The review was instigated to elaborate on why repetitive incidents were happening in the organization despite its effort to complete a root cause investigation. The project reviewed several high potential incidents over three years using the concept of complexity and system thinking, the cornerstones of Resilience Engineering.
In resilience engineering, failure is not the representation of a functional system’s malfunctioning or breakdown but rather the adaptions necessary to handle the real world’s complexity. Individuals and organizations must constantly adjust to the system’s current conditions because of time and resource limitations. The fundamental approach in Resilience Engineering is that the system is incomplete. People at all levels of the organization need to create safety. Therefore, Resilience Engineering wants to understand how people build, or engineer, adaptive margin into their system, creating safety by developing capacities that help them anticipate and absorb pressures, variations, and disruptions.
Hollnagel, Woods, and Dekker define resilience as: “a resilient system is able effectively to adjust its functioning before, 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.”.
In this project, we reviewed the organization’s capability to learn from previous incidents and near misses using Resilience Engineering’s framework. The review’s ambition has been to provide the foundation for implementing a resilience engineering framework in their high-risk operations to enable the organization to recognize risk and ultimately promote organizational learning.