The ETTO Principle: Efficiency-Thoroughness Trade-Off

The ETTO Principle: Efficiency-Thoroughness Trade-Off PDF

Author: Professor Erik Hollnagel

Publisher: Ashgate Publishing, Ltd.

Published: 2012-10-01

Total Pages: 166

ISBN-13: 1409485994

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Accident investigation and risk assessment have for decades focused on the human factor, particularly ‘human error’. This bias towards performance failures leads to a neglect of normal performance. It assumes that failures and successes have different origins so there is little to be gained from studying them together. Erik Hollnagel believes this assumption is false and that safety cannot be attained only by eliminating risks and failures. The alternative is to understand why things go right and to amplify that. The ETTO Principle looks at the common trait of people at work to adjust what they do to match the conditions. It proposes that this efficiency-thoroughness trade-off (ETTO) is normal. While in some cases the adjustments may lead to adverse outcomes, these are due to the same processes that produce successes.

The ETTO Principle

The ETTO Principle PDF

Author: Erik Hollnagel

Publisher: Ashgate Publishing, Ltd.

Published: 2009

Total Pages: 166

ISBN-13: 9780754676775

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Accident investigation and risk assessment have for decades focused on the human factor, particularly 'human error'. This bias towards performance failures leads to a neglect of normal performance. It assumes that failures and successes have different origins so there is little to be gained from studying them together. Erik Hollnagel believes this assumption is false and that safety cannot be attained only by eliminating risks and failures. The alternative is to understand why things go right and to amplify that.The ETTO Principle looks at the common trait of people at work to adjust what they do to match the conditions. It proposes that this efficiency-thoroughness trade-off (ETTO) is normal. While in some cases the adjustments may lead to adverse outcomes, these are due to the same processes that produce successes.

The ETTO Principle: Efficiency-Thoroughness Trade-Off

The ETTO Principle: Efficiency-Thoroughness Trade-Off PDF

Author: Erik Hollnagel

Publisher: CRC Press

Published: 2017-11-01

Total Pages: 162

ISBN-13: 1317033612

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Accident investigation and risk assessment have for decades focused on the human factor, particularly 'human error'. Countless books and papers have been written about how to identify, classify, eliminate, prevent and compensate for it. This bias towards the study of performance failures, leads to a neglect of normal or 'error-free' performance and the assumption that as failures and successes have different origins there is little to be gained from studying them together. Erik Hollnagel believes this assumption is false and that safety cannot be attained only by eliminating risks and failures. The ETTO Principle looks at the common trait of people at work to adjust what they do to match the conditions - to what has happened, to what happens, and to what may happen. It proposes that this efficiency-thoroughness trade-off (ETTO) - usually sacrificing thoroughness for efficiency - is normal. While in some cases the adjustments may lead to adverse outcomes, these are due to the very same processes that produce successes, rather than to errors and malfunctions. The ETTO Principle removes the need for specialised theories and models of failure and 'human error' and offers a viable basis for effective and just approaches to both reactive and proactive safety management.

Resilience Engineering

Resilience Engineering PDF

Author: David D. Woods

Publisher: CRC Press

Published: 2017-11-01

Total Pages: 328

ISBN-13: 131706528X

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For Resilience Engineering, 'failure' is the result of the adaptations necessary to cope with the complexity of the real world, rather than a breakdown or malfunction. The performance of individuals and organizations must continually adjust to current conditions and, because resources and time are finite, such adjustments are always approximate. This definitive new book explores this groundbreaking new development in safety and risk management, where 'success' is based on the ability of organizations, groups and individuals to anticipate the changing shape of risk before failures and harm occur. Featuring contributions from many of the worlds leading figures in the fields of human factors and safety, Resilience Engineering provides thought-provoking insights into system safety as an aggregate of its various components, subsystems, software, organizations, human behaviours, and the way in which they interact. The book provides an introduction to Resilience Engineering of systems, covering both the theoretical and practical aspects. It is written for those responsible for system safety on managerial or operational levels alike, including safety managers and engineers (line and maintenance), security experts, risk and safety consultants, human factors professionals and accident investigators.

FRAM, the Functional Resonance Analysis Method

FRAM, the Functional Resonance Analysis Method PDF

Author: Erik Hollnagel

Publisher: Ashgate Publishing, Ltd.

Published: 2012

Total Pages: 161

ISBN-13: 1409445518

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There has not yet been a comprehensive method that goes behind 'human error' and beyond the failure concept, and various complicated accidents have accentuated the need for it. The Functional Resonance Analysis Method (FRAM) fulfils that need. This book presents a detailed and tested method that can be used to model how complex and dynamic socio-technical systems work, and understand both why things sometimes go wrong but also why they normally succeed.

