EASA Resilience
Joined: Dec 2002
Posts: 2,776
Likes: 350
From: UK
Book review; Human … & … Machine on human performance
'The 5 Principles of Human Performance: A contemporary update of the building blocks of Human Performance for the new view of safety.' T. Conklin
A publishers view - 'buy this'
"Conklin’s book is an interesting and informal discussion with the reader about the 5 Principles of Human Performance principle by principle, chapter by chapter. These 5 theories about how humans perform in organisations are principles, the building blocks of Human Performance, through which we have established a new way to think about safety and reliability in our worlds. …and changing the way we think about work is a vital step towards improvement.Work never stops and work is never normal. This idea would scare a mere-mortal manager, but an enlightened leader knows the power of continuous learning and improvement. Work is constantly in motion, therefore learning must continue. Work is never the same, therefore we never really know how work is being done. If we don’t know how we perform work how will we know how we can improve? The 5 Principles of Human Performance are, in a sense, a repository of the central values of Human Performance. Keeping these principles at the core of our thinking, training, and practices will allow the basic building blocks of this philosophy to help organizational programs reduce the normal philosophical drift that is present and predictable in all safety programs. Having these espoused principles keeps us all honest and keeps our Human Performance effort on track and successful."
A summary via ChatGPT, a view from technology - 'use this'
CAUTION the text below is generated by a machine, it has no brain, please use your own.
After some thought, this is quite useful as a basis of practical activity; resilience, adaptability.
https://chatgpt.com/share/66eeda94-0...6-21e531a9a08a
An alternative, human view; - note reoccurring themes;
Work as Imagined (WAI) and Work as Done (WAD)
Adaptation
The role of complexity
Learning from everyday work
https://www.linkedin.com/pulse/book-...n-brent-pmhtc/
With similar themes - human performance, in the ICAO guidance. Page 21
https://www.easa.europa.eu/community...Regulators.pdf
A publishers view - 'buy this'
"Conklin’s book is an interesting and informal discussion with the reader about the 5 Principles of Human Performance principle by principle, chapter by chapter. These 5 theories about how humans perform in organisations are principles, the building blocks of Human Performance, through which we have established a new way to think about safety and reliability in our worlds. …and changing the way we think about work is a vital step towards improvement.Work never stops and work is never normal. This idea would scare a mere-mortal manager, but an enlightened leader knows the power of continuous learning and improvement. Work is constantly in motion, therefore learning must continue. Work is never the same, therefore we never really know how work is being done. If we don’t know how we perform work how will we know how we can improve? The 5 Principles of Human Performance are, in a sense, a repository of the central values of Human Performance. Keeping these principles at the core of our thinking, training, and practices will allow the basic building blocks of this philosophy to help organizational programs reduce the normal philosophical drift that is present and predictable in all safety programs. Having these espoused principles keeps us all honest and keeps our Human Performance effort on track and successful."
A summary via ChatGPT, a view from technology - 'use this'
CAUTION the text below is generated by a machine, it has no brain, please use your own.
After some thought, this is quite useful as a basis of practical activity; resilience, adaptability.
https://chatgpt.com/share/66eeda94-0...6-21e531a9a08a
An alternative, human view; - note reoccurring themes;
Work as Imagined (WAI) and Work as Done (WAD)
Adaptation
The role of complexity
Learning from everyday work
https://www.linkedin.com/pulse/book-...n-brent-pmhtc/
With similar themes - human performance, in the ICAO guidance. Page 21
https://www.easa.europa.eu/community...Regulators.pdf
Joined: Jul 2003
Posts: 1,323
Likes: 54
From: An Island Province
Resilience is the action arm of HRO
Interventions and measurements of highly reliable, resilient organization
implementations:-
Background, Hallmarks, Implementation
https://safety177496371.wordpress.co...ture-review-2/
implementations:-
Background, Hallmarks, Implementation
https://safety177496371.wordpress.co...ture-review-2/
Thread Starter
Joined: Mar 2006
Posts: 1,115
Likes: 86
From: England
Safety starts with silence
"We live in an increasingly complex world. The variability of situations we can end up in is almost limitless, so it is practically impossible to be fully prepared for every possible situation. There comes the resilience. We can anticipate but we must necessarily be flexible enough and ready to adapt without hesitation to new situations that have never been experienced. It is like to live hand on a pulse.
Statistics are a good thing. Sometimes it's good to look in the rearview mirror and see that we're on the right track and have done a good job, but that just doesn't tell you anything about tomorrow. Today we must be better than yesterday and tomorrow better than today. This is the only way we can guarantee the level of safety in the future as well.
Just like music starts with complete silence - our safety in aviation starts from zero. Safety is still not waiting for us. We build it from scratch every day."
Atte Jokinen, Captain, Finnair
Statistics are a good thing. Sometimes it's good to look in the rearview mirror and see that we're on the right track and have done a good job, but that just doesn't tell you anything about tomorrow. Today we must be better than yesterday and tomorrow better than today. This is the only way we can guarantee the level of safety in the future as well.
Just like music starts with complete silence - our safety in aviation starts from zero. Safety is still not waiting for us. We build it from scratch every day."
Atte Jokinen, Captain, Finnair
Joined: Dec 2002
Posts: 2,776
Likes: 350
From: UK
Resilience starts with thinking
Resilience starts with thinking - cliffs and fences
Note the one which mitigated risk - the likelihood of harm;
Safety - reducing risk to the lowest practical value.
Hindsight; they should have avoided the situation (a mechanism for blame).
Learning; ask how they came to be at the starting position, for what reason, objective.
An ambulance down in the valley
https://tonycooke.org/stories-and-il...ulance-valley/
Chesterton's Fence
https://fs.blog/chestertons-fence/
Flying can be fun - sliding down rock faces, but also very unforgiving - particularly landing.
Note the one which mitigated risk - the likelihood of harm;
Safety - reducing risk to the lowest practical value.
Hindsight; they should have avoided the situation (a mechanism for blame).
