ERIK HOLLNAGEL

THE DESIGN, management, and analysis of work tacitly assumes that we know how things are done or should be done. Since humans - and organisations - are supposed to follow procedures, rules, and guidelines, the planning and management of work, including accident investigation and risk assessment, assume that compliance is the norm. The purpose of safety analyses, for instance, is to understand why the outcome of an action or a series of actions (an activity, an operation) was unacceptable (adverse) rather than acceptable (successful) - as in event investigation - or how that could possibly happen in the future - as in risk assessment... IN REALITY work is never completely regular or orderly, except in very special cases. It is therefore inadvisable to assume that work is as we imagine and that compliance guarantees success. Work-as-done (WAD) will always be different from work-as-imagined (WAI) because it is impossible to know in advance what the actual conditions of work will be, not..

Also known as: functional resonance