Erik Hollnagel

Resilient Systems Plus

Working onboard offshore oil platforms, whether for production or drilling, presents a series of risks, involving two substances that are naturally unhealthy and dangerous - crude oil and natural gas. It is therefore necessary to develop integrated management systems that balance business needs, resource constraints, technical capabilities, and eme...

This is the standard version of the FRAM Model Visualiser that is freely available as a Progressive Web App at https://fmv.zerprize.co.nz. The code for the FRAM Model Visualiser (FMV) web based version is now also available on the GitHub website as a free opensource software tool for users of the FRAM methodology. This updated manual sets out the s...

The development of the FRAM methodology has an interesting basis. The current software development group has here set out its collective view of its origins. This paper thus sets out what is hoped is a definitive history and indication of where it might go next.

The study presented in this research is a systematic human factors approach comparing two striking process accidents in Latin America: the Copiapó mining accident (2010), at the San José copper–gold mine, in Chile, and the FPSO CSM accident (2015), at Camarupim offshore oil field, in Brazil. Despite being different industrial segments—mining and O&...

This study presents a reanalysis of Deepwater Horizon platform accident, occurred in April 2010, in offshore Macondo field, based on books, scientific articles and official reports prepared by the companies involved in the accident. The purpose of this reanalysis is to seek elements, factors, connections, inferences, and propositions that are new o...

The technological evolution of several productive sectors of society has demanded the same level of evolution for the oil and gas industry, both for energy production and their own systems’ functioning. The production of crude oil and natural gas in offshore units is one of the answers to this demand. However, these offshore units have critical onb...

A fundamental safety management assumption is the need to learn from accidents, to identify their causes, and to take steps to prevent their recurrence. Safety by prevention is, however, not the only solution. Since something cannot go well and fail at the same time, another approach is to learn from situations where things go well and where “nothi...

Resilience is not a unitary system quality, even though it often is treated as such. A system cannot be, and cannot have resilience, but a system can perform in a way that is resilient. Resilient performance can be understood as an ongoing condition in which problems are momentarily under control due to compensating changes. This is essential for e...

As COVID-19 spread across Brazil, it quickly reached remote regions including Amazon's ultra-peripheral locations where patient transportation through rivers is added to the list of obstacles to overcome. This article analyses the pandemic's effects in the access of riverine communities to the prehospital emergency healthcare system in the Brazilia...

Resilience Engineering (RE) studies have successfully identified and described many instances of resilient performance in high hazard sectors as well as in the far more frequent cases where people and organisations cope with the uncertainties of daily operations. Since RE was first described in 2006, a steady accumulation of insights and efforts ha...

Objectives With ever increasingly complex healthcare settings, technology enhanced simulation (TES) is well positioned to explore all perspectives to enhance patient safety and patient outcomes. Analysis from a Safety-II stance requires identification of human adjustments in daily work that are key to maintaining safety. The aim of this paper is to...

The most common reaction to suggesting that we could learn valuable lessons from the way the current pandemic has been/ is being handled, is to discourage the attempt; as it is suggested that it can all be done more accurately and authoritatively after the inevitable Public Inquiry (Slater D. , 2019). On the other hand, a more constructive approach...

Looking back at how resilience engineering made its entry onto the safety arena in 2004, resilience was initially seen as a substitute, and part extension, of safety, hence as something that could be engineered or managed. In the years since then it has become clear that how systems perform, and especially whether the performance is resilient, is m...

In the end, we must keep in mind that it is more important to ask the right questions than simply to hunt for answers to the questions that we – and others – habitually ask.

Safety is usually seen as a problem when it is absent rather than when it is present, where accidents, incidents, and the like represent a lack of safety rather than the presence of safety. To explain this lack of safety, one or more causes must be found. In the management of industrial safety, the human factor has traditionally been seen as a weak...

Task analysis (TA) has been one of the primary tools of human factors from the very beginning. This chapter begins by defining TA as the study of who should do what, why it is necessary and finally how and when it should be done. The demand for TA only arose when the use of technology became more pronounced or even indispensable, especially when to...

Workplaces in the oil and gas (O&G) industry have evolved to become part of the modern complex sociotechnical system that characterises onshore and offshore facilities today. The intense interactions between workers, systems, equipment and processes have made companies in this sector more productive. However, significant and complex risks have also...