Learning; ask how they came to be at the starting position, for what reason, objective.
An ambulance down in the valley
https://tonycooke.org/stories-and-il...ulance-valley/
Chesterton's Fence
https://fs.blog/chestertons-fence/
Flying can be fun - sliding down rock faces, but also very unforgiving - particularly landing.
Joined: Jul 2003
Posts: 1,323
Likes: 54
From: An Island Province
How do you train for resilience ?
Airbus Competency-Based Training and Assessment. "… recognizing the need for a training paradigm shift given the progress in aircraft technology and the ever-evolving operational landscape."
Airbus Total System Approach; "… a fundamental shift in how we prepare pilots for the challenges of the 21st century."
… a more adaptable and resilient pilot workforce, better equipped to handle unforeseen situations.
The focus on core competencies enhances training efficiency, reducing the need to train for every possible scenario.
"… skills and knowledge necessary to handle a wide range of situations."
"… ability to adapt and problem-solve, leading to more resilient and adaptable flight crews."
https://aircraft.airbus.com/en/newsr...gogy-standards
Invest in training for everyone, individual, operator, system resilience:
https://aircraft.airbus.com/en/search?f[0]=keywords:Training&page=0
and on my favourite subject - avoiding overruns; technology - Runway Sense.
https://aircraft.airbus.com/en/newsr...during-monsoon
Airbus Total System Approach; "… a fundamental shift in how we prepare pilots for the challenges of the 21st century."
… a more adaptable and resilient pilot workforce, better equipped to handle unforeseen situations.
The focus on core competencies enhances training efficiency, reducing the need to train for every possible scenario.
"… skills and knowledge necessary to handle a wide range of situations."
"… ability to adapt and problem-solve, leading to more resilient and adaptable flight crews."
https://aircraft.airbus.com/en/newsr...gogy-standards
Invest in training for everyone, individual, operator, system resilience:
https://aircraft.airbus.com/en/search?f[0]=keywords:Training&page=0
and on my favourite subject - avoiding overruns; technology - Runway Sense.
https://aircraft.airbus.com/en/newsr...during-monsoon
Joined: Dec 2002
Posts: 2,776
Likes: 350
From: UK
"… focussing on work as done"
"… underlying principles, such as Safety II, resilience, and adaptive capacity"
https://www.iata.org/en/programs/saf...athay-pacific/
"… underlying principles, such as Safety II, resilience, and adaptive capacity"
https://www.iata.org/en/programs/saf...athay-pacific/
Joined: Jul 2003
Posts: 1,323
Likes: 54
From: An Island Province
The Ironies of Human Factors
'The Ironies of Human Factors' Hollnagel and Dekker
Unfortunately behind a pay wall - unless someone knows better; an authors e-print perhaps ?
Abstract.
https://www.tandfonline.com/doi/full...eedAccess=true
ChatGPT expanded summary (beware, a machine view, it has no brain so use your own)
https://chatgpt.com/share/677c05d9-3...2-047a73ed2873
Background Refs:
Automation: ( human, technology, and operating environment )
http://johnrooksby.org/papers/ECCE20...er_ironies.pdf (30 yrs on - 12 yrs ago)
"Most systems nowadays are socio-technical systems that involve people working together, and with technology. The resilience of these systems is heavily dependent on the people who use them to act as the last line of defence when the technology inevitably fails, possibly in ways that were not expected by the designers. People are good at stepping in to save the day because they are inherently flexible and adaptable."
General: https://www.tandfonline.com/doi/epdf...eedAccess=true
Unfortunately behind a pay wall - unless someone knows better; an authors e-print perhaps ?
Abstract.
https://www.tandfonline.com/doi/full...eedAccess=true
ChatGPT expanded summary (beware, a machine view, it has no brain so use your own)
https://chatgpt.com/share/677c05d9-3...2-047a73ed2873
Background Refs:
Automation: ( human, technology, and operating environment )
http://johnrooksby.org/papers/ECCE20...er_ironies.pdf (30 yrs on - 12 yrs ago)
"Most systems nowadays are socio-technical systems that involve people working together, and with technology. The resilience of these systems is heavily dependent on the people who use them to act as the last line of defence when the technology inevitably fails, possibly in ways that were not expected by the designers. People are good at stepping in to save the day because they are inherently flexible and adaptable."
General: https://www.tandfonline.com/doi/epdf...eedAccess=true
Joined: Dec 2002
Posts: 2,776
Likes: 350
From: UK
Resilience Engineering 20 years on
Resilience Engineering 20 years on
"Resilience Engineering is a different systems view * and one that encompasses different layers of human systems, the different layers of technological capabilities, and grounding these in the complexities of operations in the face of uncertainty, time pressures, and surprise.
Resilience Engineering is a different view of human and technological systems view that centers on adaptive capacities – how adaptive units interact as events disrupt plans in progress, coordinating over distributed roles and players, built-on/working with various technological capabilities, in systems that serve human purposes."
https://www.linkedin.com/posts/david...ium=member_ios
Foresight review of resilience engineering, Designing for the expected and unexpected (10 years back)
"Resilience describes the emergent property or attributes that some systems have which allows them to withstand, respond and/or adapt to a vast range of disruptive events by preserving and even enhancing critical functionality. The term is used widely over many different fields of study, but quantitative metrics of the resilience of socio-technical systems are not well established and standards and processes are still emerging. Rigorous methodologies and technical integrity is needed to support the uptake and impact of resilience engineering. Resilience can be built by developing capabilities to monitor, respond, anticipate and learn. Challenges to resilience include ‘external’ threats from a range of hazards including environmental, social, economic and technological changes, and ‘internal’ threats from organisational deficiencies. New technologies can provide opportunities but also threats to resilience."
