3.2. Establishing conditions for adapting plans and procedures during crises and other events that challenge normal plans and procedures

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Often, crises challenge the plans and procedures in place. As a result, organisations need to support and maintain a clear and legitimate space of manoeuvre relative to normative plans and procedures. Such space is important for actors engaged in crisis response in order to adapt to unusual (unanticipated) circumstances. After training or real events, investigating why these adaptations occur can feed the processes of revision of checklists, procedures and policies.



Resilience is positioned in complement to plans and procedures. Plans and procedures often are not fully useful and have to be used as guides to base actions on rather than as comprehensive and accurate descriptions of actions to execute. Flexibility and improvisation compensate for gaps in the procedures, providing solutions needed on the spot.

The management of adaptive capacity discussed here is that of the considered organisation and is limited by the corresponding organisational boundaries. However, crisis situations considered might involve multiple organisations. Adaptation relative to plans and procedures therefore needs to be thought in a cross-organisational context. The application of this guideline will therefore be facilitated by applying Establishing common ground and Understanding roles and responsibilities first. The management of adaptive capacity indeed requires that common ground and understanding of roles and responsibilities are in place within and across organisations. The interventions proposed here can also highlight deficiencies in capacity to coordinate.

The interventions described here aim to capture, understand and improve the use and potential limitations of plans and procedures in their organisational context.

What is needed to establish conditions for adapting plans and procedures:

  • Clarify and rehearse plans and procedures
  • Clarify lines of authority and the autonomy discretion
  • Exercise situations that fall outside normal conditions and involve personnel across the organisation
  • Document events and training sessions (e.g., establish and maintain logs, build narratives) to capture gaps or deviations in plans and procedures as well as innovative adaptations
  • Reflect on gaps and deviations captured or on innovative adaptations
  • Revise plans and procedure, authority and autonomy. Modify training when experiences appear generalisable
  • Rely on members of the organisation familiar with resilience notions, such as resilience or safety managers, to conduct actions, lead and moderate discussions proposed here
  • Involve external experts if such resilience or safety managers are not available

Before a crisis

The foundation for trust is primarily laid down during this phase in terms of training and rehearsal on the rules of work and on different degrees of deviation according to need or severity of the situation.

Nature of Plans and Procedures
Document and rehearse relevant processes and procedures regularly. Regarding larger crises, organise lists indicating who needs to be contacted and when, including, e.g., for technical or political issues. For big crises, there should be specific infrastructure and facilities, and procedures flexible enough to be adapted to different kinds of situations and needs.

Authority Issues
Operators in direct contact with such challenges might, at a given moment, have the best knowledge of the situation and ability to act, while managers remote from the situations supervise operations and coordinate them across larger scales. It is important to clarify roles and authorities in advance and identify situations in which it might be difficult for the usual chain of command to make well-informed and fast decisions in the face of unanticipated challenges.

Capability Issues (skills, expertise)
Managers should develop a good understanding of the type of "adaptations of plans and procedures" that situations might require, as well as of the capabilities present in their organisation. Such capabilities include the ability to recognise early on that/when procedures or routines are insufficient. All levels in the organisation must understand the need to be prepared and to "release" themselves from planned activities when/if necessary. In order to do that, is possible to organise exercises regularly, as a major source of information on potential gaps, which should then be addressed through training programs. In training and preparation, address hypothetical situations that fall outside usual conditions addressed by plans and procedures. Either preplanned or random scenarios of escalation may be used. In such events, assess the adaptive capacity needed according to a scale ranging from only minor adjustments of procedure to abandoning procedure.

A baseline approach should be established in which:

  • the situation and potential implications are assessed,
  • the action alternatives are elaborated,
  • a decision is enforced, and
  • the implications of the decision (e.g., new areas of attention) are described.
  • track and log mechanisms and actions used for expanding skills, expertise and resources within response team/organisation to problem-solving should be tracked and logged, including the strategies and heuristics for integrating them.
  • consider situations in which plans and procedures are ambiguous or even missing, and innovative ways of operating must be identified on the spot.

Learning Process (normal operations vs. crises)
Operators and management, should review training processes and outcomes: Comparing anticipated issues with actions required by the situations, and revising training programs, plans and procedures based on such assessment when necessary.

