Erik hollnagel, 2011 causality in simple systems if a physician make a large incision with an operating knife and cure it, or if he open a tumor. But when should the search for the root cause stop. Professor, institute of regional health research, university of southern denmark. Download pdf resilienthealth free online new books in. Barriers and accident prevention, or how to improve safety by. Erik hollnagel, 2015 some myths about industrial safety erik hollnagel professor, university of southern denmark email. The fourth edition of the handbook of human factors and ergonomics has been completely revised and updated. It includes exactly how you should save guide resilience engineering in practice. Practitioners from various fields, such as aviation and air traffic management, patient safety, offshore exploration and production, have quickly realised the potential of resilience engineering and have became early adopters. The ability of current perfusion data management systems to gather perfusion data in real time provides a powerful tool for amassing and analysing eve. Erik hollnagel, 2011 resilience engineering and safety management erik hollnagel email. Erik hollnagel, 2010 three approaches to safety 1850 1900 1950 2000 age of technology age of human factors age of safety management design, automation.
They drive at night can visual enhancement systems keep the. Woods, nancy leveson for resilience engineering, failure is the result of the adaptations necessary to cope with the complexity of the real world, rather than a breakdown or malfunction. Use features like bookmarks, note taking and highlighting while reading safetyii in practice. Hollnagel 2006 made a valuable contribution by defining the four capabilities of resilient systems. The functional resonance analysis method fram the fram has its own webpage here. The button generates a report for the current model. As a consequence of this definition, safety is also measured indirectly, not by its presence or as a quality in itself. A file save option dialogue will also appear on closing the fmv, if unsaved changes were made. Erik hollnagel, 2008 then came the human factor 10 20 30 40 50 60 70 80 100 90 1960 1965 1970 1975 1980 1985 1990 1995 % attributed cause 2000 technology. Handbook of human factors and ergonomics wiley online books. Accident analysis and barrier functions erik hollnagel, ife n version 1. Scale invariance is a feature of structures or functions that does not change when the scale changes.
Wears, erik hollnagel this book is the 3rd volume in the resilient health care series. But until the first decades of the 19th century, risks were accepted as more or less natural in the sense that they were directly associated with. Instructions for use of the fram model visualiser fmv. Senior researcher, department manager, and later principal scientist, computer resources international. Erik hollnagel, 2018 black holes and matter in the safety universe erik hollnagel, ph. Erik hollnagel professor, university of southern denmark e. Their combined citations are counted only for the first article. Erik hollnagel, 2010 causality in simple systems if a physician make a large incision with an operating knife and cure it, or if he open a tumor. Professor erik hollnagel, professor jeffrey braithwaite, dr robyn claywilliams program 08. Driving requires a combination of openloop and closed loop control. Zalerts allow you to be notified by email about the availability of new books according to your search query. However, it is also reported that the term was used in the 1980s in european cognitive systems engineering research. A brief introduction to resilience engineering erik hollnagel professor, university of southern denmark chief consultant, centre for quality, region of southern denmark hollnagel.
The purpose of the rather roundabout definition given above is to avoid statements such as a system is resilient if, since this narrows resilience to a specific. Erik hollnagel, robert l wears, jeffrey braithwaite. The user can choose where to save the file and how to name it. Whenever an accident happens there is a natural concern to find out in detail exactly what happened and to determine the causes of it. A white paper professor erik hollnagel university of southern denmark, institute for. In the 1960s, technology and equipment were often cited as the attributable cause of adverse events. Erik hollnagel, 2012 resilience engineering and crisis management erik hollnagel, professor, ph. So how in perfusion does one measure dynamic non eventsthe stuff that goes right. Erik hollnagel to cite this version mines paristech. The etto principle efficiencythoroughness tradeoff. Safetyi and safetyii, the past and future of safety management find, read and.
Erik hollnagel, 2011 three types of models 1940 1960 1980 2000 single causes root 1920 sequential model simple linear emergent outcomes systemic model. The presence of the soft file of this book resilience engineering in practice. Erik hollnagel nov20, by erik hollnagel is type of obtaining encounter quickly. Resilience engineering as an approach to safety for. A new understanding of safety find, read and cite all. Erik hollnagel is also editorinchief of ashgate studies in resilience engineering. Download for offline reading, highlight, bookmark or take notes while you read safetyi and safetyii. Pdf book resilience engineering in practice volume 2 becoming. This acclaimed book by erik hollnagel is available at in several formats for your ereader.
This term is reported to have been coined by pietro cacciabue and erik hollnagel in 1995. Hollnagel then turns to root causes and as we will see erik not too fond of the term root cause, or at least of some of its mainstream applications. Erik hollnagel, 2017 i equivalence of success and failures failure is normally explained as a breakdown or malfunctioning of a system andor its. A new understanding of safety find, read and cite all the research you need on researchgate. Erik hollnagel, 2012 a birds eye view of resilience engineering erik hollnagel, professor, ph.
He has published more than 350 papers and authored or edited 20 books, some of the most recent titles being resilient health care ashgate, 20, the functional resonance analysis method ashgate, 2012, and resilience engineering in practice ashgate, 2011. A great passage from erik hollnagels barriers and accident prevention on the search for causes. Fram module 1 understanding accidents functional resonance. Understanding accidents, or how not to learn from the past. Pdf on jun 30, 2016, erik hollnagel and others published resilience engineering. 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. Erik hollnagel believes this assumption is false and that safety cannot be attained only by eliminating risks and failures. Erik hollnagel introduction to the rag the number of things that go right increase, then the number of things that go wrong will consequently decrease. Erik hollnagel, 20 resilience engineering as an approach to safety for industry and society erik hollnagel, professor, ph. Erik hollnagel, 2011 three ages of industrial safety 1850 1900 1950 2000 1931 industrial accident prevention 1893 railroad safety appliance act 1769.
Normal performance is variable and this rather than failures and errorsis why. Erik hollnagel a dynamic non event the green stuff on the slide. Volume 2 becoming resilient ashgate studies in resilience engineering by christopher p nemeth erik hollnagel free pdf d0wnl0ad audio books. Erik hollnagel, 2016 different work processes work is typically focused.
Indeed, whenever the result of an action or event falls significantly short of what was expected. Erik hollnagel, 2012 resilience engineering and fram today june 7, 2012. Resilient health care is a product of both the policy and managerial efforts to organize, fund and improve services, and the clinical care which is delivered directly to patients. Most people think of safety as the absence of accidents and incidents or as an acceptable. This book is the result of a oneday seminar on safety and risks in the use of expert systems which was held in copenhagen on may 19th, 1988. The four essential abilities of resilience so what does an organisation need to be resilient. Macrocognition indicates a descriptive level of cognition performed in natural instead of artificial laboratory environments. Safetyi and safetyii professor erik hollnagel on vimeo. Erik hollnagel has been full professor of humanmachine interaction at linkaping university s, since 1999. Developing the resilience potentials kindle edition by hollnagel, erik.
This includes all existing third edition chapters plus new chapters written to cover new areas. This website is available with pay and free online books. The report is in a standard pdf format and opens in the users native pdf. Safety analysis and safety synthesis erik hollnagel hollnagel. The past and future of safety management ebook written by erik hollnagel. His main message is that accident investigation often stops too early, at a convenient or arbitrary point. How to be safe by looking at what goes right instead of. Resilience engineering has since 2004 attracted widespread interest from industry as well as academia. Download it once and read it on your kindle device, pc, phones or tablets.
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