"Engineered solutions to improved resilience of socio-technical systems will require a transdisciplinary approach including engineering; the natural, physical, and social sciences; economics; and policy. Solutions will require assessment and predictive capabilities that do not presently exist, including identification, collection and analysis of relevant data. Pro-active approaches such as ‘Safety 2’ and performance-based engineering can support the resilience goal of preserving critical system functionality in the face of anticipated and unanticipated conditions. The report also identifies the serious challenge of retrofitting existing systems. There are a wide range of possible actions and interventions that could support resilience. These range from developing facilities and tools to supporting new knowledge and technologies; fostering international collaboration and understanding of global systems; establishing foundational research; learning from ecology and ecosystems; and developing better incentives for improving resilience."
What is resilience engineering?
The term resilience has been in use for many years by a variety of disciplines. It describes the emergent property, or attribute, that some systems have which allows them to withstand, respond and/or adapt to a vast range of disruptive events. Pages 7-10
Impacts, trends, and opportunities: the challenges to resilience
The challenges to achieving improved resilience, in particular of complex socio-technical systems, include a range of external and internal (organisational) influences: Pages 19-20
https://www.lrfoundation.org.uk/site...ngineering.pdf
* An Introduction to Systems Thinking
https://vdoc.pub/download/systems-on...g-svom93d433o0
or
https://www.dropbox.com/scl/fi/dkibr...=02nstruy&dl=0
"Resilience Engineering is a different systems view * and one that encompasses different layers of human systems, the different layers of technological capabilities, and grounding these in the complexities of operations in the face of uncertainty, time pressures, and surprise.
Resilience Engineering is a different view of human and technological systems view that centers on adaptive capacities – how adaptive units interact as events disrupt plans in progress, coordinating over distributed roles and players, built-on/working with various technological capabilities, in systems that serve human purposes."
https://www.linkedin.com/posts/david...ium=member_ios
Foresight review of resilience engineering, Designing for the expected and unexpected (10 years back)
"Resilience describes the emergent property or attributes that some systems have which allows them to withstand, respond and/or adapt to a vast range of disruptive events by preserving and even enhancing critical functionality. The term is used widely over many different fields of study, but quantitative metrics of the resilience of socio-technical systems are not well established and standards and processes are still emerging. Rigorous methodologies and technical integrity is needed to support the uptake and impact of resilience engineering. Resilience can be built by developing capabilities to monitor, respond, anticipate and learn. Challenges to resilience include ‘external’ threats from a range of hazards including environmental, social, economic and technological changes, and ‘internal’ threats from organisational deficiencies. New technologies can provide opportunities but also threats to resilience."
"Engineered solutions to improved resilience of socio-technical systems will require a transdisciplinary approach including engineering; the natural, physical, and social sciences; economics; and policy. Solutions will require assessment and predictive capabilities that do not presently exist, including identification, collection and analysis of relevant data. Pro-active approaches such as ‘Safety 2’ and performance-based engineering can support the resilience goal of preserving critical system functionality in the face of anticipated and unanticipated conditions. The report also identifies the serious challenge of retrofitting existing systems. There are a wide range of possible actions and interventions that could support resilience. These range from developing facilities and tools to supporting new knowledge and technologies; fostering international collaboration and understanding of global systems; establishing foundational research; learning from ecology and ecosystems; and developing better incentives for improving resilience."
What is resilience engineering?
The term resilience has been in use for many years by a variety of disciplines. It describes the emergent property, or attribute, that some systems have which allows them to withstand, respond and/or adapt to a vast range of disruptive events. Pages 7-10
Impacts, trends, and opportunities: the challenges to resilience
The challenges to achieving improved resilience, in particular of complex socio-technical systems, include a range of external and internal (organisational) influences: Pages 19-20
https://www.lrfoundation.org.uk/site...ngineering.pdf
* An Introduction to Systems Thinking
https://vdoc.pub/download/systems-on...g-svom93d433o0
or
https://www.dropbox.com/scl/fi/dkibr...=02nstruy&dl=0
Last edited by safetypee; 22nd January 2025 at 08:38.
Joined: Jul 2003
Posts: 1,323
Likes: 54
From: An Island Province
Reason and Resilience
James Reason's Legacy: Have you made a slip, lapse or mistake in your interpretation?
There are very few professionals that will not have been taught about James Reason’s work so in honour of him, his work and his passing away this week, it is important that his legacy is shared and that the interpretations of his work are correct.
Many have not engaged with his original writing and have been exposed to it second or third hand. These interpretations include the claim that the dominant root cause of incidents is human error and the incorrect use of his work on incident causation (swiss cheese model) to claim that it is violations and compliance failures that lead to barriers and safeguards failing. His work on error types used to classify causes in taxonomies then go no further to assess the underlying latent conditions!
This is not what he intended, and it is not factually correct.
His work fundamentally challenged traditional safety paradigms by shifting focus from individual blame to systemic factors.
Human Error: He introduced error classifications as slips, lapses, mistakes and violations and how they emerge from the normal cognitive processes of humans rather than moral failures in intent, as bad apples or stupid people. He shows that errors are inevitable through skill, rule and knowledge-based performance of people moderated by their sense-making processes and the systemic environment they are in.
Managing the Risks of Organizational Accidents: He developed his accident causation model (named the swiss cheese by colleagues) showing that for an accident to happen, there had to be alignment of
(i) latent organisational failures (which he later called conditions as they were never deemed failures but normal),
(ii) local workplace conditions and
(iii) active human errors.
For these active human errors, he noted that people ‘triggered’ these underlying and inadequate conditions, which resulted in people suffering the consequences rather than causing them.
Echoing Jens Rasmussen his peer, he said “Incidents are as a result of unkind environments, triggered by people but not caused by people”.
Just Culture: He introduced Just Culture principles promoting system error reduction with error management over elimination and providing the distinction between blameless errors versus reckless violations. We see this now with the modern concept of setting up systems to ‘fail safely’, ‘error proof work systems’ and to act with the belief that incidents WILL happen and when they do, the question is not who to blame but how will you ensure people are not hurt.
