A book edited by Erik Hollnagel, David D. Woods and Nancy Leveson (and containing chapters by these and many other authors), from 2006, about an improved approach to safety management.
"Resilience Engineering" is a well-integrated collection of quite thorough explorations and analyses of safety management in complex systems, both on the theoretical level as well as in the form of case studies. Even though the title might give an initial impression of the book being focused on technical systems, it is actually quite universally applicable and looks at techno-social systems as wholes, mainly in the form of technologically oriented organizations.
The core idea of "Resilience Engineering" is to move the field of safety management from the kind of design-time analysis that has been expected to produce "demonstrably safe" systems that should be safe within predescribed working conditions but in reality still experience failures due to the unpredictability and complexity of the real world, to the construction of adaptively resilient systems that are actively monitoring and adjusting for dangerous deviations.
Also, the book calls for better accident models that do not view failures as simply breakdowns or deviations of the components from the design specifications, but also as events that may easily arise as occasional unexpected consequences of interactions between otherwise acceptably working parts: "Rather than looking for causes we should look for concurrences, and rather than seeing concurrences as exceptions we should see them as normal and therefore also as inevitable. This may at times lead to the conclusion that even though an accident happened nothing really went wrong, in the sense that nothing happened that was out of the ordinary. Instead it is the concurrence of a number of events, just on the border of the ordinary, that constitutes an explanation of the accident or event."
Additionally, the book notes that even if the theoretical basis for understanding and preventing the majority of failures would be well-developed and widely available (which it isn't), there is still a major practical concern to tackle: safety management incurs an additional cost for the system, and in real life the pressing need for higher efficiency keeps (justifiably) trying to minimize all costs. Therefore, "from a risk management perspective, the key question is how to keep concern for risk alive when things look safe". And this can be particularly difficult due to the effectively working safety measures seeming unnecessary to a superficial observer for the very reason that those measures successfully prevent the failures and leave an impression of a safe environment. Or, as the book puts it: "superficially a safety manager’s job is to handle irony: the core of a good safety culture is a self-defeating prophecy, and a whistle blower’s ultimate achievement is to be wrong". The solution is to create a well-developed and strong safety culture that avoids the erosion of critical safety measures in the endless push for efficiency.
I definitely found the book educative and enjoyable, and would recommend it to anybody who has a deeper interest in safety management and in the adaptivity issues of (complex) systems.
More info about the book at Amazon: http://www.amazon.com/dp/0754649040/