Triggering questions

Nature of Plans and Procedures
  • Are plans and procedures in place for all operators?
  • Are they rehearsed regularly?
  • Is there flexibility for operators to adapt when situations are unexpected?

Authority Issues

  • What roles will be in charge of abnormal situations?
  • Will they be in a capacity to quickly make informed decisions if such a situation occurs?
  • Would other roles be in a better position to make decisions?
  • Do these roles have the authority to do so?

Capability Issues (skills, expertise)

  • Are operators trained on unusual situations for which plans and procedures are limited?
  • Does training include situations in which they need to solve problems or make trade-offs?
  • Do they experience situations in which they need to show initiative, outside of the regular line of command, in order to act quickly?

Learning Process (normal operations vs. crises)

  • How regularly are training programs reviewed and revised?

During a crisis

During a crisis, organisations are expected to execute and revise plans continuously. They should keep records of the plans and procedures used, as well as of the breaking points and brittleness that justified deviations from the initial plans and procedures. Many of the actions proposed below aim to capture such elements so that they can be used in the AFTER phase.

Nature of Plans and Procedures
Keep a log of procedures used and not used, and the causes for the latter case.

Authority Issues
Ensure especially availability of management support: Managers should provide relevant and timely mechanisms and interfaces for authorising specific courses of action, especially when the actions needed might exceed the defined space for manoeuvre.

Capability Issues (skills, expertise)
Is it important to track mechanisms and actions used for expanding skills, expertise and resources within response team/organisation to solve problems. Strategies and heuristics for integrating them to the response team should be documented for revision in the "after" phase.

Learning Process (normal operations vs. crises)
Use (simple) techniques to record precariousness, breaches and brittleness that trigger deviations from plans and procedures. For instance, indicate the level of deviation and its justification.

After a crisis

As far as possible, revise crisis management processes, reconstruct adaptive capability process, assess performances, adjust or calibrate normative base, and describe prospects for future resilient performance.

Nature of Plans and Procedures
Revise procedures and plans if the actual experience (DURING) is generalisable (see Systematic management of policies)

Authority Issues
Consider whether the defined space for manoeuvre was sufficient, and whether authority was conducted in a functional and proper way when decision support was needed, within or beyond the space for manoeuvre.

Capability Issues (skills, expertise)
If needed, assess training needs in order to close gaps in capabilities.

Learning Process (normal operations vs. crises)
After the crisis phase, it is important to learn lessons in order to match the procedures to the circumstances that emerged in the crisis itself. Reconstruct adaptive behaviour and capacity based on prior training records and notes from past events. To do so, build narratives that capture both coherence and disruptions. Describe deviations according to a useful scale, assess whether they were justifiable, and suggest, if needed, alternative pathways that are retrospectively coherent (but beware of the advantages of hindsight). If possible, define indicators of critical conditions, create lists of lessons learned, or narratives that capture a number of critical issues in a coherent way.

Triggering questions

Nature of Plans and Procedures
  • What were issues with plans and procedures in the situations experienced?
  • Have these issues been identified before?
  • Can the solutions found be used in other situations?

Authority Issues

  • Were people in charge of decisions authorised to make them?
  • Did people recognise that they had authority (e.g., when they didn’t exert it)?
  • Is there any indication of need to revise the space for manoeuvre?

Capability Issues (skills, expertise)

  • Did people have the skills, expertise needed?
  • Were they able to exert existing skills, expertise into combined action?

Learning Process (normal operations vs. crises)

  • Do we have detailed accounts of the events?
  • Can we identify deviations from plans and procedures?
  • Can we make sense of such deviations?
  • Could there have been better alternatives?


Understanding the context

Detailed objectives

The guideline Adaptation relative to events describes the general need for managing adaptation. This guideline is more specific and focuses on the operationalisation of plans and procedures, and on their deviation. Resilience is positioned in complement to plans and procedures. Organisations have turned away from being checklist dependent, and have shown preference to having a broader knowledge in all personnel and increased teamwork. Plans and procedures often are not fully useful and have to be used as “skeletons” to base actions on rather than as comprehensive and accurate guides. Flexibility and improvisation compensate for gaps in the procedures, providing solutions needed on the spot. Hence, two modes of safety thinking, "compliance" vs "resilience" are mutually interwoven. This situation, in which resilience has to unfold in a more or less dominating context of compliance, is not only a matter of practicality, but also a dominant expectation or "imperative" stemming from, e.g., laws, regulations, bureaucratic principles, institutional traditions and social preference.