Above all, further work on his just culture principles has brought this further into ultra safe industries to protect reporting cultures and employee safety engagement with evolved iterations to avoid being ‘just cultured’ through a process rather than driving Reason’s original mindset which was about looking to the system to identify the factors that influenced the error.
Metrics: He argued against "body count" safety metrics, stating that "Low injury rates can create false security - catastrophic risks persist even when minor incidents decline". He showed how production pressures erode safety defenses regardless of good injury statistics.
He also challenged the use of injury metrics by promoting the use of hazard reporting and near misses as work system weaknesses worthy of taking action on.
Further work, he then critiqued traditional incident causation models for overlooking socio-technical system interactions and failing to address migration of work systems towards danger.
He proposed safety resilience rather than compliance-based metrics. We can see the trajectory of this work in contemporary discussions of drift, variability of normal work and resilience engineering.
Ultimately, he provided the basis for key shifts that have yet to see consistently prevalent around how safety is taught or done.
To move from human error as the cause and conclusion of incidents towards error being a symptom of work system flaws
To move from injury rate tracking as the primary measure of safety to the consistent analysis of latent conditions, error traps and strength of barriers
To move from the belief that incidents are caused in a linear manner towards understanding that incidents happen due to complex system interactions combining both proximate and remote factors in time and place to when an incident occurs.
Reason was a legend – and one that provided us a foundation not only to understand safety better but to treat workers better in how we learn and improve our work systems. His analysis moves us upstream from looking at workers actions to organisational decision making and system design.
A key question to ask ourselves is whether we as professionals have the skills, courage and mindset to accept that this has to happen to make work safer.
Maeve O'Loughlin
There are very few professionals that will not have been taught about James Reason’s work so in honour of him, his work and his passing away this week, it is important that his legacy is shared and that the interpretations of his work are correct.
Many have not engaged with his original writing and have been exposed to it second or third hand. These interpretations include the claim that the dominant root cause of incidents is human error and the incorrect use of his work on incident causation (swiss cheese model) to claim that it is violations and compliance failures that lead to barriers and safeguards failing. His work on error types used to classify causes in taxonomies then go no further to assess the underlying latent conditions!
This is not what he intended, and it is not factually correct.
His work fundamentally challenged traditional safety paradigms by shifting focus from individual blame to systemic factors.
Human Error: He introduced error classifications as slips, lapses, mistakes and violations and how they emerge from the normal cognitive processes of humans rather than moral failures in intent, as bad apples or stupid people. He shows that errors are inevitable through skill, rule and knowledge-based performance of people moderated by their sense-making processes and the systemic environment they are in.
Managing the Risks of Organizational Accidents: He developed his accident causation model (named the swiss cheese by colleagues) showing that for an accident to happen, there had to be alignment of
(i) latent organisational failures (which he later called conditions as they were never deemed failures but normal),
(ii) local workplace conditions and
(iii) active human errors.
For these active human errors, he noted that people ‘triggered’ these underlying and inadequate conditions, which resulted in people suffering the consequences rather than causing them.
Echoing Jens Rasmussen his peer, he said “Incidents are as a result of unkind environments, triggered by people but not caused by people”.
Just Culture: He introduced Just Culture principles promoting system error reduction with error management over elimination and providing the distinction between blameless errors versus reckless violations. We see this now with the modern concept of setting up systems to ‘fail safely’, ‘error proof work systems’ and to act with the belief that incidents WILL happen and when they do, the question is not who to blame but how will you ensure people are not hurt.
Above all, further work on his just culture principles has brought this further into ultra safe industries to protect reporting cultures and employee safety engagement with evolved iterations to avoid being ‘just cultured’ through a process rather than driving Reason’s original mindset which was about looking to the system to identify the factors that influenced the error.
Metrics: He argued against "body count" safety metrics, stating that "Low injury rates can create false security - catastrophic risks persist even when minor incidents decline". He showed how production pressures erode safety defenses regardless of good injury statistics.
He also challenged the use of injury metrics by promoting the use of hazard reporting and near misses as work system weaknesses worthy of taking action on.
Further work, he then critiqued traditional incident causation models for overlooking socio-technical system interactions and failing to address migration of work systems towards danger.
He proposed safety resilience rather than compliance-based metrics. We can see the trajectory of this work in contemporary discussions of drift, variability of normal work and resilience engineering.
Ultimately, he provided the basis for key shifts that have yet to see consistently prevalent around how safety is taught or done.
To move from human error as the cause and conclusion of incidents towards error being a symptom of work system flaws
To move from injury rate tracking as the primary measure of safety to the consistent analysis of latent conditions, error traps and strength of barriers
To move from the belief that incidents are caused in a linear manner towards understanding that incidents happen due to complex system interactions combining both proximate and remote factors in time and place to when an incident occurs.
Reason was a legend – and one that provided us a foundation not only to understand safety better but to treat workers better in how we learn and improve our work systems. His analysis moves us upstream from looking at workers actions to organisational decision making and system design.
A key question to ask ourselves is whether we as professionals have the skills, courage and mindset to accept that this has to happen to make work safer.
