SafetyInsights.org

Due to multiple requests – I’ve compiled several papers discussing various aspects of S-II, Resilience Engineering (RE), HOP, HRO and similar.

I plan for this to be a live list – so check back occasionally.

Let me know if I’ve missed any bangers.

Note:

• This isn’t a systematic list – I’ve focused more on applied/operational papers that may interest practitioners
• There’s >200 studies in this area, particularly from Resilience Engineering; I’ve provided some systematic review papers if you’re interested in the state of the art (they’re good for understanding what has been researched, and for chasing citations)
• These aren’t assessed or provided based on quality (e.g. I’m not saying this is good evidence, or the best examples – it’s just some examples)
• I’ve tried to provide a direct link to the full paper where possible (e.g. ResearchGate), but some are behind paywalls. You can try to source the paper via swashbuckling piratey ways, or directly contact the author (ResearchGate is good for that); you can also read my summary on this site (use the search engine).

Shout me a coffee

Don’t forget to check out these two sites for a larger number of articles:

Papers

Publications

Systematic Reviews / State of the Art

Safety-II and Resilience Engineering in a Nutshell: An Introductory Guide to Their Concepts and Methods

Interventions and measurements of highly reliable/resilient organization implementations: A literature review

Conceptualising learning from resilient performance: A scoping literature review

Resilience Engineering: current status of the research and future challenges

A systematic literature review of resilience engineering: Research areas and a research agenda proposal

Applications of resilience engineering principles in different fields with a focus on industrial systems: A literature review

Resilience engineering: an integrative review of fundamental concepts and directions for future research in safety management

The integration of lean and resilience paradigms: A systematic review identifying current and future research directions

 A risk science perspective on the discussion concerning Safety I, Safety II and Safety III

Perspectives of the new safety

Operational

Effects of human performance improvement and operational learning on organizational safety culture and occupational safety and health management performance

The Implementation of Safety-II: Learning from Normal Work in Practice

Learning from organizational incidents: Resilience engineering for high‐risk process environments

Human performance contributions to safety in commercial aviation

How is Safety–II Being Applied in Practice and is it Working?

FOCUS ON SUCCESS: A SAFETY–II APPROACH ON OPERATIONAL MANEUVERS IN THE ITAIPU BINACIONAL HYDROPOWER PLANT

Perceptions on Workplace Safety–Traditional or New View Paradigm

Safety differently: A case study in an Aviation Maintenance-Repair-Overhaul facility

Application of Safety-II in nuclear power operations: A study on how Safety-II can complement the safety of sub-shutdown (Swedish)

Background, theoretical / discussion

A practitioner’s experiences operationalizing Resilience Engineering

Integrating the best of BBS & HOP

Applying HRO and resilience engineering to construction: Barriers and opportunities

Safety-II Approach in the O&G Industry: Human Factors and Non-Technical Skills Building Safety

HUMAN FACTORS IN DEEPWATER DRILLING: A New Approach to Safety and Operational Excellence

Resilience is not a silver bullet–Harnessing resilience as core values and resource contexts in a double adaptive process

Taking a new view for researching occupational safety in construction: site safety practice

Assessing the Sharp End: Reflections on Pilot Performance Assessment in the Light of Safety Differently

From Safety-I to Safety-II: a white paper

A Qualitative Journey to Seeing Safety Differently

Sending up a FLARE: enhancing resilience in industrial maintenance through the timely mobilization of remote experts

Key elements to avoid drifting out of the safety space

Framework or similar

Human Performance Learning and Improvement: A Research Agenda

A Framework to Operationalize Human Performance Learning and Improvement

A Framework to Strengthen Learning Culture and Safeguards

Framework for measuring resilience of safety management systems in Australian building repair and maintenance companies

Towards a Conceptual Framework for Resilience Engineering

Resilience engineering to assess risks for the air traffic management system: A new systemic method

DISC model as a conceptual tool for engineering organisational resilience: Two case studies in nuclear and healthcare domains