Scope of the card The scope is twofold. "Downwards", it is about clarifying the reach and grasp of the normative base, and ensuring that adaptive actions do not deviate from plans and procedures in an unduly manner. "Upwards", it is about maintaining trust in the capacity to autonomously judge and decide when and where to deviate in order to ensure resilience according to situational needs. Both these aspects will benefit from a continuous and systematic reconciliation between the rules of work and the actual adaptive capacity (AC), in which both experienced and conceived/exercised AC is used to revise and improve the rules.

Nature of plans and procedures
Plans and procedures, and operators knowledge of them, constitute the base for operations. But procedures cannot be too prescriptive because the reality of crisis situations cannot be fully specified, and can even be surprising. Resilience implies behaving flexibly in the face of changing situations where procedures do not support action adequately (not specific enough or not relevant to unanticipated situation).

Authority issues
Supporting flexibility beyond the normal bases for operations (represented by plans and procedures) supposes that managers give authority and legitimacy to operators to deviate from the normal (normative) base when situations require to. Ideally, a legitimate space for manoeuvre therefore needs to be created, communicated and maintained. Organisations need to be able to calibrate and justify the degree of non-compliance and alternative action, thereby also building trust that allows them to go even further when the situation calls for it.

Capability Issues (skills, expertise)
The ability to adjust behaviour beyond procedures is a typical trait of resilience in the situations for which there is no clear existing guide to action. Such ability requires skills to appropriately assess the situation at hand, as well as solve problems and implement innovative actions. Such skills need to exist at the individual and collective level, given the distributed nature of crisis management operations. Hence, the adaptive capacity addressed here also depends on other skills and expertise related to, e.g., anticipation.

Learning Process (normal operations vs. crises)
Exercises and real operations represent opportunities for organisations to understand their capacity to adapt beyond plans and procedures. Following the aspects above, they need to facilitate the capture and preserve of experiences of adaptation to develop and improve the corresponding abilities. This learning process serves as direct input to the revision of plans, procedures, training material and organisational mechanisms of decision. This guideline therefore provides input for Systematic management of policies.

Targeted actors

Managers are the primary target of this CC; they expected to implement the interventions in different ways:

  • setting up the proposed activities regularly to enable discussions about adaptation in the context of the rules of work,
  • discussing the rationale behind the rules and the boundaries for deviations in order to ensure accountability (needed to avoid after the fact blame-games);
  • involving actors at all levels of the organisation. In particular:
    • team leaders and other operational personnel who are engaged in crisis management activities;
    • and higher-level managers who act as policy level and are relevant observers of the processes of adaptation relative to rules.

Members of the organisation familiar with resilience notions (e.g., resilience or safety managers), play a key role in conducting events (possibly with the help of external experts) leading and moderating discussions about brittleness.

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Healthcare actors

Ministry of Health, Regulatory Bodies and Scientific-Technical Institutions. Within each of them: Site Director or Manager (could be Director General), Quality Manager, Safety Manager, Regulatory Manager, Human Resources Manager. Then, according to the area -: the Head of the Department (or Service), and the Head of the specific Unit (or, other specific Units according to the specific mission of the institution). Each of these actors have financial and signature authority, according to the legal frame of the body.

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Air Traffic Management actors

The roles and responsibilities of involved actors change according to the type of crisis and the related environment of operations. The "Adaptation relative to procedures" must encompass most of the activities of the organization, at all levels starting from senior management to front line operators.