Maeve O'Loughlin
Joined: Jul 2003
Posts: 1,323
Likes: 54
From: An Island Province
Three more from James Reason
Human error and organisational failure
http://www.ncbi.nlm.nih.gov/pmc/arti...v014p00056.pdf
Human error: models and management
https://europepmc.org/backend/ptpmcr...9&blobtype=pdf
Safety paradoxes and safety culture
https://www.dropbox.com/scl/fi/d0rbc...=lsxjdjzb&dl=0
Human error and organisational failure
http://www.ncbi.nlm.nih.gov/pmc/arti...v014p00056.pdf
Human error: models and management
https://europepmc.org/backend/ptpmcr...9&blobtype=pdf
Safety paradoxes and safety culture
https://www.dropbox.com/scl/fi/d0rbc...=lsxjdjzb&dl=0
Thread Starter
Joined: Mar 2006
Posts: 1,115
Likes: 86
From: England
Some references:
Resilience Engineering in a Nutshell: Erik Hollnagel
https://www.erikhollnagel.com/oneweb...el_preface.pdf
Safety-II and Resilience Engineering in a Nutshell: An Introductory Guide to Their Concepts and Methods; Safety-II, Resilience Engineering, and FRAM: Dong-Han Ham
https://www.sciencedirect.com/scienc...93791120303619
Anticipating Failures: What Should Predictions Be About? Erik Hollnagel
https://ia601204.us.archive.org/6/it..._ADP010439.pdf
Resilience Engineering in a Nutshell: Erik Hollnagel
https://www.erikhollnagel.com/oneweb...el_preface.pdf
Safety-II and Resilience Engineering in a Nutshell: An Introductory Guide to Their Concepts and Methods; Safety-II, Resilience Engineering, and FRAM: Dong-Han Ham
https://www.sciencedirect.com/scienc...93791120303619
Anticipating Failures: What Should Predictions Be About? Erik Hollnagel
https://ia601204.us.archive.org/6/it..._ADP010439.pdf
Joined: Jul 2003
Posts: 1,323
Likes: 54
From: An Island Province
Lead with resilience instead of blind adherence
From LinkedIn; a component of resilience. A dream ?
The Prince of Homburg Effect – When rule-breaking turns into heroism
In many organizations, strict rule-following is considered a mark of professionalism and integrity. But reality is more complex. Sometimes, safety, efficiency, or even innovation, arise precisely because someone bends the rules.
This is known as useful illegality: rule-breaking that paradoxically helps an organization function more effectively. And when it leads to success… it’s often celebrated. This is the Prince of Homburg Effect: you break the rules, but if the outcome is positive, you’re a hero. If it fails, you’re to blame.
The origin is a 19th-century play with modern lessons. In The Prince of Homburg by Heinrich von Kleist, a young cavalry officer disobeys an order in battle—distracted by personal longing and confused by ambiguous command. He attacks the enemy against orders… and wins.
But victory is not enough. He is court-martialed for insubordination and sentenced to death. Only after a deep personal transformation, accepting responsibility, recognizing the limits of his rank, and showing moral courage, does he earn a symbolic pardon. He is crowned, not executed.
The story ends with the question: “Was this a dream?”
The answer: “A dream, what else?”
Why it matters for organizations today:
Deviations from rules are often tolerated… as long as they deliver results. Success brings praise; failure brings outrage.
Informal practices arise in the grey zones where formal rules can’t keep up with real-world complexity.
What can we take from this?
- Make informal practices visible and discussable. Rules aren’t enough.
- Judge not only compliance, but also intent and context.
- Lead with resilience instead of blind adherence.
After all, in complex environments, organizations need people with the judgment to know when and why to adapt—not as an exception, but as a form of professional wisdom.
“A dream, what else?”
That final line reminds us: the boundary between order and improvisation, between discipline and discretion, is never static. And that’s exactly where resilience is born.
From an internal link:-
https://organizationaldialoguepress....Illegality.pdf
The Prince of Homburg Effect – When rule-breaking turns into heroism
In many organizations, strict rule-following is considered a mark of professionalism and integrity. But reality is more complex. Sometimes, safety, efficiency, or even innovation, arise precisely because someone bends the rules.
This is known as useful illegality: rule-breaking that paradoxically helps an organization function more effectively. And when it leads to success… it’s often celebrated. This is the Prince of Homburg Effect: you break the rules, but if the outcome is positive, you’re a hero. If it fails, you’re to blame.
The origin is a 19th-century play with modern lessons. In The Prince of Homburg by Heinrich von Kleist, a young cavalry officer disobeys an order in battle—distracted by personal longing and confused by ambiguous command. He attacks the enemy against orders… and wins.
But victory is not enough. He is court-martialed for insubordination and sentenced to death. Only after a deep personal transformation, accepting responsibility, recognizing the limits of his rank, and showing moral courage, does he earn a symbolic pardon. He is crowned, not executed.
The story ends with the question: “Was this a dream?”
The answer: “A dream, what else?”
Why it matters for organizations today:
Deviations from rules are often tolerated… as long as they deliver results. Success brings praise; failure brings outrage.
Informal practices arise in the grey zones where formal rules can’t keep up with real-world complexity.
What can we take from this?
- Make informal practices visible and discussable. Rules aren’t enough.
- Judge not only compliance, but also intent and context.
- Lead with resilience instead of blind adherence.
After all, in complex environments, organizations need people with the judgment to know when and why to adapt—not as an exception, but as a form of professional wisdom.
“A dream, what else?”
That final line reminds us: the boundary between order and improvisation, between discipline and discretion, is never static. And that’s exactly where resilience is born.
From an internal link:-
https://organizationaldialoguepress....Illegality.pdf
Thread Starter
Joined: Mar 2006
Posts: 1,115
Likes: 86
From: England
Thoughts on Culture, Safety-I and Safety-II, and Resilience by E Hollnagel https://erikhollnagel.com/onewebmedi...20mar%2016.pdf
Also see safety culture maturity Hollnagel & Slater
https://iilsc.com/wp-content/uploads...e_maturity.pdf
Focusing and learning from things that go right
https://www.dropbox.com/scl/fi/moske...=1d5qv1k9&dl=0
Also see safety culture maturity Hollnagel & Slater
https://iilsc.com/wp-content/uploads...e_maturity.pdf
Focusing and learning from things that go right
https://www.dropbox.com/scl/fi/moske...=1d5qv1k9&dl=0
Thread Starter
Joined: Mar 2006
Posts: 1,115
Likes: 86
From: England
Safety science +ve —ve
https://www.matec-conferences.org/ar...2018_01003.pdf
An interesting paper which considers the potential effects of using or being required to use some of the new views of safety
In particular, if resilience is inappropriately being imposed on the industry - para 4.2. Reconsider posts #1 #3, #6.