A resilience markers framework for small teams

WAI / WAD or Daily Work, Normal Work, Variability

Exploring everyday work as a dynamic non‑event and adaptations to manage safety in intraoperative anaesthesia care: an interview study

Balancing Safety I and Safety II: Learning to manage performance variability at sea using simulator-based training

Is Performance Variability Necessary? A Qualitative Study on Cognitive Resilience in Forestry Work

Resilience in the blood transfusion process: Everyday and long-term adaptations to ‘normal’ work

Mind the gap: Examining work-as-imagined and work-as-done when dispensing medication in the community pharmacy setting

Navigating operating procedures in everyday work in a petrochemical facility: A comparative analysis of WAI and WAD

Where Two Ends Meet: Operator and Stakeholder Perceptions of Procedures

Investigating a new classification to describe the differences between Work-As-Imagined and Work-As-Done

The realities of procedure deviance: A qualitative examination of divergent work-as-done and work-as-imagined perspectives

Analyzing work-as-imagined and work-as-done of incident management teams using interaction episode analysis

A method to identify investigative blind spots (MIBS): Addressing blunt-end factors of ultra-safe organizations’ investigation-work-as-done

How to improve inter-organizational learning from safety investigations?

Rules / SWMS / JSA etc

Reducing gaps between paper and practice requires more than a technical alignment

Exploring Safe Work Method Statements in the Australian Construction Industry: a Prospective Study in Resilience Engineering

Resilience Engineering, Gaps and Prescription of Safe Work Method Statements Part 1: The View of Organisational Outsiders

Investigating Resilience Engineering Through Safe Work Method Statements in Residential Construction

Working to rule, or working safely part 1

Working to rule, or working safely – part 2

Exploring goal conflicts and how they are managed in a biomedical laboratory using Rasmussen’s model of boundaries

Learning / investigations

Evaluation of Learning Teams Versus Root Cause Analysis for Incident Investigation in a Large United Kingdom National Health Service Hospital

Experience of learning from everyday work in daily safety huddles—a multi-method study

Debrief it all: a tool for inclusion of Safety–II

Implementing New Practices: An Empirical Study of Organizational Learning in Hospital Intensive Care Units

Understanding how work as done of incident investigators supports a safety-II approach

Using Safety-II and resilient healthcare principles to learn from Never Events

A Bottom-Up Approach to Understanding the Efficacy of Event-Analysis in Healthcare: Paradigm Shift from Safety to Resilience Engineering

Qualitative findings from a pilot stage implementation of a novel organizational learning tool toward operationalizing the Safety–II paradigm in health care

Effects of a systems approach in occurrence investigations

Could System-Focused Incident Review in Healthcare Bridge The Gap Between The “Work-As-Imagined” and The “Work-As-Done”?

A case study on how the approach to human error guides the incident reporting among nurses in a hospital setting

“Old” and “new” safety thinking: Perspectives of aviation safety investigators

Tracing New Safety Thinking Practices in Safety Investigation Reports

Improving culture of care through maximising learning from observations and events: Addressing what is at fault

Blame

Mitigating work conditions that can inhibit learning from errors: Benefits of error management climate perceptions

Taking the Hit: Focusing on Caregiver “Error” Masks Organizational-Level Risk Factors for Nursing Aide Assaults

A review of literature: individual blame vs. organizational function logics in accident analysis

Blame Conformity: Leading Eyewitness Statements can Influence Attributions of Blame for an Accident

Agentive Language in Accident Investigation: Why Language Matters in Learning from Events

A Construction Industries View on Accountability in a No-Blame Culture

Critical & Commentaries

The Emperor has no clothes: A critique of Safety–II

Safety III: A systems approach to safety and resilience

The unintended consequences of no blame ideology for incident investigation in the US construction industry

Are the new safety paradigms (only) about safety and sufficient to ensure it? An overview and critical commentary

Brave New World: Can Positive Developments in Safety Science and Practice also have Negative Sides?

