systems Team Players</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/3454245_Toward_a_Theory_of_Complex_and_Cognitive_Systems" rel="nofollow">Toward a Theory of Complex and Cognitive Systems</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/308194080_Multiple_Systemic_Contributors_versus_Root_Cause_Learning_from_a_NASA_Near_Miss" rel="nofollow">Multiple systemic contributors versus root cause: learning from a NASA Near Miss</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/313737506_Bootstrapping_multiple_converging_cognitive_task_analysis_techniques_for_system_design" rel="nofollow">Bootstrapping multiple converging cognitive task analysis techniques for system design</a> (<a href="https://resilienceroundup.com/issues/70" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/2484621_New_Arctic_Air_Crash_Aftermath_Role-Play_Simulation_Orchestrating_a_Fundamental_Surprise" rel="nofollow">New Arctic Air Crash Aftermath Role-Play Simulation Orchestrating a Fundamental Surprise</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/220108174_Mapping_Cognitive_Demands_in_Complex_Problem-Solving_Worlds%3CPaste%3E" rel="nofollow">Mapping Cognitive Demands in Complex Problem-Solving Worlds</a> (mentions disturbance management)</li>
|
||
<li><a href="https://www.researchgate.net/publication/290071190_Fixation_Errors_Failures_to_Revise_Situation_Assessment_in_Dynamic_and_Risky_Systems" rel="nofollow">Fixation Errors: Failures to Revise Situation Assessment in Dynamic and Risky Systems</a></li>
|
||
<li><a href="http://csel.eng.ohio-state.edu/productions/pexis/readings/submod4/nine%20steps%20CTW2002.pdf" rel="nofollow">Nine Steps to Move Forward From Error</a> <a href="https://safety177496371.wordpress.com/2022/11/03/nine-steps-to-move-forward-from-error/" rel="nofollow">BH</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/8648890_Handoff_strategies_in_settings_with_high_consequences_for_failure_Lessons_for_health_care_operations" rel="nofollow">Handoff strategies in settings with high consequences for failure: lessons for health care operations</a> (<a href="https://resilienceroundup.com/issues/56" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="http://sidneydekker.com/wp-content/uploads/2013/01/CH005.pdf" rel="nofollow">The High Reliability Organization Perspective</a> (<a href="https://resilienceroundup.com/issues/09/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/270960170_Automation_surprises" rel="nofollow">Automation surprises</a></li>
|
||
<li><a href="https://doi.org/10.1016/j.ress.2019.106740" rel="nofollow">Safety II professionals: How resilience engineering can transform safety practice</a> (<a href="https://resilienceroundup.com/issues/64/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117777/" rel="nofollow">Gaps in the continuity of care and progress on patient safety</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/250890631_Systems_with_Human_Monitors_A_Signal_Detection_Analysis" rel="nofollow">Systems with human monitors: a signal detection analysis</a></li>
|
||
<li><a href="https://www.sciencedirect.com/science/article/abs/pii/095183209090022F" rel="nofollow">On taking human performance seriously</a>, 1990</li>
|
||
<li><a href="https://doi.org/10.1016/j.burns.2018.12.003" rel="nofollow">Beyond surge: Coping with mass burn casualty in the closest hospital to the Formosa Fun Coast Dust Explosion</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/284173210_Designing_for_Expertise" rel="nofollow">Designing for Expertise</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/334267822_Steering_the_Reverberations_of_Technology_Change_on_Fields_of_Practice_Laws_that_Govern_Cognitive_Work" rel="nofollow">Steering the Reverberations of Technology Change on Fields of Practice: Laws that Govern Cognitive Work</a> (<a