Resilience-in-Action: Proactive Safety in a Changing World
DAVID WOODS, Professor,
Integrated Systems Engineering Division,
The Ohio State University
BIG ROOM SESSION
Room: Sagamore 3-4-5
Wednesday, April 26, 2017, 1:30 PM-3:15 PM
Failure is due to brittle systems, not human error. Systems operate successfully due to sources of resilience, usually hidden or underappreciated. Explaining accidents as due to an error by a person hides the operation of the systemic factors that create brittleness and undermine resilience. Breakdowns in learning lead organizations to miss signals that operations are becoming more brittle as relentless production pressure erodes the capabilities that provide resilience in the face of surprises. Learning about resilience-in-action highlights how people in various roles anticipate bottlenecks ahead, act to fill gaps, and are able to stretch system performance in the face of smaller and larger surprises. These resilient capabilities create safety in high-performance/risk-critical settings. Analyses of dramatic failures of complex systems, such as the Columbia space shuttle accident, highlight this pattern and the need for proactive safety. Findings gathered from many settings and organizations, including firefighting and disaster response, show us how to build proactive safety management and sustain the capability to put resilience-in-action in an uncertain and changing world.