Workarounds

TBA

Healthcare / Resilient Healthcare

What kinds of insights do Safety-I and Safety-II approaches provide? A critical reflection on the use of SHERPA and FRAM in healthcare

Understanding Complex Work Using the Resilience Mechanisms Framework: An Ethnographic Study

Resilience and resilience engineering in health care

Resilient health care: a systematic review of conceptualisations, study methods and factors that develop resilience

A paradigm shift to enhance patient safety in healthcare, a resilience engineering approach: Scoping review of available evidence

Implementing resilience engineering for healthcare quality improvement using the CARE model: a feasibility study protocol

Understanding procedural violations using Safety-I and Safety–II: The case of community pharmacies

Second victims / Restorative Justice / Just Culture

Restorative just culture significantly improves stakeholder inclusion, second victim experiences and quality of recommendations in incident responses

Restorative justice / JC checklist from Sidney Dekker

‘Just culture:’ Improving safety by achieving substantive, procedural and restorative justice

From individual behaviour to system weaknesses: The re-design of the Just Culture process in an international energy company. A case study

The Barriers and Enhancers to Trust in a Just Culture in Hospital Settings: A Systematic Review

Requirements for implementing a ‘just culture’ within healthcare organisations: an integrative review

Just culture’s ‘‘line in the sand” is a shifting one; an empirical investigation of culpability determination

Restorative just culture significantly improves stakeholder inclusion, second victim experiences and quality of recommendations in incident responses

Restorative Just Culture: a Study of the Practical and Economic Effects of Implementing Restorative Justice in an NHS Trust

KPIs, performance indicators, measurement systems

A resilience engineering-based framework for assessing safety performance measurement systems: A study in the construction industry

Resilience engineering indicators and safety management: A systematic review

Challenges and potential to improve airline safety and demonstrate resilience through monitoring

Leading indicators applied to maintenance in the framework of resilience engineering: A conceptual approach

Development of early warning indicators based on resilience engineering

HRO

Voices from the Field: Wildland Fire Managers and High-Reliability Organizing Mindfulness

Different approaches to learning from errors: Comparing the effectiveness of high reliability and error management approaches

Scoping review of peer-reviewed empirical studies on implementing high reliability organisation theory

Resilience Skills & training

Improving resilience in high-risk organizations: principles for the design of innovative training situations

Resilience skills as emergent phenomena: A study of emergency departments in Brazil and the United States

EXPLORING SYNERGIES BETWEEN THE DESIGN OF PROCEDURES AND THE DEVELOPMENT OF RESILIENCE SKILLS

Safety-II: Building safety capacity and aeronautical decision-making skills to commit better mistakes

Developing Resilience, Foresight & Intuition During Clinical Handovers

Resilience management system and development of resilience capability on site workers

Resilience and the Training of Nuclear Operators–A View from the Shop Floor

Translating resilience: a framework to enhance communication and implementation

The design of scenario-based training from the resilience engineering perspective: A study with grid electricians

Training organisational resilience in escalating situations

Resilience, FRAM and Networks

Exploring associations between resilience and construction safety performance in safety networks

A new systems approach to safety management with applications to Arctic ship navigation

Free fall-a case study of resilience, its degradation, and recovery, in an emergency department

Improving performance reliability in surgical systems

Theoretical discussion

Incorporating Safety-II in future gas systems

Road-safety-II: Opportunities and barriers for an enhanced road safety vision

Safety differently: a new view of safety excellence

Applying the new view of safety in a biomedical laboratory

Reconstructing human contributions to accidents: the new view on error and performance

A Trade Union Perspective on “The New View” of Health and Safety

Six stages to the new view of human error

Learning from Normal Work: How to Proactively Reduce Risk When Nothing Goes Wrong

Searching for the origins of the myth: 80% human error impact on maritime safety

State of science: Evolving perspectives on ‘human error‘

Pilot error versus sociotechnical systems failure: a distributed situation awareness analysis of Air France 447

Simulations etc.