Also see the thread Safety Management - Trust - for everyone - Challenge Safety the safety plan at https://www.jreast.co.jp/e/data/pdf/...afety_plan.pdf includes aspects of resilience and safety-II, and looks further ahead (differently) than most regulatory views, and also appears to have bypassed any adverse effects of introducing new views of safety.
And a late addition, a book review:- Industrial Accident Prevention by E. Hollnagel, related to resilience.
https://chatgpt.com/share/68c69a49-5...7-ee3d36760892
An interesting paper which considers the potential effects of using or being required to use some of the new views of safety
In particular, if resilience is inappropriately being imposed on the industry - para 4.2. Reconsider posts #1 #3, #6.
Also see the thread Safety Management - Trust - for everyone - Challenge Safety the safety plan at https://www.jreast.co.jp/e/data/pdf/...afety_plan.pdf includes aspects of resilience and safety-II, and looks further ahead (differently) than most regulatory views, and also appears to have bypassed any adverse effects of introducing new views of safety.
And a late addition, a book review:- Industrial Accident Prevention by E. Hollnagel, related to resilience.
https://chatgpt.com/share/68c69a49-5...7-ee3d36760892
Joined: Dec 2002
Posts: 2,776
Likes: 350
From: UK
resilience is safer than anticipation
Book review and safety management discussion: risk, regulation, and resilience.
"… resilience, not regulation, is the ultimate form of safety."
"… the safest societies are not those that prevent all failures, but those that learn fastest from them."
The resilience mindset in aviation:
Accept uncertainty.
Detect early.
Respond flexibly.
Learn continuously.
Distribute authority and knowledge.
"Aaron Wildavsky’s Searching for Safety (1988) on risk management and public policy. The book challenges the dominant idea that safety can be achieved through regulation and control, proposing instead that resilience and adaptability offer a more effective path to societal safety. Wildavsky contrasts two core strategies — “anticipation” and “resilience” — and argues that overregulation and excessive precaution can paradoxically make societies less safe."
resilience is safer than anticipation
https://chatgpt.com/share/68eb7b92-9...c-db55ecf6f3f1
P.S. The word 'Risk' in this discussion relates more to a situation involving exposure to danger (hazards) opposed to chance or possibility used in some risk assessments.
"… resilience, not regulation, is the ultimate form of safety."
"… the safest societies are not those that prevent all failures, but those that learn fastest from them."
The resilience mindset in aviation:
Accept uncertainty.
Detect early.
Respond flexibly.
Learn continuously.
Distribute authority and knowledge.
"Aaron Wildavsky’s Searching for Safety (1988) on risk management and public policy. The book challenges the dominant idea that safety can be achieved through regulation and control, proposing instead that resilience and adaptability offer a more effective path to societal safety. Wildavsky contrasts two core strategies — “anticipation” and “resilience” — and argues that overregulation and excessive precaution can paradoxically make societies less safe."
resilience is safer than anticipation
https://chatgpt.com/share/68eb7b92-9...c-db55ecf6f3f1
P.S. The word 'Risk' in this discussion relates more to a situation involving exposure to danger (hazards) opposed to chance or possibility used in some risk assessments.
Last edited by safetypee; 12th October 2025 at 16:18.
Joined: Dec 2002
Posts: 2,776
Likes: 350
From: UK
Safety in Complex Organizations
Headlines from the expanded summary book review:-
"Safety in Complex Organizations: A Cultural Approach" – Teemu Reiman
Safety is not a state to be reached but a way of being together in uncertainty.
… safety is not about control—it’s mindfulness, continuous learning, and shared care for one another.
… safety is fundamentally about relationships—between people, systems, and meanings.
A cultural approach does not replace technical controls but complements them by addressing the human and social drivers of safety performance.
… safety emerges when organizations can discuss the undiscussable—when they confront ambiguity, reflect on assumptions, and treat safety as a shared moral and practical responsibility.
.
"Safety in Complex Organizations: A Cultural Approach" – Teemu Reiman
Safety is not a state to be reached but a way of being together in uncertainty.
… safety is not about control—it’s mindfulness, continuous learning, and shared care for one another.
… safety is fundamentally about relationships—between people, systems, and meanings.
A cultural approach does not replace technical controls but complements them by addressing the human and social drivers of safety performance.
… safety emerges when organizations can discuss the undiscussable—when they confront ambiguity, reflect on assumptions, and treat safety as a shared moral and practical responsibility.
.
- Safety culture = shared assumptions and values guiding behavior.
- Complexity = unpredictable interactions, requiring adaptive learning.
- Leadership = defines priorities and models cultural norms.
- Communication = essential for sensemaking and transparency.
- Trade-offs = must be consciously balanced.
- Psychological safety = foundation for learning and reporting.
- Learning = comes from both success and failure.
- Resilience = ability to adapt and recover.
- Hidden failures = cultural blind spots that accumulate.
- Cultural change = slow, but transformative when authentic.
Thread Starter
Joined: Mar 2006
Posts: 1,115
Likes: 86
From: England
From Safety to Safely
Joining those who use LLMs for book reviews - low risk and fact checkable; a new contribution from Eric Hollnagel 'From Safety to Safely' (read that again; from condition to activity)
First a human review; subjectivity, emotion, … and a question - theory into practice.
“This book is for middle and senior managers, board members, and independent consultants…” I read these words with enthusiasm as I stumbled across Prof Hollnagel’s latest book. In typical Erik fashion, there is the attention-grabbing, play-on-words title: “from safety to safely”. So, as a scientist-practitioner, independent consultant, and applied research, it is no wonder that I was drawn to this new work.
But unfortunately, I was disappointed.
Perhaps in a sign of things to come, I found myself finishing the entire 139 pages within a short 2-hour flight.
Sections were repetitive (e.g., ‘Part II’ and Perrow’s Normal Accident Theory), distracting (e.g., historical tangents, although interesting, served little practical purpose), and unnecessarily esoteric (e.g., terms such as ‘causal consonance’ and ‘visio centum’ only decrease the book’s accessibility to a practitioner audience). Although I could appreciate the intellectualism going on here, my practitioner brain was left clutching at straws and often coming up empty-handed. Adding to my frustration were many copy-editing errors that snuck their way through quality control.
