Erik hollnagel, 2012 resilience engineering and crisis management erik hollnagel, professor, ph. Download for offline reading, highlight, bookmark or take notes while you read safetyi and safetyii. The antidotes have necessarily been relative to the commonly agreed causes of harm and injury. 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. The past and future of safety management ebook written by erik hollnagel. Technical document prepared by the industrial safety chair. 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.
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. Plan study do act patient identified as sdb cpapmad therapy improvement in ef and ntprobnp improvement in quality of life subjective prospective consecutive patient enrolment. Erik hollnagel professor, university of southern denmark chief consultant, centre for quality, region of southern denmark email. Safety ii is more than just incident and accident prevention. A visualizer for fram functional resonance accident model, a jcsmodel developed by erik hollnagel at liu, sweden. Re from safetyi to safetyii symbio news and report. A functioncentred approach to joint drivervehicle system design. Rag resilience analysis grid introduction erik hollnagel. Erik hollnagel has been full professor of humanmachine interaction at linkaping university s, since 1999. Rescas fundamentals of resilient organisational performance. Now available from ashgate publishing resilient health care. Section 2 applied cognition in human technical systems.
Indeed, whenever the result of an action or event falls significantly short of what was expected. Resilience is an expression of how people, alone or together, cope an organizations performance can be said to be resilient if it can. Erik hollnagel resilience is an expression of how people, alone or together, cope an organizations performance can be said to be resilient if it can function as required under expected and unexpected conditions alike. Once you have installed adobe air, you just rightclick on the fmv file and select open. Indeed, the use of flight pro files can allow the identification of p arts of flights that make sense from a crew perspective and can then be mined to extract outliers. How to be safe by looking at what goes right instead of. The reason for this understanding of safety is not hard to find. This document is published by eurocontrol for information purposes. Erik hollnagel, 2014 the causality credo 1 adverse outcomes happen because something has gone wrong causes. Resilience engineering as an approach to safety for industry. Denmarks professor erik hollnagel explains why safety management should move to ensuring that as many things as possible go right safety in action 2014.
Pdf on the use of flight operating procedures for the. The bumpy road to better risk control mary kay oconnor. Reallife stories of how people change their organizations buyin. Erik hollnagel, 2018 black holes and matter in the safety universe erik hollnagel, ph. 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. Physician quality improvement summit november 19, 2018. Resilience engineering as an approach to safety for industry and society. Erik hollnagel, 20 resilience engineering as an approach to safety for industry and society erik hollnagel, professor, ph. Yet despite decades of attention, activity and investment, improvement has been glacially slow. Erik hollnagel is also editorinchief of ashgate studies in resilience engineering. Safety is the state in which harm to persons or of property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of. The sia national safety convention offers ohs professionals an unparalleled opportunity to keep up to date with the latest national and international developments 18 24. Erik hollnagel studies multicriteria decision analysis, ship hydrodynamics, and ethnographic fieldwork.
Patient safety in everyday work, improving patient safety by investigating how health care professionals perform everyday work. This acclaimed book by erik hollnagel is available at in several formats for your ereader. His main message is that accident investigation often stops too early, at a convenient or arbitrary point. Senior researcher, department manager, and later principal scientist, computer resources international. Indeed, although it has been instrumental towards a systemic and organisational perspective on. This tool helps modelling the the fram table and visualize it. Erik hollnagel nov20, by erik hollnagel is just what individuals currently need.
Erik hollnagel, 2016 different work processes work is typically focused. 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. A great passage from erik hollnagels barriers and accident prevention on the search for causes. Improving performance reliability in surgical systems. This video is about rb day 1 10 professor erik hollnagel. Three related experiments looked at the effects of an nves on. Erik hollnagel, phd university of southern denmark the history of safety management can be seen as a series of proposals for antidotes to the occurrences of accidents, incidents, and adverse outcomes in general. In an attempt to prevent future accidents, there is an underlying assumption shorrock, 2014 for.