A novel approach to explore Safety-I and Safety–II perspectives in in situ simulations—the structured what if functional resonance analysis methodology

Engagement

Safety through engaged workers: The link between Safety-II and work engagement

Safety-I / Safety -II comparisons, integrations, SMS, trade-offs

Cognitive gap and correlation of safety-I and safety-II: A case of maritime shipping safety management

Integrating Safety-I and Safety-II: Learning from failure and success in construction sites

Safety–I and safety–II: opportunities for an integrated approach in the construction industry

Building a safer future: Analysis of studies on safety I and safety II in the construction industry

Integrating safety–I and safety–II approaches in near miss management: A critical analysis

A method for assessing health and safety management systems from the resilience engineering perspective

Resilience engineering and safety management systems in aviation

Burnout and network centrality as proxies for assessing the human cost of resilient performance

From Safety-I (a focus on errors) to Safety-II (a focus on successes)?

Competence Assessment of Air Traffic Controllers: A transition from Safety-I to Safety-II

Trade-Offs Under Pressure: Heuristics and Observations Of Teams Resolving Internet Service Outages

The Adaptable and Resilient Safety System: The Human Factor in Future In-Time Aviation Safety Management Systems

Unpacking Safety–II in action: weak signals of potential error in patient handling tasks

Goal conflicts in helicopter safety: dilemmas across maintenance, pilots, and management

A framework for identifying and analyzing sources of resilience and brittleness: a case study of two air taxi carriers

ARE TRADE-OFFS EXPERIENCED AND IF YES, HOW? STUDYING ORGANIZATIONAL RESILIENCE THROUGH OPERATORS’DILEMMAS

Debriefs, walkarounds etc.

A Meta-Analysis of the Effectiveness of the After-Action Review (or Debrief) and Factors That Influence Its Effectiveness

Impact of leadership walkarounds on operational, cultural and clinical outcomes: a systematic review

Safety management by walking around (SMBWA): A safety intervention program based on both peer and manager participation

‘I think we should just listen and get out’: a qualitative exploration of views and experiences of Patient Safety Walkrounds

Clutter, false safety, rituals, symbolism

Safety clutter: the accumulation and persistence of ‘safety’work that does not contribute to operational safety

How audits fail according to accident investigations: A counterfactual logic analysis

Audit masquerade: How audits provide comfort rather than treatment for serious safety problems

The ritualisation of the surgical safety checklist and its decoupling from patient safety goals

Should We Cut the Cards? Assessing the Influence of “Take 5” Pre-Task Risk Assessments on Safety

Hazard reporting: How can it improve safety?

An ethnography of the safety professional’s dilemma: Safety work or the safety of work?

How reliance on resilient performance ‘hides’ or even contributes to system brittleness

To report or not to report: What happens when middle managers receive bad news about safety issues?

Why Formal Stop Work Schemes Do Not Work

Practitioners

The safety advisor in 2036: what skills and knowledge will be needed to cope with the complex adaptative world of Industry 4.0

Safety II professionals: How resilience engineering can transform safety practice

A qualitative survey of factors shaping the role of a safety professional

Naturalistic Decision Making / RPD / Heuristics and similar

Macrocognition: from theory to toolbox

 Simple heuristics that make us smart

Simple heuristics could make us smart; but which heuristics do we apply when?

Training fast and frugal heuristics in military decision making

Decision errors and accidents: Applying naturalistic decision making to accident investigations

A naturalistic decision making perspective on studying intuitive decision making

Taking stock of naturalistic decision making

Applications for naturalistic decision–making.

Thinking inside the box: The ShadowBox method for cognitive skill development

Using the ShadowBox™ method to detect the ‘investigator’and ‘proceduralist’mindsets in frontline social workers

Naturalistic decision making: navigating uncertainty in complex sociotechnical work

The ShadowBox approach to cognitive skills training: An empirical evaluation

ShadowBox™: Flexible training to impart the expert mindset

Cognitive Skills Training for Frontline Social Workers: A Pilot Study

The application of naturalistic decision–making techniques to explore cue use in rugby league playmakers