Resilience Engineering IV and the Fray Bentos Pie (Newport to Nice Part II)

I’m currently sitting on a my hotel bed after dinner on the second day of the fourth Resilience Engineering Symposium at Sophia Antipolis, near Nice, France. I presented my paper this morning titled, “Unwritten rules for safety and performance in an Oncology Day Care Unit: Testing the Resilience Markers Framework” and I’ve been really happy with the feedback on RMF, our insights and the presentation.

I opened the presentation with reference to #errordiary to emphasise the point that human errors are normal and everyday occurrences. David Woods later remarked that James Reason handed out diaries for people to record their errors many years ago and these days we can just invite them to Twitter. My next point was to say that although we make these errors people use resilience strategies to help reduce the potential for error, e.g. we leave things by the front door so we don’t forget them when we leave home, when I adjust my tyre pressures at the petrol station I hold the dust caps from my tyres in my hand and replace them immediately so I don’t forget them, and I used the Fray Bentos pie example:

“It was a normal Saturday night, when I was an undergraduate student, and my girlfriend and myself experienced what arguably could be called an unexampled event. A Fray Bentos pie was on the menu. These are pies that come in a tin, you open the top and put it in the oven, the puff pastry rises to leave a delicious and nutritious pie to eat. On this occasion she had followed the normal procedures of opening the top of the tin ready to place the pie in the oven but had forgotten to check the cooking instructions which were on the underside of the tin. Realising this mistake she was just about to raise our dinner above her head and tip the tin to see the instructions. I had to act fast as the threat of tipping the contents of the tin over her head and losing my dinner was all too apparent. I thought there must be a better way of doing this and innovating in the face of certain disaster I went to the cupboard and retrieved another tin so we could access the cooking instructions in safety. A few weeks later the same thing happened and without pause or reference to me at all she retrieved a spare tin and accessed the information.”

These strategies form part of our resilience repertoire that people can enact in the face of threats and opportunities. Importantly they are informal and beyond design-basis. We also distinguish between the BIG R moments where innovation happens, and the little r moments were pre-existing resilience strategies are shared and adopted. In the Fray Bentos example I had a BIG R moment where I devised the strategy to retrieve a spare tin, my girlfriend then had a little r moment as she adopted this pre-existing strategy a few weeks later.

The presentation developed by introducing the Resilience Markers Framework (RMF), which is something we propose to help analyse positive resilience strategies at the sharp-end.

With reference to previous literature we pointed out that papers that were too abstract that pointed out high-level qualities and principles that an organisation should aim for to be resilient were hard to apply in practice because it was not clear what their specifics looked like. In contrast, case studies that were too specific were hard to generalise to other contexts. What we wanted to aim for was a framework that bridged from the high level to the low level. We proposed a three level framework t do this:

1. Resilience Markers Level – High
2. Strategy Level – Mid
3. Observational Level – Low

To cut a long story short we expanded the strategy level into the four elements of the markers framework, and tested this by applying it to data in the Oncology Day Care Unit – the details of which can be found in the paper.

There is lots more work to be done, which is great, but RMF has the potential for observing resilience strategies across contexts and domains. It could also be used for recognising and sharing best practices i.e. we can transfer and utilise other people’s best practices (improving little r mechanisms).


3 responses to this post.

  1. Posted by elaine pelletier on November 14, 2011 at 2:44 pm

    Hi Dominic, I was passing on your recent RMF article to colleagues and found your blog here. It certainly captures the quality of your presentation at the symposium! Thanks for this!


  2. Hi Elaine, thanks for the compliment. I gave a slightly extended and updated version of the talk to another group recently which was received well. I’ve shared the slides here:

    Errordiary, which I referred to last time, has also developed . This includes some everyday resilience strategies:


  3. […] person has incorrect knowledge of the situation. We can reduce the risk of these errors by creating resilience strategies and designing situations so they are less likely to occur in the first place (short YouTube clip). […]


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