ABSTRACT

Resilience has always been a critical property of all human (and most other “live”) systems, but its more recent use in the safety literature has brought an old term to a new understanding. As such, this newer usage has the potential to be more insightful and, thus, more useful when trying to understand accident causation. Prior to the relatively new concepts of the new view of human error and how organizations and people are resilient to failure, investigators relied on a blame-and-train-type 204mentality. That is, actors at the sharp end, being the last ones involved, are blamed for the event and are retrained, so they will perform better next time. However, more frequently, the actors at the sharp end are either fired and/or prosecuted, which further represents a strictly old view mentality.