The actors involved are those listed below:

  • Air Navigation Service Providers (both civil and military)
  • Aircraft owners and operators
  • Aircraft manufacturers
  • Aviation regulatory authorities (National and International)
  • ATFCM (Air Traffic Flow and Capacity Management)
  • International aviation organizations (i.e. EUROCONTROL, ICAO, CANSO, etc)
  • Investigative agencies
  • Flying public
  • Airport operator (if airports and/or ground operations are concerned by the crisis)
  • Firefighters (if airports and/or ground operations are concerned by the crisis)
  • Police (if airports and/or ground operations are concerned by the crisis)

Expected benefits

  • Improves understanding of adaptive capacity when exercised in the context of normative base and expectations of compliance.
  • Supports justification and legitimacy of resilient operation as deviation from normative preparations and plans.
  • Provides a basis for accountability, thereby facilitating authority and trust to enforce resilient operation according to needs (as perceived by Resilience Management), while deviating from the normative base
  • Contributes to a higher degree of predictability of which actors may be involved and when, as well as what they may do and how. In turn, it also contributes indirectly to an increased mutual understanding and calibrated mutual expectations among the actors.

Relation to adaptive capacity

The concept puts issues of Adaptive Capacity in organizational/institutional contexts in which there is a normative expectation/preoccupation towards checklists, plans and procedures, separating between

  1. Issues related to the nature of plans and procedures in the organization and how much flexibility they provide by design (e.g., how specific they are, what is their grasp and reach).
  2. Issues of authority and legitimacy of deviation in the face of existing plans and procedures (normative base) organizations expect operators to comply to.
  3. Issues of skills and expertise at the individual, team or organization levels, related to the capability to accurately assess the situation, and act in it, when plans and procedures are not obviously available to support operations.
  4. Issues of organizational learning when adaptations performed highlight the gaps and limitations related to the two previous aspects.

Relation to risk management

The narratives of adaptive capacity, and the defining moments that trigger the need alternative (non-normative) action, should be revised with an eye on the key underlying assumptions of existing risk assessments. If these "breaking points" actually are inconsistent with the underlying assumptions, a revised risk assessment is justified-

To the extent that an adaptive capacity (AC) is trusted, its presence can also be considered as a mitigating factor in a risk assessment owned by the stakeholders


In a world characterized by complex interdependence, crises that originate in one country have the potential to rapidly diffuse across borders and have profound regional and even global impacts. The eruption of the Icelandic volcano Eyjafjallajkull in April 2010 demonstrates how rapidly a natural disaster can morph from a local crisis with local effects to a cascading crisis with international effects across multiple sectors. In this case, the relevant authorities did exhibit institutional resilience and came up with creative solutions in just a few days, in the form of new operating thresholds that distinguished between three degrees of ash contamination. This new methodology was incorporated in the guidelines SRA (Safety Risk Assessment) common criteria for airline operators. This may be seen as an example of active reconciliation between the normative base and the AC.

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Healthcare illustration

For many Regions, de novo development of guidelines is very hard because of evidence base, lack of time, expertise, resources. so they make use of high-quality already existing generic guidelines: this weakens the efficacy and efficiency of the intervention. To avoid the enlisted issues, we outline a systematic, participatory approach for evaluating and adapting available guidelines to a local context of use. Whether evidence comes from a case study/report, informed consent, clinical practice guidelines, end-users must consider if or how the generic guidelines could be adapted to the local context.

Care of ulcers of the leg, the task force collectively assessed the quality of individual guidelines and their recommendations. They developed a protocol that was feasible to implement locally and that was endorsed by stakeholders. The guideline was condensed to a one-page algorithm to enhance use by the clinicians, and documentation forms were created for collection of clinical data. For example, to streamline the process of assessment and facilitate application of evidence-based care, documentation forms were created to collect information about the cause of the ulcer, with venous symptoms and history on one side of the page and arterial symptoms on the other.(Howard M. Kimmel, DPM, MBA, FACFAS; and Angela L. Robin, DPM)

Implementation considerations


Nature of plans and procedures
The combination of resilience and compliance to rules may encompass a number of variations, spanning from slight adjustment of or facilitation for procedures, to abandoning procedures completely. The actual design of rules will have an impact on the possible range of variation.

Authority issues
Resilience as a concept is associated with the idea of safety as an emergent property. This is ultimately contradictory to the underlying idea of a normative repertoire; that safety is an instrumental result from a priori anticipation and routinization. Hence, the managerial challenge of "resilience in the context of its opposite" (namely compliance), is also a managerial challenge of combining two different organizational approaches to safety.

Capability Issues (skills, expertise)
Providing the relevant actors broad knowledge and information that direct them to identify the situation and the optimal response, are important prerequisites for achieving an adaptive capacity as described here.