href="https://resilienceroundup.com/issues/steering-the-reverberations-of-technology-change-on-fields-of-practice-laws-that-govern-cognitive-work/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/profile/David_Woods11/publication/225921479_Distant_Supervision-Local_Action_Given_the_Potential_for_Surprise/links/0a85e53baa4009ad8e000000/Distant-Supervision-Local-Action-Given-the-Potential-for-Surprise.pdf" rel="nofollow">Distant Supervision–Local Action Given the Potential for Surprise</a> (<a href="https://resilienceroundup.com/issues/75/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/335366770_Coping_With_a_Mass_Casualty_Insights_into_a_Hospital's_Emergency_Response_and_Adaptations_After_the_Formosa_Fun_Coast_Dust_Explosion" rel="nofollow">Coping With a Mass Casualty: Insights into a Hospital’s Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion</a> (<a href="https://resilienceroundup.com/issues/76/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="http://aaclab.mit.edu/resources/FarjadianAnnaswamyWoods2019.pdf" rel="nofollow">A Shared Pilot-Autopilot Control Architecture for Resilient Flight</a> (<a href="https://resilienceroundup.com/issues/a-shared-pilot-autopilot-control-architecture-for-resilient-flight/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/12195752_Team_Play_with_a_Powerful_and_Independent_Agent_A_Full-Mission_Simulation_Study" rel="nofollow">Team Play with a Powerful and Independent Agent: A Full-Mission Simulation Study</a> (<a href="https://resilienceroundup.com/issues/team-play-with-a-powerful-and-independent-agent-a-full-mission-simulation-study/" rel="nofollow">TWRR</a>)</li>
|
||
<li><a href="https://www.researchgate.net/publication/239030256_How_Not_to_Have_to_Navigate_Through_Too_Many_Displayjjs" rel="nofollow">How Not to Have to Navigate Through Too Many Displays</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/251196422_Discovering_How_Distributed_Cognitive_Systems_Work" rel="nofollow">Discovering How Distributed Cognitive Systems Work</a></li>
|
||
<li><a href="http://dx.doi.org/10.13140/RG.2.2.29675.36648" rel="nofollow">Human Performance in Anesthesia</a></li>
|
||
<li><a href="https://www.researchgate.net/profile/David-Woods-19/publication/jjgg255648297_Creating_Foresight_Lessons_for_Enhancing_Resilience_from_Columbia/links/542becf50cf29bbc126ac095/Creating-Foresight-Lessons-for-Enhancing-Resilience-from-Columbia.pdf" rel="nofollow">Creating Foresight: Lessons for Enhancing Resilience from Columbia</a></li>
|
||
<li><a href="http://faculty.washington.edu/roesler/publications/design_cycle2005.pdf" rel="nofollow">Inventing the Future of Cognitive Work: Navigating the "Northwest Passage"</a></li>
|
||
<li><a href="https://www.sciencedirect.com/science/article/abs/pii/S0951832015000812" rel="nofollow">A practitioner’s experiences operationalizing Resilience Engineering</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/228809190_Understanding_rigor_in_information_analysis" rel="nofollow">Understanding rigor in information analysis</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/347964304_Human_Performance_in_Anesthesia_Human_Performance_in_Anesthesia_Human_Performance_in_Anesthesia" rel="nofollow">Human Performance in Anesthesia: A Corpus of Cases</a></li>
|
||
<li><a href="https://europepmc.org/article/NBK/nbk43670" rel="nofollow">Minding the Gaps: Creating Resilience in Health Care</a></li>
|
||
<li><a href="https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=ffe74633027ee354ebbf0ff9a6418e75f3b7a047" rel="nofollow">From Counting Failures to Anticipating Risks: Possible Futures for Patient Safety</a></li>
|
||
<li><a href="https://pdfs.semanticscholar.org/a0d3/9cc66adc64e297048a32b71aeee209a451af.pdf" rel="nofollow">Resilience Engineering: New directions for measuring and maintaining safety in complex systems</a></li>