The FRAM Model Visualiser (FMV)

Since the first missions and until today, the aerospace industry has been making significant technological advances and developments, working in the edge of innovation and technology. Despite the considerable advances in this sector, the degree of complexity and the risks associated are inherent to the process. In this sense, the development of saf...

Although security and safety can both be traced back to antiquity, security was only recognised as a serious problem in the 1980s. At that time safety had already an accepted set of methods and solutions. The ‘new’ problem of security was therefore initially treated as a variant of safety and treated analogously, the predominant approaches being se...

The Evolution of Technology in the workplace in the O&G industry carry this segment to a present dilemma, where in given situations, there is so much complexity that the system operability became quite complex too. In this context, the traditional ways to promote safety-regulations and procedures-can't deal with the demands from these complex syste...

Background: Resilience engineering has been advocated as an alternative to the management of safety over the last decade in many domains. However, to facilitate metrics for measuring and helping analyze the resilience potential for emergency departments (EDs) remains a significant challenge. The study aims to redesign the Hollnagel's resilience as...

The New FRAM Model Visualiser with the FRAM Model Interpreter - A Users Manual

The development of the Functional Resonance Analysis Method (FRAM) has been motivated by the perceived limitations of fundamentally deterministic and probabilistic approaches to understand complex systems’ behaviour. Congruent with the principles of Resilience Engineering, over recent years the FRAM has been progressively developed in scientific te...

Complex systems present a challenge to designers and users alike, in that it is difficult to be confident that the current, tried and tested methods of analysing and predicting systems’ behaviour can cover all of the variabilities experienced in their practical operations in the real world.This paper sets out to develop a methodology to provide a m...

The most common reaction to suggesting that we could learn valuable lessons from the way the current pandemic has been/ is being handled, is to discourage the attempt; as it is suggested that it can all be done more accurately and authoritatively after the inevitable Public Inquiry (Bennet). On the other hand, a more constructive approach, aimed at...

The offshore exploration, drilling, and production, in O&G industry, are one of the most necessary activities of human Society. However, since its beginning in North America, the process variables - such as temperature, pressure and depth - have increased their operational parameters considerably, leaving the 21 meters deep, on land in 1859, extrem...

Since the beginning of the well-drilling activities of oil and gas industry, in the 19th century, these activities have presented specific risks that, over the course of their evolution to the present day, have greatly increased their potential to cause harm to people, the environment, and corporate sustainability. Stimulated by the world’s energy...

This study presents a Human Factors and non-technical skills recognition and analysis in the operations activities of an offshore drilling platform, using the FRAM (Functional Resonance Analysis Method) to build a model of how the work is done by the drillers. The observations on board and the discussion together with the drillers provided the info...

Resilience Engineering has become popular in health care as a new approach for improving patient safety. However, to date there is no agreed syllabus for this subject. The aim of this study was to consult the wider resilient health care community of researchers and practitioners to identify topics, concepts and mindsets, and teaching approaches tha...

Purpose: The purpose of this paper is to understand how the hospital staff (nurses and physicians) at two hospital wards have coped with everyday work having leaders in conflict or longer periods without one or the other leader and whether the way the staff handled the challenges was resilient. Design/methodology/approach: Through semi-structure...

Resilient Health Care (RHC) is predicated on the idea that health care systems constantly adjust to changing circumstances. RHC has become increasingly popular as a new way to improve patient safety, but to date there is no agreed way of using RHC as the basis for teaching patient safety. A key resource for patient safety educators is the World Hea...

The study reported here reviewed and analyzed multi-team organizations in offshore operations to identify and understand the factors that are essential for good operation. It was found that the most prominent contribution to good operations was the balancing of structure and flexibility during work (anchor handling operations). The enabling factor...

The title of this volume is “Security by design”. This can be read as a statement, as an expression of confidence that it is possible to be secure by design. In that case the obvious next step is to think about possible ways of ensuring security by design, starting, for instance, with the solutions that have been developed to solve the seemingly an...

Hollnagel's updated version including the tutorial cup noodle example

Purpose To understand how staff at various levels perceive and understand hospital accreditation generally and in relation to quality improvement (QI) specifically. Design/methodology/approach In a newly accredited Danish hospital, we conducted semi-structured interviews to capture broad ranging experiences. Medical doctors, nurses, a quality coor...