Like the black cat that signified ‘déjà vu’ in The Matrix, Prof. Hollnagel’s recycling of older content had me doing a double-take, fast-forwarding through pages, desperately searching for something new to be gleaned. I powered through a refresher drawn almost exactly from his 2004 book (“From Safety-I to Safety-II”), a chapter on ‘Systemic Potentials Management’ (which is a relabelling of ‘Resilience Potentials’ from his 2018 book: “Safety-II in Practice”), and a reimagined ‘Resilience Analysis Grid’ methodology. Even the concluding Coda chapter, which promised to “connect the dots” read more like a descriptive summary rather than a guided tour of the main argumentation and a final resounding crescendo.
At one point, I found myself disagreeing, which came at p.129, where Prof. Hollnagel drops a short paragraph, entitled ‘Is risk really necessary?’. The central argument is that ‘risk’ corresponds to a ‘Safety-I’ (now relabelled as ‘Zero Accident Vision’) approach and should be replaced with ‘chance’ or ‘possibility’. Isn’t the definition of risk management “identifying, assessing, and mitigating potential negative impacts while also seeking to identify and capitalise on potential opportunities’? Surely the framing of risk as an integration of avoiding harm with approaching opportunities makes it compatible with Safety-I AND Safety-II?
However, the book is well-researched and it did get me thinking:
Is there a helpful analogy between accident causation models and physical sciences models, whereby some models are useful and helpful at different levels of analysis (e.g., the ongoing practical utility of Newton’s laws at a macro, everyday level versus the abstract messiness of quantum theory at a micro level)?
I was left wondering: can we translate safety science theory into practice more effectively? What do you think?
The opinions expressed in this review are entirely subjective and those of the author, Dr Tristan Casey. This book was reviewed with a practitioner lens as per the marketing material, but it may appeal to a more academic audience. You can find the book direct from its publisher here:https://www.routledge.com/From-Safet...ryLT3QuLiSXLDE
Chat GPT review - focus on the practical
https://chatgpt.com/share/69061ef9-3...b-53ffd80192d3
Note embedded references, and sources list at the end.
Questions:
Ask: What enables us to succeed despite variability? What capacities are under-stress or vulnerable?
… what worked well today, why it worked, and how we can do more of it.
Ask what was supposed to happen, what actually happened, what enabled success, what prevented harm although variation occurred.
"… experiencing safety opposed to knowing safety"
and for further comparison, the contribution from Grok
https://grok.com/share/c2hhcmQtMw%3D...1-2d60813e3b0a
(App or 'continue with web')
Again note sources list at the end.
First a human review; subjectivity, emotion, … and a question - theory into practice.
“This book is for middle and senior managers, board members, and independent consultants…” I read these words with enthusiasm as I stumbled across Prof Hollnagel’s latest book. In typical Erik fashion, there is the attention-grabbing, play-on-words title: “from safety to safely”. So, as a scientist-practitioner, independent consultant, and applied research, it is no wonder that I was drawn to this new work.
But unfortunately, I was disappointed.
Perhaps in a sign of things to come, I found myself finishing the entire 139 pages within a short 2-hour flight.
Sections were repetitive (e.g., ‘Part II’ and Perrow’s Normal Accident Theory), distracting (e.g., historical tangents, although interesting, served little practical purpose), and unnecessarily esoteric (e.g., terms such as ‘causal consonance’ and ‘visio centum’ only decrease the book’s accessibility to a practitioner audience). Although I could appreciate the intellectualism going on here, my practitioner brain was left clutching at straws and often coming up empty-handed. Adding to my frustration were many copy-editing errors that snuck their way through quality control.
Like the black cat that signified ‘déjà vu’ in The Matrix, Prof. Hollnagel’s recycling of older content had me doing a double-take, fast-forwarding through pages, desperately searching for something new to be gleaned. I powered through a refresher drawn almost exactly from his 2004 book (“From Safety-I to Safety-II”), a chapter on ‘Systemic Potentials Management’ (which is a relabelling of ‘Resilience Potentials’ from his 2018 book: “Safety-II in Practice”), and a reimagined ‘Resilience Analysis Grid’ methodology. Even the concluding Coda chapter, which promised to “connect the dots” read more like a descriptive summary rather than a guided tour of the main argumentation and a final resounding crescendo.
At one point, I found myself disagreeing, which came at p.129, where Prof. Hollnagel drops a short paragraph, entitled ‘Is risk really necessary?’. The central argument is that ‘risk’ corresponds to a ‘Safety-I’ (now relabelled as ‘Zero Accident Vision’) approach and should be replaced with ‘chance’ or ‘possibility’. Isn’t the definition of risk management “identifying, assessing, and mitigating potential negative impacts while also seeking to identify and capitalise on potential opportunities’? Surely the framing of risk as an integration of avoiding harm with approaching opportunities makes it compatible with Safety-I AND Safety-II?
However, the book is well-researched and it did get me thinking:
Is there a helpful analogy between accident causation models and physical sciences models, whereby some models are useful and helpful at different levels of analysis (e.g., the ongoing practical utility of Newton’s laws at a macro, everyday level versus the abstract messiness of quantum theory at a micro level)?
- Are accident causation models defined by two dimensions: time (retrospective focus versus prospective focus) and complexity (simplistic versus complex)? Does this help us to classify and use accident causation models more strategically?
- When we deal with complexity as human beings, should we shift from ‘knowing’ (a logical, technical approach) to ‘experiencing’ (a more intuitive, holistic approach)?
I was left wondering: can we translate safety science theory into practice more effectively? What do you think?
