The ETTO Principle Efficiency Thoroughness Trade Off

Author: Erik Hollnagel
Publisher: CRC Press
ISBN: 9781317033608
Release Date: 2017-11-01
Genre: Technology & Engineering

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

A Systems Approach to Managing the Complexities of Process Industries

Author: Fabienne Salimi
Publisher: Elsevier
ISBN: 9780128042182
Release Date: 2017-11-28
Genre: Technology & Engineering

A Systems Approach to Managing the Complexities of Process Industries discusses the principles of system engineering, system thinking, complexity thinking and how these apply to the process industry, including benefits and implementation in process safety management systems. The book focuses on the ways system engineering skills, PLM, and IIoT can radically improve effectiveness of implementation of the process safety management system. Covering lifecycle, megaproject system engineering, and project management issues, this book reviews available tools and software and presents the practical web-based approach of Analysis & Dynamic Evaluation of Project Processes (ADEPP) for system engineering of the process manufacturing development and operation phases. Key solutions proposed include adding complexity management steps in the risk assessment framework of ISO 31000 and utilization of Installation Lifecycle Management. This study of this end-to-end process will help users improve operational excellence and navigate the complexities of managing a chemical or processing plant. Presents a review of Operational Excellence and Process Safety Management Methods, along with solutions to complexity assessment and management Provides a comparison of the process manufacturing industry with discrete manufacturing, identifying similarities and areas of customization for process manufacturing Discusses key solutions for managing the complexities of process manufacturing development and operational phases

Simplicity in Safety Investigations

Author: Ian Long
Publisher: Routledge
ISBN: 9781351598989
Release Date: 2017-08-31
Genre: Technology & Engineering

This innovative book aims to bring the science of safety into a simple and practical approach to investigating workplace incidents. As a basis, it uses the ideas of some of the great safety science thinkers of our time. These include Sidney Dekker, Todd Conklin, Erik Hollnagel, Daniel Kahneman, James Reason and Dylan Evans, alongside others and the author’s own extensive industry experience. Simplicity in Safety Investigations: A Practitioner's Guide to Applying Safety Science will better equip readers to deal with incident investigations by helping them understand the science behind investigation techniques, and by exploring coaching and leadership styles that help them ask better questions both before and after workplace incidents. The first two chapters of the book focus on our mindset as we approach and undertake investigations, and the simple things we all must do before an investigation starts. The third chapter is a step-by-step guide on how to undertake both simple and more detailed workplace incident investigations. Chapter 4 is reserved for a more detailed review and set of explanations around the science and thinking behind the method and approach. This book serves as an easy-to-follow, real-world reference for supervisors, managers and safety practitioners across many industries.

FRAM The Functional Resonance Analysis Method

Author: Professor Erik Hollnagel
Publisher: Ashgate Publishing, Ltd.
ISBN: 9781409487036
Release Date: 2012-10-01
Genre: Technology & Engineering

There has not yet been a comprehensive method that goes behind 'human error' and beyond the failure concept, and various complicated accidents have accentuated the need for it. The Functional Resonance Analysis Method (FRAM) fulfils that need. This book presents a detailed and tested method that can be used to model how complex and dynamic socio-technical systems work, and understand both why things sometimes go wrong but also why they normally succeed.

Resilient Health Care Volume 2

Author: Robert L. Wears
Publisher: Ashgate Publishing, Ltd.
ISBN: 9781472437846
Release Date: 2015-03-28
Genre: Political Science

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

Psychology of Science

Author: Robert W. Proctor
Publisher: Oxford University Press
ISBN: 9780199753628
Release Date: 2012-07-12
Genre: Medical

Symposium held at Purdue Univ. in June 4-5, 2010.

Safety I and Safety II

Author: Professor Erik Hollnagel
Publisher: Ashgate Publishing, Ltd.
ISBN: 9781472423078
Release Date: 2014-05-28
Genre: Political Science

Safety has traditionally been defined as a condition where the number of adverse outcomes was as low as possible (Safety-I). From a Safety-I perspective, the purpose of safety management is to make sure that the number of accidents and incidents is kept as low as possible, or as low as is reasonably practicable. This means that safety management must start from the manifestations of the absence of safety and that - paradoxically - safety is measured by counting the number of cases where it fails rather than by the number of cases where it succeeds. This unavoidably leads to a reactive approach based on responding to what goes wrong or what is identified as a risk - as something that could go wrong. Focusing on what goes right, rather than on what goes wrong, changes the definition of safety from ‘avoiding that something goes wrong’ to ‘ensuring that everything goes right’. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. From a Safety-II perspective, the purpose of safety management is to ensure that as much as possible goes right, in the sense that everyday work achieves its objectives. This means that safety is managed by what it achieves (successes, things that go right), and that likewise it is measured by counting the number of cases where things go right. In order to do this, safety management cannot only be reactive, it must also be proactive. But it must be proactive with regard to how actions succeed, to everyday acceptable performance, rather than with regard to how they can fail, as traditional risk analysis does. This book analyses and explains the principles behind both approaches and uses this to consider the past and future of safety management practices. The analysis makes use of common examples and cases from domains such as aviation, nuclear power production, process management and health care. The final chapters explain the theoretical and practical consequences of the new perspective on the level of day-to-day operations as well as on the level of strategic management (safety culture). Safety-I and Safety-II is written for all professionals responsible for their organisation's safety, from strategic planning on the executive level to day-to-day operations in the field. It presents the detailed and tested arguments for a transformation from protective to productive safety management.

New Century New Trends

Author: J. J. Persensky
Publisher: Institute of Electrical & Electronics Engineers(IEEE)
ISBN: 0780374509
Release Date: 2002
Genre: Technology & Engineering


Understanding Healthcare Delivery Science

Author: Michael Howell
Publisher: McGraw Hill Professional
ISBN: 9781260026498
Release Date: 2019-09-27
Genre: Medical

A new title in the acclaimed Understanding series that focuses on the science of healthcare delivery Over the past decade, the subject of Systems Science has skyrocketed in importance in the healthcare field. With its engaging, clinically relevant style, Understanding Healthcare Delivery Science is the perfect introduction to this timely topic. It covers every aspect of what actually constitutes “best care” and how it can be most efficiently delivered from an operational standpoint. The book is exceptional for two other reasons: numerous case vignettes put the content in a clinically relevant framework, and its comprehensive coverage spans everything from quality and safety to data and policy. Readers will find a valuable opening section that delivers an outstanding introductory discussion of Healthcare Delivery Science Co-author Dr. Michael Howell is a nationally recognized expert on healthcare quality, whose research has been covered by The New York Times, CNN, and Consumer Reports. He has served on national quality- and safety-related national advisory panels for the CDC, Society of Critical Care Medicine, CMS, and others. An active healthcare delivery scientist, Dr. Howell has published more than 90 research articles, editorials, and book chapters on topics related to quality, safety, patient-centeredness, and critical care.