Purpose The purpose of the study is to determine whether one leader set-up is better than the others according to interdisciplinary cooperation and leader legitimacy. Design/methodology/approach The study is a qualitative study based on semi-structured interviews at three Danish hospitals. Findings The study found that the leadership set-up di...

The use of non-linear models to understand complex processes in healthcare is not a fully adopted concept. Current patient safety research focuses on events by studying adverse events, typically trying to understand the root causes of failures. This article describes an attempt in a Danish hospital to create an understanding of how complex processe...

Objective The objective was to develop an understanding, using the Functional Resonance Analysis Method (FRAM), of the factors that could cause a deer hunter to misidentify their intended target. Background Hunting is a popular activity in many communities. However, hunters vary considerably based on training, experience, and expertise. Surprising...

Objective: To examine the association between compliance with accreditation and recommended hospital care. Design: A Danish nationwide population-based follow-up study based on data from six national, clinical quality registries between November 2009 and December 2012. Setting: Public, non-psychiatric Danish hospitals. Participants: Patients wit...

Objective: To examine the association between compliance with accreditation and recommended hospital care. Design: A Danish nationwide population-based follow-up study based on data from six national, clinical quality registries between November 2009 and December 2012. Setting: Public, non-psychiatric Danish hospitals. Participants: Patients...

The work in patient safety is often centred on adverse events and errors. Typical methods to improve patient safety are reactive and focus on understanding past failures. This article presents the development of a proactive method towards improving patient safety and understanding why processes function as intended on a daily basis. The paper prese...

Safety-I is defined as the freedom from unacceptable harm. The purpose of traditional safety management is therefore to find ways to ensure this ‘freedom’. But as socio-technical systems steadily have become larger and less tractable, this has become harder to do. Resilience engineering pointed out from the very beginning that resilient performance...

Objective: To identify predictors of the effectiveness of hospital accreditation on process performance measures. Design: A multi-level, longitudinal, stepped-wedge, nationwide study. Participants: All patients admitted for acute stroke, heart failure, ulcers, diabetes, breast cancer and lung cancer at Danish hospitals. Intervention: The Dan...

This study aimed to investigate why there is variability in taking blood. A multi method Pilot study was completed in four National Health Service Scotland hospitals. Human Factors/Ergonomics principles were applied to analyse data from 50 observations, 15 interviews and 12-months of incident data from all Scottish hospitals. The Functional Resonan...

Purpose Despite the practice of dual leadership in many organizations, there is relatively little research on the topic. Dual leadership means two leaders share the leadership task and are held jointly accountable for the results of the unit. To better understand how dual leadership works, this study aims to analyse three different dual leadership...

Objective To assess changes over time in quality of hospital care in relation to the first accreditation cycle in Denmark. Design, setting and participants We performed a multi-level, longitudinal, stepped-wedge, nationwide study of process performance measures to evaluate the impact of a mandatory accreditation programme in all Danish public hosp...

This chapter looks at disaster management as a form of safety management, using the perspective of resilience engineering. In safety management, control can be lost by not being ready to respond, by having too little time, by lacking knowledge of what is going on, or by lacking the necessary resources. To maintain control unsurprisingly requires th...

Objective: To examine the association between compliance with hospital accreditation and length of stay (LOS) and acute readmission (AR). Design: A nationwide population-based follow-up study from November 2009 to December 2012. Setting: Public, non-psychiatric Danish hospitals. Participants: In-patients admitted with one of 80 diagnoses. I...

Background: Uptake of guidelines in healthcare can be variable. A focus on behaviour change and other strategies to improve compliance, however, has not increased implementation success. The contribution of other factors such as clinical setting and practitioner workflow to guideline utilisation has recently been recognised. In particular, differe...

The current approach to patient safety, labelled Safety I, is predicated on a 'find and fix' model. It identifies things going wrong, after the event, and aims to stamp them out, in order to ensure that the number of errors is as low as possible. Healthcare is much more complex than such a linear model suggests. We need to switch the focus to what...

To examine whether performance measures improve more in accredited hospitals than in non-accredited hospital. A historical follow-up study was performed using process of care data from all public Danish hospitals in order to examine the development over time in performance measures according to participation in accreditation programs. All patients...

To examine the association between compliance with hospital accreditation and 30-day mortality. A nationwide population-based, follow-up study with data from national, public registries. Public, non-psychiatric Danish hospitals. In-patients diagnosed with one of the 80 primary diagnoses. Accreditation by the first version of The Danish Healthcare Q...