Re-framing is the process by which a person ''fills the gap'' between what is expected and what has been observed, that is, to try and make sense of what is going on following a surprise. It is an active and adaptive process guided by expectations, which are based on knowledge and experience. In this article, surprise situations in cockpit operations are examined by investigating the re-framing process. The results show difficulties that pilots have in re-framing following surprise, including the identification of subtle cues and managing uncertainties regarding automated systems, coping with multiple goals, tasks and narrow time frames and identifying an appropriate action. A crew-aircraft sensemaking model is presented, outlining core concepts of re-framing processes and sensemaking activities. Based on the findings, three critical areas are identified that deserve further attention to improve pilot abilities to cope with unexpected events; (1) identification of what enables and obstructs re-framing, (2) training to build frames and develop re-framing strategies and (3) control strategies as part of the reframing process.

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Managing complexity and uncertainty in high-risk sociotechnical systems requires people to continuously adapt. Designing resilient systems that support adaptive behavior requires a deepened understanding of the context in which adaptations take place, of conditions and enablers to implement these adaptations, and of their effects on the overall system. Also, it requires a focus on how people actually perform, not how they are presumed to perform according to textbook situations. In this paper, a framework to analyze adaptive behavior in everyday situations in which systems are working near the margins of safety is presented. Further, the variety space diagram has been developed as a means to illustrate how system variability, disturbances, and constraints affect work performance. The examples that underlie the framework and the diagram are derived from nine focus groups with representatives working with safety-related issues in different work domains, including health care, nuclear power, transportation, and emergency services.

Abstract. Accident investigation reports usually lead to a set of recommendations for change. These recommendations are, however, sometimes resisted for reasons such as various aspects of ethics and power. When accident investigators are aware of this, they use several strategies to overcome the resistance. This paper describes strategies for dealing with four different types of resistance to change. The strategies were derived from qualitative analysis of 25 interviews with Swedish accident investigators from seven application domains. The main contribution of the paper is a better understanding of effective strategies for achieving change associated with accident investigation.