The review was instigated to elaborate why repetitive incidents were happening in the organisation despite the organisations effort to complete root cause investigation. The project reviewed a number of high potential incidents over a three-year period using the concept of complexity and system thinking, the cornerstones of Resilience Engineering.
In Resilience Engineering failure is not the representation of malfunctioning or breakdown of a functional system, but rather the adaptions necessary to handle the complexity of the real world. Individuals and organisations must always adjust to the current conditions of the system because of limitations of time and resources. The fundamental approach in Resilience Engineering is that the system is incomplete and people, at all levels of the organisation, needs to create safety by the way they complete their work. Therefore, Resilience Engineering wants to understand how people build, or engineer, adaptive margin into their system, how they create safety by developing capacities that help them anticipate and absorb pressures, variations and disruptions.
Resilience is defined by Hollnagel, Woods and Dekker as: “A resilient system is able effectively to adjust its functioning prior to, during, or following changes and disturbances, so that it can continue to perform as required after a disruption or a major mishap, and in the presence of continuous stresses”. The four cornerstones, or four essential capabilities of Resilience Engineering are:
- Knowing what to do, i.e., how to respond to regular and irregular disruptions and disturbances by adjusting normal functioning. This is the ability to address the actual.
- Knowing what to look for, i.e, how to monitor that which is or could become a threat in the near term. The monitoring must cover both that which happens in the environment and that which happens in the system itself, i.e., its own performance. This is the ability to address the critical.
- Knowing what to expect, i.e., how to anticipate developments and threats further into the future, such as potential disruptions, pressures, and their consequences. This is the ability to address the potential.
- Knowing what has happened, i.e., how to learn from experience, in particular to learn the right lessons from the right experience. This is the ability to address the factual.
In this project we reviewed the organisations capability to learn from previous incidents and near misses using the framework of Resilience Engineering. The ambition of the review has been to provide the foundation for implementing the framework of Resilience Engineering in their high-risk operations to better enable the organisation to recognize risk and ultimately enable organisational learning.