Safety-I and Safety-II

Safety-I and Safety-II PDF

Author: Erik Hollnagel

Publisher: CRC Press

Published: 2018-04-17

Total Pages: 167

ISBN-13: 1317059794

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Safety has traditionally been defined as a condition where the number of adverse outcomes was as low as possible (Safety-I). From a Safety-I perspective, the purpose of safety management is to make sure that the number of accidents and incidents is kept as low as possible, or as low as is reasonably practicable. This means that safety management must start from the manifestations of the absence of safety and that - paradoxically - safety is measured by counting the number of cases where it fails rather than by the number of cases where it succeeds. This unavoidably leads to a reactive approach based on responding to what goes wrong or what is identified as a risk - as something that could go wrong. Focusing on what goes right, rather than on what goes wrong, changes the definition of safety from ’avoiding that something goes wrong’ to ’ensuring that everything goes right’. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. From a Safety-II perspective, the purpose of safety management is to ensure that as much as possible goes right, in the sense that everyday work achieves its objectives. This means that safety is managed by what it achieves (successes, things that go right), and that likewise it is measured by counting the number of cases where things go right. In order to do this, safety management cannot only be reactive, it must also be proactive. But it must be proactive with regard to how actions succeed, to everyday acceptable performance, rather than with regard to how they can fail, as traditional risk analysis does. This book analyses and explains the principles behind both approaches and uses this to consider the past and future of safety management practices. The analysis makes use of common examples and cases from domains such as aviation, nuclear power production, process management and health care. The final chapters explain the theoret

Resilient Health Care

Resilient Health Care PDF

Author: Erik Hollnagel

Publisher: CRC Press

Published: 2019-07-23

Total Pages: 254

ISBN-13: 1317065166

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Health care is everywhere under tremendous pressure with regard to efficiency, safety, and economic viability - to say nothing of having to meet various political agendas - and has responded by eagerly adopting techniques that have been useful in other industries, such as quality management, lean production, and high reliability. This has on the whole been met with limited success because health care as a non-trivial and multifaceted system differs significantly from most traditional industries. In order to allow health care systems to perform as expected and required, it is necessary to have concepts and methods that are able to cope with this complexity. Resilience engineering provides that capacity because its focus is on a system’s overall ability to sustain required operations under both expected and unexpected conditions rather than on individual features or qualities. Resilience engineering’s unique approach emphasises the usefulness of performance variability, and that successes and failures have the same aetiology. This book contains contributions from acknowledged international experts in health care, organisational studies and patient safety, as well as resilience engineering. Whereas current safety approaches primarily aim to reduce or eliminate the number of things that go wrong, Resilient Health Care aims to increase and improve the number of things that go right. Just as the WHO argues that health is more than the absence of illness, so does Resilient Health Care argue that safety is more than the absence of risk and accidents. This can be achieved by making use of the concrete experiences of resilience engineering, both conceptually (ways of thinking) and practically (ways of acting).

Barriers and Accident Prevention

Barriers and Accident Prevention PDF

Author: Erik Hollnagel

Publisher: Routledge

Published: 2016-12-05

Total Pages: 213

ISBN-13: 1351955934

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Accidents are preventable, but only if they are correctly described and understood. Since the mid-1980s accidents have come to be seen as the consequence of complex interactions rather than simple threads of causes and effects. Yet progress in accident models has not been matched by advances in methods. The author's work in several fields (aviation, power production, traffic safety, healthcare) made it clear that there is a practical need for constructive methods and this book presents the experiences and the state-of-the-art. The focus of the book is on accident prevention rather than accident analysis and unlike other books, has a proactive rather than reactive approach. The emphasis on design rather than analysis is a trend also found in other fields. Features of the book include: -A classification of barrier functions and barrier systems that will enable the reader to appreciate the diversity of barriers and to make informed decisions for system changes. -A perspective on how the understanding of accidents (the accident model) largely determines how the analysis is done and what can be achieved. The book critically assesses three types of accident models (sequential, epidemiological, systemic) and compares their strengths and weaknesses. -A specific accident model that captures the full complexity of systemic accidents. One consequence is that accidents can be prevented through a combination of performance monitoring and barrier functions, rather than through the elimination or encapsulation of causes. -A clearly described methodology for barrier analysis and accident prevention. Written in an accessible style, Barriers and Accident Prevention is designed to provide a stimulating and practical guide for industry professionals familiar with the general ideas of accidents and human error. The book is directed at those involved with accident analysis and system safety, such as managers of safety departments, risk and safety consultants, human factors professionals, and accident investigators. It is applicable to all major application areas such as aviation, ground transportation, maritime, process industries, healthcare and hospitals, communication systems, and service providers.