|
||
<li><a href="https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=15f31969c4e1f4f599c5c68aa63f3bf930e0406f" rel="nofollow">Behind Human Error: Taming Complexity to Improve Patient Safety</a></li>
|
||
<li><a href="https://www.researchgate.net/publication/239357782_Escaping_failures_of_foresight" rel="nofollow">Escaping failures of foresight</a></li>
|
||
<li><a href="https://thebulletin.org/2025/05/the-silicon-valley-way-move-fast-and-breakaviation-safety/" rel="nofollow">The Silicon Valley Way: Move fast and break…aviation safety?</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected talks</h3><a id="user-content-selected-talks-11" class="anchor" aria-label="Permalink: Selected talks" href="#selected-talks-11"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://www.youtube.com/watch?v=GnVXfgC-5Jw&feature=youtu.be" rel="nofollow">Overview of resilience engineering</a></li>
|
||
<li><a href="https://vimeo.com/104759707" rel="nofollow">Creating safety by engineering resilience</a></li>
|
||
<li><a href="https://www.youtube.com/watch?v=7STcaWjJoww" rel="nofollow">The Mystery of Sustained Adaptability</a></li>
|
||
<li><a href="https://www.youtube.com/watch?v=V2qj5gMsjrU" rel="nofollow">Resilience is a verb</a></li>
|
||
<li><a href="https://www.youtube.com/watch?v=KJJ2NCjc2Wg" rel="nofollow">Complexity workshop keynote</a></li>
|
||
<li><a href="https://www.youtube.com/watch?v=QSiXEZLZ1y0&t=6s" rel="nofollow">De-Confounding Reliability, Robustness, and Resilience</a></li>
|
||
<li><a href="https://www.c-span.org/video/?c4531343/user-clip-david-woods-senate-hearing" rel="nofollow">2003 Senate Hearing testimony</a></li>
|
||
<li><a href="https://www.youtube.com/watch?v=ZuLUp94wki4" rel="nofollow">Shock and Resilience</a></li>
|
||
<li><a href="https://www.youtube.com/watch?v=vlYtd-eUjY8" rel="nofollow">Hedging bets</a></li>
|
||
<li><a href="https://youtu.be/OwdMgEf2MsA" rel="nofollow">REA 2021</a></li>
|
||
<li><a href="https://www.youtube.com/watch?v=fbwDnpuys7w" rel="nofollow">Adobe Summit Talk: Why do reliable systems fail?</a></li>
|
||
<li><a href="https://resiliencefoundations.github.io/overview.html" rel="nofollow">Resilience Foundations videos</a></li>
|
||
</ul>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Online courses</h3><a id="user-content-online-courses" class="anchor" aria-label="Permalink: Online courses" href="#online-courses"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<ul dir="auto">
|
||
<li><a href="https://resiliencefoundations.github.io/video-1-introduction-pt-1-it's-all-about-viability.html" rel="nofollow">Cognitive Systems Engineering Laboratory's (CSEL) Resilience Engineering 101 Series</a></li>
|
||
<li><a href="https://www.youtube.com/playlist?list=PLvlZBj1NU_ikTy1ot30EbEbYMAoBf9eAt" rel="nofollow">Resilience Engineering: An Introductory Short Course</a></li>
|
||
</ul>
|
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<div class="markdown-heading" dir="auto"><h2 tabindex="-1" class="heading-element" dir="auto">John Wreathall</h2><a id="user-content-john-wreathall" class="anchor" aria-label="Permalink: John Wreathall" href="#john-wreathall"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
||
<p dir="auto">Wreathall is an expert in human performance in safety. He works at the
|
||
<a href="http://www.wreathall.com/" rel="nofollow">WreathWood Group</a>, a risk and safety studies
|
||
consultancy.
|
||
Wreathall tweets as <a href="https://twitter.com/wreathall" rel="nofollow">@wreathall</a>.</p>
|
||