The opinions expressed in this review are entirely subjective and those of the author, Dr Tristan Casey. This book was reviewed with a practitioner lens as per the marketing material, but it may appeal to a more academic audience. You can find the book direct from its publisher here:https://www.routledge.com/From-Safet...ryLT3QuLiSXLDE
Chat GPT review - focus on the practical
https://chatgpt.com/share/69061ef9-3...b-53ffd80192d3
Note embedded references, and sources list at the end.
Questions:
Ask: What enables us to succeed despite variability? What capacities are under-stress or vulnerable?
… what worked well today, why it worked, and how we can do more of it.
Ask what was supposed to happen, what actually happened, what enabled success, what prevented harm although variation occurred.
"… experiencing safety opposed to knowing safety"
and for further comparison, the contribution from Grok
https://grok.com/share/c2hhcmQtMw%3D...1-2d60813e3b0a
(App or 'continue with web')
Again note sources list at the end.
Last edited by PEI_3721; 5th November 2025 at 16:40.
Joined: Jul 2003
Posts: 1,323
Likes: 54
From: An Island Province
Safety is a choice, renewed each day, by every person in the system
Humans tend to have a cautionary negative attitude; it's easier to critique work than identify and explain the positive aspects.
Thus, searching the recent EASA publication 'CONVERSATION AVIATION' #02 for safety buzzwords 'resilience' 'psychological safety' it was refreshing not to to find any 'buzz'.
Yet aspects of resilience, are in the document - 'Winter Aviation', starting with the masterful Forward - "remain vigilant, adaptive, and proactive"; "maintaining the right mindset, protecting our people, caring for our equipment, respecting compliance, recognising risks, and committing to continuous learning, we ensure that winter is not just endured, it is mastered".
"Safety is a choice, renewed each day, by every person in the system."
and more; ramp, cabin, engineering, ATC, runway.
'Winter Aviation' is not a document just for Europe; every one requires winter awareness; tropical, desert, or temperate operators, may visit. (Not to forget that the northern 'snowbirds' who fly south can still encounter poor runway conditions in tropical rainstorms - like landing on snow or ice).
As yet to identify any caution about air/runway temperatures +/- 3 deg C, with increasing risk, also other aspects of climate change; more storms and turbulence.
The content justifies the sub title :
https://www.easa.europa.eu/community...025_winter.pdf
..
Thus, searching the recent EASA publication 'CONVERSATION AVIATION' #02 for safety buzzwords 'resilience' 'psychological safety' it was refreshing not to to find any 'buzz'.
Yet aspects of resilience, are in the document - 'Winter Aviation', starting with the masterful Forward - "remain vigilant, adaptive, and proactive"; "maintaining the right mindset, protecting our people, caring for our equipment, respecting compliance, recognising risks, and committing to continuous learning, we ensure that winter is not just endured, it is mastered".
"Safety is a choice, renewed each day, by every person in the system."
aka Resilience.
Thence an SMS section 'beyond the illusion of safety'; note thread The illusion of safetyand more; ramp, cabin, engineering, ATC, runway.
'Winter Aviation' is not a document just for Europe; every one requires winter awareness; tropical, desert, or temperate operators, may visit. (Not to forget that the northern 'snowbirds' who fly south can still encounter poor runway conditions in tropical rainstorms - like landing on snow or ice).
As yet to identify any caution about air/runway temperatures +/- 3 deg C, with increasing risk, also other aspects of climate change; more storms and turbulence.
The content justifies the sub title :
'STARTING POSITIVE CONVERSATIONS ABOUT SAFETY'
..https://www.easa.europa.eu/community...025_winter.pdf
..
Last edited by alf5071h; 7th November 2025 at 14:39.
Thread Starter
Joined: Mar 2006
Posts: 1,115
Likes: 86
From: England
Train for Surprise and improve Resilience potentials
Resilience; it is 4 yrs since the specific questions in #3 - #6 were posed re EASA / Airbus definitions.
The EASA view remains confusing.
However the Airbus position can be better understood if the first document is considered in conjunction with the preceding philosophy and description of training - learning (education) :
Training Pilots for Resilience https://mms-safetyfirst.s3.eu-west-3...resilience.pdf
Learning from the evidence https://mms-safetyfirst.s3.eu-west-3...e-evidence.pdf
“Training is more than ticking boxes". “It is a matter of bringing the pilot and the aircraft work safely and efficiently together” - what it takes to manage any operational situation.
Train for Surprise and improve Resilience potentials
The EASA view remains confusing.
However the Airbus position can be better understood if the first document is considered in conjunction with the preceding philosophy and description of training - learning (education) :
Training Pilots for Resilience https://mms-safetyfirst.s3.eu-west-3...resilience.pdf
Learning from the evidence https://mms-safetyfirst.s3.eu-west-3...e-evidence.pdf
“Training is more than ticking boxes". “It is a matter of bringing the pilot and the aircraft work safely and efficiently together” - what it takes to manage any operational situation.
Train for Surprise and improve Resilience potentials
Thread Starter
Joined: Mar 2006
Posts: 1,115
Likes: 86
From: England
The ref paper was noted in post # 30
From another forum see the Grok summary and suggested document; are there any operators who have this type of guidance?
Is the suggestion appropriate, something which the industry requires - in conjunction with the training suggestions (note previous post #59)
https://grok.com/share/c2hhcmQtMw_57...e-d1c3f17016a0
'Continue with web' option
Ref: "How is anticipation, as part of system resilience, operationalised on the flight deck, and to what extent does the regulation facilitate it?" https://lup.lub.lu.se/luur/download?...ileOId=9140014
From another forum see the Grok summary and suggested document; are there any operators who have this type of guidance?
Is the suggestion appropriate, something which the industry requires - in conjunction with the training suggestions (note previous post #59)
https://grok.com/share/c2hhcmQtMw_57...e-d1c3f17016a0
'Continue with web' option
Ref: "How is anticipation, as part of system resilience, operationalised on the flight deck, and to what extent does the regulation facilitate it?" https://lup.lub.lu.se/luur/download?...ileOId=9140014