Incremental Safety Practices

Erik Hollnagel is Scientific Director at the Institute of Resilient Systems Plus, Seoul, South Korea, Honorary Professor, Faculty of Medicine and Health Sciences at Macquarie University, Sydney Australia, Visiting Fellow of the Institute for Advanced Study of the Technische Universität München, Germany, and Professor Emeritus from universities in Sweden, France, and Denmark. His work focuses on unified system change and management. He is the author of more than 500 publications including articles from recognized journals, conference papers, and reports as well as 31 books, and is still struggling to make sense of the blooming, buzzing confusion.David Slater is a director of the engineering consultancy Cambrensis Ltd and an Honorary Professor in the School of Engineering, Cardiff University, UK. His current research interests centre on trying to understand how complex sociotechnical systems behave in practice; having developed predictive system behaviour models for risk analysis and regulatory purposes in theory (Imperial College) and in practice (HMIP, Environment Agency and DG Environment (EC)). These models were applied to real-life incidents, from Flixborough to Grenfell Tower and COVID-19, and the development of these methodologies to include the human factor is his current focus. David is currently working with Cardiff University Hospital and the Manchester Children’s Hospital on systems to improve safety and resilience in healthcare.

• Einleitung: notwendig Kurswechsel (or Introduction: a necessary change of course) 1. Prologue: Background and Scope Part I: Aviation 2. Learning from Normal Work: How Personal Flight Data Enables Incremental Safety in Commercial Aviation 3. Adaptive Safety Learning – Resilience and the Presence of Incremental Safety Part II: Healthcare 4. Seven steps that make it easier for work to go well 5. Improving systems of care using Resilient Health Care principles: Facilitating family-initiated escalation of concerns in paediatric emergency care 6. Introduction of functional resonance analytical methodology (FRAM) into a large NHS healthcare institution 7. Advancing Healthcare Safety in the Netherlands through Incremental Learning Approaches 8. Enabling success in dynamic environments: incremental safety practices in the emergency CT pathway 9. Reinforcement learning in simulation-based team training in healthcare Part III: Retail 10. Micro-experimenting for incremental safety 11. Incremental safety practices in large-scale logistics Part IV: Other domains 12. Doing Difficult Work Well 13. Integration of Safety-I and Safety-II Perspectives in Mining 14. Incremental Safety Approach in an Italian Railway Company: Bridging Training and Consultancy Part V: Editorial 15. Summary of Methods 16. Summary of Actions 17. Summary of Evidence: Incremental Safety Practices in Complex Systems – A Cross-Case Comparative Analysis 18. Epilogue: Incremental versus decremental safety

"Safety involves more than just incident prevention. With Incremental Safety Practices, we have an opportunity to take safety to new levels helping organizations achieve operational excellence reducing harm and loss to the lowest extent possible. With Incremental Safety everyone succeeds." Tom McDaniel,St. Petersburg, Florida-based safety, resilience, and human performance specialist with extensive international industrial experience, former Siemens human performance leadership roles, and current consulting work through McDaniel Scientific Group"In complex systems, safety improves not through sweeping transformations but through deliberate learning about how work is actually carried out. Armed with this understanding we can then make meaningful and sustainable improvements to work. Incremental Safety Practices brings together a thoughtful and practical set of real-world examples that shows how organisations strengthen safety and work performance through continuous adaptation." David Provan, Chief Executive Officer, Forge Works"Safety in complex systems is rarely transformed in one leap; it is built through countless adjustments in everyday work. Incremental Safety Practices shows, across sectors, how organisations can strengthen safety and performance through practical, cumulative change. This is an important and timely contribution, and destined to become a treasured resource." Jeffrey Braithwaite, PhD, FIML, FCHSM, FFPHRCP, FAcSS, Hon FRACMA, FAHMS, Professor of Health Systems Research, Faculty of Medicine, Health and Human Sciences, Founding Director, Australian Institute of Health Innovation, Director, Centre for Healthcare Resilience and Implementation Science and Chair, International Academy of Quality and Safety"If you are waiting around for something to fail in order to learn, you are a day late and a dollar short. Erik Hollnagel, in his book Incremental Safety Practices discusses the power of learning from everyday work in a deep and important way. Learning is an organizational response - learning is a corrective action - learning happens as a deliberate organizational strategy. Our organization’s depend on out ability to help guide them to becoming better leaders. This book takes you and your organization on an insightful journey in order to demonstrate how organizations can develop safer and resilient systems, one learning at a time, using Hollnagel’s wisdom and wit to create learning based upon everyday work." Todd Conklin, Human Performance and Organizational Safety expert, Senior Advisor for Organizational and Safety Culture, Los Alamos National Laboratory, author of Pre-Accident Investigations: An Introduction to Organizational Safety