<div class="markdown-heading" dir="auto"><h3 tabindex="-1" class="heading-element" dir="auto">Selected publications</h3><a id="user-content-selected-publications-44" class="anchor" aria-label="Permalink: Selected publications" href="#selected-publications-44"><svg data-component="Octicon" class="octicon octicon-link" viewBox="0 0 16 16" version="1.1" width="16" height="16" aria-hidden="true"><path d="m7.775 3.275 1.25-1.25a3.5 3.5 0 1 1 4.95 4.95l-2.5 2.5a3.5 3.5 0 0 1-4.95 0 .751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018 1.998 1.998 0 0 0 2.83 0l2.5-2.5a2.002 2.002 0 0 0-2.83-2.83l-1.25 1.25a.751.751 0 0 1-1.042-.018.751.751 0 0 1-.018-1.042Zm-4.69 9.64a1.998 1.998 0 0 0 2.83 0l1.25-1.25a.751.751 0 0 1 1.042.018.751.751 0 0 1 .018 1.042l-1.25 1.25a3.5 3.5 0 1 1-4.95-4.95l2.5-2.5a3.5 3.5 0 0 1 4.95 0 .751.751 0 0 1-.018 1.042.751.751 0 0 1-1.042.018 1.998 1.998 0 0 0-2.83 0l-2.5 2.5a1.998 1.998 0 0 0 0 2.83Z"></path></svg></a></div>
|
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<ul dir="auto">
|
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<li><a href="https://www.crcpress.com/Resilience-Engineering-in-Practice-A-Guidebook/Paries-Wreathall-Hollnagel/p/book/9781472420749" rel="nofollow">Resilience engineering in practice: a guidebook</a></li>
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|
||
<path d="M0 6.75C0 5.784.784 5 1.75 5h1.5a.75.75 0 0 1 0 1.5h-1.5a.25.25 0 0 0-.25.25v7.5c0 .138.112.25.25.25h7.5a.25.25 0 0 0 .25-.25v-1.5a.75.75 0 0 1 1.5 0v1.5A1.75 1.75 0 0 1 9.25 16h-7.5A1.75 1.75 0 0 1 0 14.25Z"></path><path d="M5 1.75C5 .784 5.784 0 6.75 0h7.5C15.216 0 16 .784 16 1.75v7.5A1.75 1.75 0 0 1 14.25 11h-7.5A1.75 1.75 0 0 1 5 9.25Zm1.75-.25a.25.25 0 0 0-.25.25v7.5c0 .138.112.25.25.25h7.5a.25.25 0 0 0 .25-.25v-7.5a.25.25 0 0 0-.25-.25Z"></path>
|
||
</svg>
|
||
<svg aria-hidden="true" data-component="Octicon" height="16" viewBox="0 0 16 16" version="1.1" width="16" data-view-component="true" class="octicon octicon-check js-clipboard-check-icon color-fg-success d-none m-2 tmp-m-2">
|
||
<path d="M13.78 4.22a.75.75 0 0 1 0 1.06l-7.25 7.25a.75.75 0 0 1-1.06 0L2.22 9.28a.751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018L6 10.94l6.72-6.72a.75.75 0 0 1 1.06 0Z"></path>
|
||
</svg>
|
||
</clipboard-copy>
|
||
</div>
|
||
</template>
|
||
<template id="snippet-clipboard-copy-button-unpositioned">
|
||
<div class="zeroclipboard-container">
|
||
<clipboard-copy aria-label="Copy code to clipboard" class="ClipboardButton btn btn-invisible js-clipboard-copy m-2 p-0 d-flex flex-justify-center flex-items-center" data-copy-feedback="Copied!" data-tooltip-direction="w">
|
||
<svg aria-hidden="true" data-component="Octicon" height="16" viewBox="0 0 16 16" version="1.1" width="16" data-view-component="true" class="octicon octicon-copy js-clipboard-copy-icon">
|
||
<path d="M0 6.75C0 5.784.784 5 1.75 5h1.5a.75.75 0 0 1 0 1.5h-1.5a.25.25 0 0 0-.25.25v7.5c0 .138.112.25.25.25h7.5a.25.25 0 0 0 .25-.25v-1.5a.75.75 0 0 1 1.5 0v1.5A1.75 1.75 0 0 1 9.25 16h-7.5A1.75 1.75 0 0 1 0 14.25Z"></path><path d="M5 1.75C5 .784 5.784 0 6.75 0h7.5C15.216 0 16 .784 16 1.75v7.5A1.75 1.75 0 0 1 14.25 11h-7.5A1.75 1.75 0 0 1 5 9.25Zm1.75-.25a.25.25 0 0 0-.25.25v7.5c0 .138.112.25.25.25h7.5a.25.25 0 0 0 .25-.25v-7.5a.25.25 0 0 0-.25-.25Z"></path>
|
||
</svg>
|
||
<svg aria-hidden="true" data-component="Octicon" height="16" viewBox="0 0 16 16" version="1.1" width="16" data-view-component="true" class="octicon octicon-check js-clipboard-check-icon color-fg-success d-none">
|
||
<path d="M13.78 4.22a.75.75 0 0 1 0 1.06l-7.25 7.25a.75.75 0 0 1-1.06 0L2.22 9.28a.751.751 0 0 1 .018-1.042.751.751 0 0 1 1.042-.018L6 10.94l6.72-6.72a.75.75 0 0 1 1.06 0Z"></path>
|
||
</svg>
|
||
</clipboard-copy>
|
||
</div>
|
||
</template>
|
||
|
||
|
||
|
||
|
||
</div>
|
||
<div id="js-global-screen-reader-notice" class="sr-only mt-n1" aria-live="polite" aria-atomic="true" ></div>
|
||
<div id="js-global-screen-reader-notice-assertive" class="sr-only mt-n1" aria-live="assertive" aria-atomic="true"></div>
|
||
</body>
|
||
</html>
|
||
|