Introduction (00:00:00)
Title Slide (00:02:50)
TMI (00:03:18)
Title Slide (00:06:30)
Paradigm shift on safety management (00:08:53)
TMI (00:10:51)
Doing things safely is ongoing, but (00:12:30)
Doing things safely is ongoing, but (2) (00:16:17)
Sharp end and Blunt end (00:18:05)
Transformation and Adaptation (00:18:50)
Patters of Reverberations (00:19:40)
The operator's job is to make up for the holes in designers work (00:20:38)
Law of Fluency (00:22:20)
After the Accident - Hindsight Bias (00:23:12)
Emergence: Reactive to Proactive (00:24:37)
Breakdowns in Adaptations Directed at Coping with Complexity (00:25:51)
Images of Resilience, of Brittleness (00:26:53)
Images of Resilience, of Brittleness (2) (00:29:09)
Automation Surprises, Anomaly Response (00:30:59)
Patterns Across Cases (00:33:50)
5 Generic Patterns in Columbia (00:34:15)
Essentials of Resilience (00:36:14)
Essentials 2 (00:37:35)
Original marginal Boundary (00:37:57)
Photo #3 (00:38:25)
How to be Prepared to be Surprised? (00:40:34)
Potential for surprise (00:44:32)
All joint systems are adapted to the potential for surprise… (00:46:22)
Re-framing & Broadening Checks (00:47:03)
Resilience (00:47:30)
Components of resilience (00:47:55)
cross-scale interactions (00:48:09)
Conflict, Conflict, Conflict Picture (00:48:46)
Silver bullets or goal tradeoffs? (00:50:43)
Balancing Production/Safety (00:52:45)
Videos (00:57:40)
Dilemmas of Safety Organizations (01:01:56)
The 4 I's of Safety Organizations (01:07:30)
Incidents: stories of resilience or brittleness? (01:14:08)
Fundamental Gap (01:15:36)
Engineering Resilience (01:15:57)
Presentation of Tile (01:25:40)
