1. Let’s not forget
The Sharp End
when improving Resilience
Anders Ellerstrand

2. Anders Ellerstrand
Sweden
Air Traffic Control
DCOP member

3. The Resilience Abilities:
A - The ability to anticipate
L - The ability to learn and evolve
M - The ability to monitor
R - The ability to respond and adapt

4. DRMG:
• “The DRMGs are intended for
/directly addressed to policy
makers, decision makers and
managers at different levels in
an organization. They can only
indirectly affect the activities of
front line operators or first
responders in crisis
management.”

5. DRMG:
• “The DRMGs are not directly
addressed to front line
operators or first responders in
crisis management (although
their activities will be indirectly
impacted by the DRMGs, if
their practices and procedures
have been revised or designed
based on the DRMGs).”

6. You can divide an
operational system -
into a sharp end and a
blunt end…

7. The Blunt End:
Control and support
Low Risk and High Power

8. The Sharp End:
First responders
High Risk and Low Power

9. M - The ability to monitor
• “Knowing what to look for or being able to monitor
that which is or could seriously affect the system’s
performance in the near term – positively or
negatively. The monitoring must cover the system’s
own performance as well as what happens in the
environment.”
• “One type of indicators are called ‘leading’
indicators, because they can be used as valid
precursors for changes and events that are about to
happen. ‘Leading’ indicators are generally seen as
very attractive (Hopkins, 2009). The main difficulty
with ‘leading’ indicators is that the interpretation
requires an articulated description, or model, of
how the system functions.”
Reference: Hollnagel, E. (2015) Introduction to the Resilience Analysis Grid (RAG)

10. Work-as-Imagined (WAI)/ Work as Prescribed (WAP)

11. Work-as-Done (WAD)

12. WAI – WAD
The knowledge is at the sharp end…

13. M - The ability to monitor

14. L - The ability to learn and evolve
• “Knowing what has happened, or being able to
learn from experience, in particular to learn the
right lessons from the right experience.”
• “Counting how often something happens is not
learning. Knowing how many accidents have
occurred, for instance, says nothing about why they
have occurred, nor anything about the many
situations when accidents did not occur. And
without knowing why something happens, as well
as knowing why it does not happen, it is impossible
to propose effective ways to improve safety.”
Reference: Hollnagel, E. (2015) Introduction to the Resilience Analysis Grid (RAG)

15. Reference: Hollnagel, E., Wears, R.L. and Braithwaite, J. (2015) From Safety-I to Safety-II: A White Paper. The Resilient Health Care Net:
Published simultaneously by the University of Southern Denmark, University of Florida, USA, and Macquarie University, Australia.

16. Drifting…
On April 14, 1994, two U.S. Air Force F-15 fighters
accidentally shot down two U.S. Army Black
Hawk Helicopters over Northern Iraq, killing all
twenty-six peacekeepers onboard. In response to
this disaster the complete array of military and
civilian investigative and judicial procedures ran
their course.
After almost two years of investigation with
virtually unlimited resources, no culprit emerged,
no bad guy showed himself, no smoking gun was
found. This book attempts to make sense of this
tragedy--a tragedy that on its surface makes no
sense at all.

18. General conditions:
• ”…the tendency to overdesign, and a
bias to overcontrol…”
• ”A long enough period to loosely
coupled time sufficient to generate
substantial gaps between globally
synchronized rules and local subgroup
practice…”
• ”A reasonable chance that isolated
subgroups would become tightly
coupled at some point in the future.”
Reference: Snook, S. A. (2000) Friendly Fire. Princeton University Press

19. L - The ability to learn and evolve

20. A - The ability to anticipate
• “Knowing what to expect or being able to
anticipate developments further into the future,
such as potential disruptions, novel demands or
constraints, new opportunities, or changing
operating conditions.”
• “Many present day systems where industrial safety
is a concern are … underspecified. For such systems
the principles of functioning are only partly known,
descriptions contain (too) many details and take a
long time to make, and the systems keep changing
so that descriptions must be frequently updated.”
Reference: Hollnagel, E. (2015) Introduction to the Resilience Analysis Grid (RAG)

21. Competence – Lagging or Leading?
• Erik Hollnagel; Eurocontrol Hindsight magazine No 27:
• “Indeed, an almost universal response to failures and
accidents is to analyse them in order to identify the
competence that would have prevented them.”
• “Although some part of competence must be lagging, it
would clearly be interesting and useful if competence also
could be leading.”
• “A complementary and more constructive approach is to
consider what is needed for a system to function as
required in expected and unexpected conditions alike – or
in other words to perform in a resilient manner.”
• “The requisite competence could, for instance, be derived
from the set of cognitive and interpersonal skills that are
the focus of CRM – such as communication, decision
making, and leadership.”

22. CRM / Non-technical skills
1. Cooperation: Cooperation is the ability to work effectively in a crew.
2. Leadership and managerial skills: Effective leadership and managerial
skills help to achieve joint task completion within a motivated, fully
functioning team through coordination and persuasiveness.
3. Situation awareness: Situation awareness relates to one’s ability to
accurately perceive what is in the flight crew compartment and outside
the aircraft. It is also one’s ability to comprehend the meaning of
different elements in the environment and the projection of their status
in the near future.
4. Decision-making: Decision-making is the process of reaching a
judgement or choosing an option.
Reference: European Aviation Safety Agency; Acceptable Means of Compliance (AMC) and Guidance Material (GM) to Annex III – Part-ORO

23. Threat and Error Management
There are basically three categories of individual and team
countermeasures:
• Planning countermeasures: essential for managing anticipated and
unexpected threats;
• Execution countermeasures: essential for error detection and error
response;
• Review countermeasures: essential for managing the changing
conditions of a flight.
Reference: Maurino, D. (2005) Threat and error management (TEM). Vancouver: Canadian Aviation Safety Seminar (CASS)

24. Threat and Error Management
There are basically three categories of individual and team
countermeasures:
• Planning countermeasures: essential for managing
anticipated and unexpected threats;
• Briefings, plans, workload assignment, contingency
• Execution countermeasures: essential for error detection and error
response;
• Review countermeasures: essential for managing the changing
conditions of a flight.
Reference: Maurino, D. (2005) Threat and error management (TEM). Vancouver: Canadian Aviation Safety Seminar (CASS)

25. A - The ability to anticipate

26. R - The ability to respond and adapt
• “Knowing what to do or being able to respond to
regular and irregular changes, disturbances, and
opportunities by activating prepared actions or by
adjusting current mode of functioning.”
• “In order to respond, the system must therefore
first detect that something has happened, then
recognise what it is and determine whether a
response is necessary, and finally know how to
respond, when to begin, and when to stop.”
Reference: Hollnagel, E. (2015) Introduction to the Resilience Analysis Grid (RAG)

27. DRMG 3.2. Establishing conditions for adapting plans and procedures
during crises and other events that challenge normal plans and procedures.

28. DRMG 3.2. ”Often, crises challenge the plans and procedures in place. As a result, organisations need to
support and maintain a clear and legitimate space of manoeuvre relative to normative plans and procedures.”

29. DRMG 3.2. ”Such space is important for actors engaged in crisis
response in order to adapt to unusual (unanticipated) circumstances.”

30. R - The ability to respond and adapt

31. The Darwin Resilience
Management Guidelines
(DRMG) are not directly
addressed to front line operators
or first responders in crisis
management…
…but let’s not forget the sharp end…

32. Thanks –
any
questions?