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Resilience, Stability and Requisite Interpretation in Accident Investigations (Lundberg, Johansson, 2006)

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Jonas Lundberg, Bjorn Johansson

http://www.resilience-engineering-association.org/download/resources/symposium/symposium-2006%282%29/Lundberg_Johansson.pdf

JLJ - perhaps "unanticipated" is a more exact replacemant for the text "unexampled", which is not a commonly used word.

p.2-3 [Holling, 1973, p.17,21] Resilience determines the persistence of relationships within a system and is a measure of the ability of these systems to absorb changes of state variables, driving variables, and parameters, and still persist. In this definition resilience is the property of the system and persistence or probability of extinction the result... A management approach based on resilience... would emphasize the need to keep options open, the need to view events in a regional rather than local context, and the need to emphasize heterogeneity. Flowing from this would be... the recognition of our ignorance; not the assumption that future events are expected, but that they will be unexpected. The resilience framework can accommodate this shift of perspective, for it does not require a precise capacity to predict the future, but only a qualitative capacity to devise systems that can absorb and accommodate future events in whatever unexpected form they may take.

p.4 A non-linear model focuses on normal events, in the present system, variations in these, and how these events and variations can combione and give rise to negative events... or systemic accident models. From a systeic perspective, resilience is described as "an organization's ability to adjust to harmful influences rather than to shun or resist them." (Hollnagel, 2006,p. 14).

p.5 To achieve safe performance, this means that we should focus on the balance between stability and resilience rather than focusing solely on resilience.

p.6 to start a process of adaptation and reconfiguration... it may also be a process of total reconfiguration of a system... When doing that, it is vital to have had requisite imagination to the extent that some preparations for the unexpected have been made.

p.6 When talking about resilience and stability, it can be useful to separate the primary system which is to be resilient or stable, from the secondary system which monitors that process, the one doing the accident analysis and the following recommendations.

p.6 Westrum (2006, p. 22) "The focus is on assessing the organization's adaptive capacity relative to challenges to the capacity - what sustains or erodes the organization's adaptive capacities?".

p.6 Normal activity in a non-resilient system might on the surface look like activity in a resilient system... so if the capacity of resilience has vanished, how do you get it back, especially if you do not know that it is gone?

p.7 To 'respond properly' does not necessarily mean small adjustments, but rather to have a preparedness to make drastic re-configurations and accept that we cannot foresee all types of events.