Learning Process (normal operations vs. crises)
A learning process of reconciliation between the adaptive capacity and the normative base/context should be supported by and provide input to the policy level (see DR-85)

Implementation cost

TORC training requires a quite substantial amount of basic preparation (see SINTEF report A27931), while the actual training with the board game and the review processes are very cost effective.

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Healthcare implementation considerations

Using the best evidence is a fundamental aspect of quality health care. Valid guidelines for clinical practice are fundamental to inform evidence-based practices. To assess the uptake and adherence to guideline-based care, auditing sessions are implemented in Healthcare. However, often through the evaluation of these functions, an exhaustive and global conformity of practices is still far from expectations. This demonstrates that high-quality guidelines and its dissemination are not sufficient to ensure evidence-based decision-making. This requires a substantive, proactive effort to encourage use at the point of decision-making.(Harrison, M., Legarè, F) The gap between valid guidelines and delivery of evidence-based care is often hampered. For instance, clinicians may not have the required skills to implement a recommended action (e.g., being unfamiliar with implementation of a novel therapy, or the hospital lacking of recommended equipment or the necessary time to deliver a guideline’s recommendation).


Relevant material

Relevant Practices, Methods and Tools


  • Narratives (cases description in newsletters – see Beth Lay references)
  • Flexible procedures for unanticipated crises. Regarding larger crises, organisations have lists indicating who needs to be contacted and when, including, e.g., for technical or political issues. For big crisis, there is specific infrastructure and facilities, and procedures flexible enough to be adapted to different kind of situations. (ANSP3; SafetyMgt)

Two references were found in the SLR

  1. Logistics management processes and practices in disaster management provide healthcare leaders. (ID 1054) TRL- Not applicable.
  2. It describes how the relevant authorities exhibited institutional resilience and came up with creative solutions in just a few days, in the form of new operating thresholds that distinguished between three degrees of ash contamination. This new methodology was incorporated in the guidelines SRA (Safety Risk Assessment) common criteria for airline operators. This allowed flights to resume and successfully avoided accidents. (ID 82) TRL- 3.


The Training for Operational Resilience Capability (TORC) combines operational and managerial under a common "resilience in the context of compliance" scheme", and by the use of a board game that also provides the necessary logging capabilities to support the implementation described above. TORC is associated with a TRL level 7-8 on "normal operation" and has also been piloted in the ATC domain related to emergency/crisis training


Safety Management Systems: Learning goes mainly through deviation reports through the SMS. Sometimes hard to connect all events to SMS, but there are organizational ways to handle other types of feedback than deviation reports: Meetings, logbooks, different ways to give feedback, and debriefings after every shift (ANSP4;OpsMgr)


  • Alter, S. (2014). Theory of workarounds. Communications of the Association for Information Systems, 34(1), 1041–1066.
  • Burian, B. K. (2006). Design Guidance for Emergency and Abnormal Checklists in Aviation. Proceedings of the Human Factors and Ergonomics Society 50 Th Annual Meeting, (October), 1–6. http://doi.org/10.1037/e577552012-023
  • Carim, G. C., Saurin, T. A., Havinga, J., Rae, A., Dekker, S. W. A., & Henriqson, É. (2016). Using a procedure doesn’t mean following it: A cognitive systems approach to how a cockpit manages emergencies. Safety Science, 89, 147–157. http://doi.org/10.1016/j.ssci.2016.06.008
  • Comfort, L (2007). Crisis Management in Hindsight: Cognition, Communication, Coordination, and Control. Public Administration Review. December 2007. Special Issue.
  • Dekker, S. W. A. (2001). Follow the procedure or survive. Human Factors and Aerospace Safety.
  • Dekker, S. W. A. (2000). The bureaucratization of safety. Safety Science, 70, 348–357. http://doi.org/10.1177/0020852300662008
  • Dekker, S. W. A. (2004). Ten questions about human error: A new view of human factors and system safety. book, Mahwah, NJ: Lawrence Erlbaum Associates, Inc.
  • Department of Homeland Security (2008). National Emergency Communication Plan. Rev. Aug 7, 2008
  • Waugh, W & Streib, G (2006). Collaboration and Leadership for Effective Emergency Management. Public Administration Review. December 2006. Special Issue
  • Hale, A., & Borys, D. (2013a). Working to rule, or working safely? Part 1: A state of the art review. Safety Science, 55, 207–221.
  • Hale, A., & Borys, D. (2013b). Working to rule or working safely? Part 2: The management of safety rules and procedures. Safety Science, 55, 222–231.
  • Henningsson, A. & Jacobsen, U. (2014). Olycksutredning – Skogsbrand Västmanland, dnr 2014/336 – MBR – 196.
  • Kontogiannis, T., & Malakis, S. (2012). Remaining safe by working at the edge of compliance and adaptation: reflective practices in aviation and air traffic control. Theoretical Issues in Ergonomics Science, (August 2012), 1–27. http://doi.org/10.1080/1463922X.2012.672597
  • Rankin, A., Lundberg, J., Woltjer, R., Rollenhagen, C., & Hollnagel, E. (2014). Resilience in Everyday Operations: A Framework for Analyzing Adaptations in High-Risk Work. Journal of Cognitive Engineering and Decision Making, 8(1), 78–97. http://www.diva-portal.org/smash/get/diva2:619907/FULLTEXT01.pdf
  • Suchman, L. A. (1987). Plans and situated actions: The problem of human machine communication. New York: Cambridge University Press.
  • Woltjer, R., Pinska-Chauvin, E., Laursen, T., & Josefsson, B. (2015). Towards understanding work-as-done in air traffic management safety assessment and design. Reliability Engineering & System Safety, 141, 115–130. http://doi.org/10.1016/j.ress.2015.03.010

