Can weak-resilience-signals (WRS) reveal obstacles compromising (rail-)system resilience?

Analysis of accidents in socio-technical systems frequently reveals unnoticed obstacles, which have grown to become the main cause of incubation and surprise at failure (Dekker, 2011). Thus far, it has proven to be a challenge to identify those unnoticed obstacles upfront among the tremendous number of events occurring during normal operations. In this article, we describe the usage of weak resilience signals (WRS)(Siegel & Schraagen, 2014), at a rail control post, to reveal obstacles compromising the resilience ..

Can team reflection of rail operators make resilience-related knowledge explicit? - An observational study design

The essential resilience capabilities – monitoring, responding, learning and anticipating - have all in common the need for relevant signals and the ability to transform them into action. However, this transformation is often lacking as seen from accident analyses revealing disturbances that are either not noted or ignored in the process leading up to the undesired result. This paper proposes to focus on signals occurring because of movements from and to system boundaries and use them for team reflection. The reflection is expected to make implicit knowledge explicit, being a first step of the needed transformation to action. An observational study is designed at a rail control post where rail signal operators reflect at the end of their shift. They reflect on the punctuality boundary through an on-line application, called the Resiliencer-punctuality. The application presents delay-development of trains, during a shift, with respect to a previous chosen period. Furthermore it provides search instruments to find specific trains of interest stimulating the reflection. A verbal analysis method is used to analyze the reflection discussion and to show a relation to resilience through learning and anticipating intentions. In addition we seek for repetitive elements in different cases to prove the learning potential. The observation designed should support the hypothesis that team reflection, on movements towards boundaries, increases resilience of the rail socio-technical syste

The role of cognitive abilities in laparoscopic simulator training

Learning minimally invasive surgery (MIS) differs substantially from learning open surgery and trainees differ in their ability to learn MIS. Previous studies mainly focused on the role of visuo-spatial ability (VSA) on the learning curve for MIS. In the current study, the relationship between spatial memory, perceptual speed, and general reasoning ability, in addition to VSA, and performance on a MIS simulator is examined. Fifty-three laparoscopic novices were tested for cognitive aptitude. Laparoscopic performance was assessed with the LapSim simulator (Surgical Science Ltd., Gothenburg, Sweden). Participants trained multiple sessions on the simulator until proficiency was reached. Participants showed significant improvement on the time to complete the task and efficiency of movement. Performance was related to different cognitive abilities, depending on the performance measure and type of cognitive ability. No relationship between cognitive aptitude and duration of training or steepness of the learning curve was found. Cognitive aptitude mediates certain aspects of performance during training on a laparoscopic simulator. Based on the current study, we conclude that cognitive aptitude tests cannot be used for resident selection but are potentially useful for developing individualized training programs. More research will be performed to examine how cognitive aptitude testing can be used to design training programs

Toward quantifying metrics for rail-system resilience: Identification and analysis of performance weak-resilience-signals

This paper aims to enhance tangibility of the resilience engineering concept by facilitating understanding and operationalization of weak-resilience-signals (WRS) in the rail sector. Within complex socio-technical systems, accidents can be seen as unwanted outcomes emerging from uncontrolled sources of entropy (functional resonance). Various theoretical models exist to determine the variability of system interactions, the resilience state, and the organization’s intrinsic abilities to reorganize and manage their functioning and adaptive capacity to cope with unexpected and unforeseen disruptions. However, operationalizing and measuring concrete and reliable manifestations of resilience and assessing their impact at a system level, has proven to be a challenge. A multi-method, ethnographic observation and resilience questionnaire, was used to determine resilience baseline conditions at an operational rail traffic control post. This paper describes the development, implementation and initial validation of WRSs identified and modelled around a ‘performance system boundary’. In addition, a WRS analysis function is introduced to interpret underlying factors of the performance WRSs and serves as a method to reveal potential sources of future resonance that could comprise system resilience. Results indicate that performance WRSs can successfully be implemented to accentuate relative deviations from resilience baseline conditions. A WRS analysis function can help to interpret these divergences, and could be used to reveal (creeping) change processes and unnoticed initiating events that facilitate emergence that degrades rail-system resilience. Establishing relevant change signals in advance can contribute to anticipation and awareness, enhance organizational learning and stimulate resilient courses of action and adaptive behavior that ensures rail operation reliability

Combining situated Cognitive Engineering with a novel testing method in a case study comparing two infusion pump interfaces

We validated the usability of a new infusion pump interface designed with a situated Cognitive Engineering approach by comparing it to a reference interface using a novel testing method employing repeated measurements and process measures, in addition to traditional outcome measures. The sample consisted of 25 nurses who performed eight critical tasks three times. Performance measures consisted of number and type of errors, deviations from a pre-established normative path solution, task completion times, number of keystrokes, mental effort and preferences in use. Results showed that interaction with the new interface resulted in 18% fewer errors, 90% fewer normative path deviations, 42% lower task completion times, 40% fewer keystrokes, 39% lower mental effort and 76% more subjective preferences in use. These outcomes suggest that within the scope of this case study, combining the situated Cognitive Engineering approach with a novel testing method addresses various shortcomings of earlier testing methods

О противодействии недружественным слияниям и поглощениям в сельском хозяйстве

Целью данной работы является определение путей повышения эффективности противодействия рейдерству в аграрной сфере Украины

Teamwork in the operating room arena

Why teamwork in high-risk medical environments Capturing team processes in the wild Two models of teamwork Case study in paediatric cardiac surgery: Social Network Analysis Conclusions and recommendation

Human factors bij de invoering van het EPD

Wat is de rol van vertrouwen in elektronische patientendossiers en hoe kunnen we dat vertrouwen bevordere