Practitioners from various fields, such as aviation and air traffic management, patient safety, offshore exploration and production, have quickly realised the potential of. Understanding accidents, or how not to learn from the past. Edited by erik hollnagel, university of southern denmark, jeffrey braithwaite, university of new south wales, australia and robert l. In relation to health care, the team led by david woods at ohio university, us and that led by charles vincent at st marys hospital, london have done much of the pioneering and development work in adapting the approach to medicine. Download for offline reading, highlight, bookmark or take notes while you read safetyii. Scope and purpose of the study it is now broadly recognized that accidents in complex systems occur through the concatenation of. Erik hollnagel, 2011 resilience engineering and safety management erik hollnagel email. Previously principal advisor, oecd halden reactor project, norway 19951999. Erik has for many years worked at universities, research centres, and industries in several countries and with problems. Introduction when most people hear the word safety they. Erik hollnagel professor, university of southern denmark e. Erik hollnagel nov20, by erik hollnagel deals you better of life that can create the top quality of the life brighter. Tom mcdaniel, global manager zero harm and human performance, siemens energy, inc. The handbook is available for downloading pdfformat.
He argues that safety management must look ahead and not only try to avoid things going wrong, but also try to ensure that they go right. Erik hollnagel, 2011 understanding accidents, or how not to learn from the past professor erik hollnagel university of southern denmark odense, denmark. Woods and nancy leveson other recommended books by john kotter the heart of change. Erik hollnagel, 2015 some myths about industrial safety erik hollnagel professor, university of southern denmark email. In this thought paper, professor erik hollnagel explores the importance of proactive approaches to safety management.
Erik hollnagel, safetyi and safetyii most traditional accident investigations tend to focus on discovering things around an event that never actually happened. Abstract resilience is the intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances so that it can sustain required operations, even after a major mishap or in the presence of continuous stress. A white paper on resilience engineering for atm eurocontrol. Rollenhagen and erik hollnagel whatyoulookforiswhatyoufind the consequences of underlying accident models in eight accident investigation manuals safety science, 2009, 47, 129711.
Their combined citations are counted only for the first article. Erik hollnagel, robert l wears, jeffrey braithwaite. Erik hollnagel, 2014 safetyi when nothing goes wrong safety is the condition where the number of adverse outcomes accidents incidents near. Safetyi and safetyii, the past and future of safety management find, read and. Barriers and accident prevention, or how to improve safety by. A brief introduction to resilience engineering erik hollnagel professor, university of southern denmark chief consultant, centre for quality, region of southern denmark hollnagel. Analysis of errors from week 2 week 5 chapter 7 comprehension and situation awareness francis t.
In an attempt to prevent future accidents, there is an underlying assumption shorrock, 2014 for this somewhat peculiar emphasis, which is. Scale invariance is a feature of structures or functions that does not change when the scale changes. Safetyi and safetyii fram etto synesis resilience engineering. Whenever an accident happens there is a natural concern to find out in detail exactly what happened and to determine the causes of it. Hollnagelsafety science 46 2008 221229 when considering how to respond to an accident, it is. Resilience engineering has since 2004 attracted widespread interest from industry as well as academia. Charles perrow, erik hollnagel and robert helmreich have written extensively on the subject. Resilient health care evokes a sort of enlightenment about how the healthcare industry might be. A white paper executive summary the publication of the iom report to err is human in 2000 served as a catalyst for a growing interest in improving the safety of health care. Download fulltext pdf download fulltext pdf barrier analysis and hollnagels functional resonance accident model article pdf available december 2008 with 75 reads. Lunds university, sweden lundberg j, rollenhagen c, hollnagel e 2009. Erik hollnagel cselab, department of computer and information science university of linkoping, se58183 linkoping, sweden email. Pdf barrier analysis and hollnagels functional resonance.
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