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Healthcare references

  • Harrison, M., Légaré, F., Graham, I.D. Fervers B. (2010) Adapting clinical practice guidelines to local context and assessing barriers to their use. Canadian Medical Association Journal, 182(2): E78–E84.
  • Straus SE, Richardson WS, Glasziou P, et al. Evidence based medicine: how to practice and teach it. Edinburgh (UK): Elsevier; 2005. pp. 95–7.
  • Howard M. Kimmel, DPM, MBA, FACFAS; and Angela L. Robin, DPM


  • Adaptive capacity
    "ability of systems, institutions, humans, and other organisms to adjust to potential damage, to take advantage of opportunities, or to respond to consequences" ISO 14080:2018(en), "The adaptive capacity of a system is usually assessed by observing how it responds to disruptions or challenges. Adaptive capacity has limits or boundary conditions, and disruptions provide information about where those boundaries lie and how the system behaves when events push it near or over those boundaries" (Source: Woods and Cook, 2006, p. 69)

  • Improvisation
    "Act of inventing, composing or performing with little or no preparation a reaction to the unexpected" (Source: ISO22300)

  • Deviation
    "(1) An alternative method of compliance with the intent of specific requirements (MIL-STD-1574A). A departure from established or usual conduct or ideology. (2) The amount by which a score or other measure differs from the mean, or other descriptive statistic. " (Source: Vincoli, 2006)

  • Gaps (in plans and procedures)
    Gaps are typically described in two ways in the context of plans and procedures:
    1. in reference to the difference between those plans and procedures and how work is actually performed (see for example Antonsen et al, 2008). This corresponds to the idea of work-as-done vs. work-as-imagined.
    2. in reference to the "holes" in the work processes, i.e. the actions that are not described in plans and procedures (see for instance Cook et al., 2000, in the context of patient safety).
    In both cases, gaps exist between it is fundamentally impossible to describe work processes exhaustively. There are always limitations in the knowledge an organisation can have about work situations and performance, and situations that arise with unusual characteristics. People fill those gaps routinely in their activities, potentially deviating from plans and procedures as a result.

  • Space (margin) for manoeuvre
    The space (or margin) for manoeuvre is the cushion of potential actions and additional resources that allow the system to continue functioning and adapting despite unexpected demands (Lay and Branlat, 2015). What creates such space varies, examples include: (1) procedures that leave room for interpretation, i.e. not extremely prescriptive; (2) available extra resources such as tactical reserves. Resilient systems are careful about creating and maintaining margins, because they correspond to a capacity to handle disruptions when they occur... without jeopardising the capacity to do so in the future (Woods and Branlat, 2010; 2011). Synonyms: margin of maneuver. Related notions: Buffer, slack, wiggle room.

  • Authority and autonomy

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