The ETTO Principle · Efficiency-Thoroughness Trade-Off by Hollnagel, Erik -- Read -- Imperial Library of Trantor

Index

Cover Page Title Page Copyright page Contents List of Figures List of Tables Prologue About the Style of this Book Sources for Prologue Chapter 1: The Need to Understand Why Things Go Wrong

Safety Requires Knowledge A Need for Certainty Explaining Something that is Out of the Ordinary The Stop Rule A Need for Simple Explanations The ETTO Principle The ETTO Principle in Practice

Changing Views

A Note on Terminology Sources for Chapter 1

Chapter 2: From Rationality to ETTOing

The Rational Human Time to Think, and Time to Do

ETTO Redefined

Feed the Birds The Value of Planning Information Pull and Information Push Descriptive Decision Rules Judgement Heuristics Work Related ETTO Rules Individual (Psychological) ETTO Rules Collective (Organisational) ETTO Rules Sources for Chapter 2

Chapter 3: Explaining Human Irrationality

Satisficing

Satisficing versus Sacrificing

Muddling Through Recognition Primed Decision-Making The Use of Schemata Speed–Accuracy Trade-Off Time–Reliability Correlation Information Input Overload ETTO as a Principle of Rationality Tractable and Intractable Systems Sources for Chapter 3

Chapter 4: Efficiency-Thoroughness Trade-Off in Practice

The Choice of Efficiency Ice Problems at Gardemoen The Leaking Barrel London Bombings Full Protection not Feasible The Challenges of Publishing Aeronautical Data Incorrect Chemotherapy Treatment A Reverse Fuel Situation The Loss of M/V Estonia Avoiding Collision at Sea Mission to Mars Concluding Remarks Sources for Chapter 4

Chapter 5: The Usefulness of Performance Variability

Underspecified Systems The Need of Performance Variability Sources and Types of Performance Variability Approximate Adjustments Failures without Malfunctions

About ‘Human Error Mechanisms’

Performance Variability and Risk The Dark Matter Sources for Chapter 5

Chapter 6: ETTOs of the Past

Accident Philosophies and the ETTO Principle The Root Cause Resultant and Emergent Effects Limitations of Causal Analyses ETTO and Learning from Experience Looking for ETTOs in Practice Collaborative ETTO What Really Happened? Small and Large Causes Sources for Chapter 6

Chapter 7: ETTOs of the Future

The Framing of the Future Understanding the Risks of the Future

ETTO Rules as Situational Response ETTO at the Sharp End and at the Blunt End The Nature of Emergent Outcomes The Small World Problem

Risk Assessment as Efficiency-Thoroughness Trade-Off

HRA as ETTO Clinical Trials of New Drugs Quantification as ETTO

Concluding Comments Sources for Chapter 7

Epilogue

Single-Loop and Double-Loop Learning From ETTO to TETO Sources for Epilogue

Subject Index