Barriers and Accident Prevention
... Modellene skiller seg fra hverandre i synet på menneskelig svikt og feilbarlighet. Mens noen modeller anser menneskelig svikt som årsak til ulykker, anser andre modeller ulykker som en konsekvens av omgivelsene og av systemkompleksitet (2). Hvilken kausalitetsforståelse som ligger bak årsaks-og ulykkesmodellen man anvender i gransking av alvorlige uønskede hendelser i helsetjenesten, påvirker hva man anser som svikt, hvor man retter sikkerhetstiltakene, og til slutt hva man laerer av uønskede hendelser (3). ...
... Det har skjedd betydelige endringer innen utvikling av årsaks-og ulykkesmodeller, og nye metoder og perspektiver har kommet til (2). Modellene har ulik grad av kompleksitet og tar for seg alt fra enkelthendelser til systemet som helhet. ...
... Erik Hollnagel (f. 1941) deler modellene inn i tre kategorier etter kausalitetsforståelsen som ligger til grunn: 1) enkle, lineaere modeller, som setter søkelys på det tekniske systemet, 2) komplekse, lineaere modeller, som favner det organisatoriske systemet, og 3) komplekse, ikkelineaere modeller, som søker kunnskap om det interaktive systemet -hvordan mennesker, teknologi og organisasjoner påvirker hverandre og fungerer under høy risiko (2). ...
... Determining the exact cause of a normal accident is a daunting task, not only because it is often a consequence of complex interactions among multiple factors (Perrow, 1984), but also due to the highly diverse types and underlying dynamics of accidents (Grant et al., 2018;Hollnagel, 2004). Despite accidents leading to the sudden downfall of once prosperous organizations, the organizational theory literature has paid little attention to the specific mechanisms of accident occurrence, except for a few pioneering works (e.g., Haunschild & Sullivan, 2002;Perrow, 1984;Weick & Sutcliffe, 2007). ...
... These accidents have primarily been examined in an interdisciplinary field known as accident/security studies. They are largely based on operational perspectives, such as equipment malfunctions, mechanical issues, system failures, or human errors made by operators, which are often identified as the main causes of accidents (e.g., Hollnagel, 2004;Lee & Kim, 2018;Muecklich et al., 2023;J. Reason, 1990). ...
... In other words, the diversion of attention from task goals to status goals among high-status organizations may increase the likelihood of accidents occurring. The literature on accidents emphasizes that focused attention is one of the most critical human factors in accident prevention (Grant et al., 2018;Hollnagel, 2004;Lee & Kim, 2018). Preventing accidents requires highly focused attention to every small detail of the task itself. ...
Plain language summary
The normal accident theory suggests that complex systems, tight connections, and limited slack resources can inadvertently lead to catastrophic or system accidents. Extending this concept to interorganizational networks, we propose that two positions commonly seen as advantageous within an interorganizational network, high status and having multiple structural holes, can unintentionally increase the risk of these normal accidents. High-status actors often need to differentiate themselves, which might not align with their core responsibilities. For instance, in the airline industry, by focusing on improving other aspects such as comfort and service, high-status airlines may not fully focus on critical safety matters. Conversely, having numerous structural holes can introduce complexity by involving diverse, non-redundant sources of information. The costs linked to high status and many structural holes can shift an organization’s attention away from operational details, increasing accident likelihood. Inadequate slack capacity magnifies the impact of high status on accidents as handling differentiation tasks becomes harder without resource flexibility. Conversely, limited slack capacity can mitigate the impact of structural holes, directing actors towards core tasks. The analysis using U.S. airline industry data indicates that accidents are more likely when airlines hold high-status or structural-hole positions in alliance networks. Moreover, we found that insufficient workforce capacity heightens the accident risk tied to high status, while dampening the effect of structural holes. Our study demonstrates that accidents can occur as unintended consequences when organizations pursue relational advantages from supposedly beneficial network positions like status and structural holes within interorganizational alliance networks.
... Since the publication of what can be considered the first systems HFE method, the cognitive work analysis (CWA) framework (Rasmussen et al. 1990(Rasmussen et al. , 1994Vicente 1999), numerous other systems HFE methods have been developed to support system analysis and design. Other recognized systems HFE methods include the Event Analysis of Systematic Teamwork (EAST; Stanton et al. 2013); the EAST-Broken Links (EAST-BL) approach (Stanton and Harvey 2017); the Accident Mapping technique (AcciMap; Svedung and Rasmussen 2002); the Functional Resonance Analysis Method (FRAM; Hollnagel 2004Hollnagel , 2012; the Networked Hazard Analysis and Risk Management System (Net-HARMS; Dallat et al. 2018); and the Systems Theoretic Accident Model and Processes (Leveson 2004) approach. STAMP has two methods: the Causal Analysis based on System Theory (STAMP-CAST; Leveson 2004), and the Systems-Theoretic Process Analysis (STAMP-STPA; Leveson 2011). ...
... FRAM (Hollnagel 2004(Hollnagel , 2012 aligns with resilience engineering principles and provides a framework for systems analysis for complex sociotechnical systems. The method describes how functions of systems (i.e., tasks and activities) resonate to amplify performance variability. ...
Systems human factors and ergonomics (HFE) methods are increasingly being applied to diverse problems across various domains. This scoping review identified peer‐reviewed applications of systems HFE methods to determine which methods have been applied, in what domains, and for what purposes. Four databases (Web of Science, Scopus, Science Direct, and Sage) were searched for articles that applied systems HFE methods. After applying a set of inclusion criteria, 367 peer‐reviewed articles were included in the review. The review revealed a growth in applications of systems HFE methods over time. Overall, cognitive work analysis (CWA) was the most frequently applied, closely followed by functional resonance analysis method (FRAM) and systems theoretic accident model and process–system‐theoretic process analysis (STAMP‐STPA). Most applications of systems HFE methods have occurred in the Healthcare domain, and approximately one‐third of the articles involved the application of multiple HFE methods, with an increasing number of these including mathematical modeling such as Systems Dynamics and Agent Based Modeling. The review suggests there is a continued demand for both qualitative and quantitative outputs in systems HFE applications. As problem spaces and system complexity continue to intensify, evaluation, and potential adaption of methods may be required, including using more than one method. The challenge of matching methods to problems continues. To select appropriate methods, consideration should be balanced between factors such as the type of system being examined, the effort required to apply the method(s), the level of complexity of the system, and the necessary output.
... The article aims to provide qualitative analysis of operational risks associated with eVTOLs in urban settings. By adopting the FRAM methodology proposed by Hollnagel (2004;, the study seeks to comprehensively understand interactions within sociotechnical systems and identify emerging failures that could compromise safety and operational efficiency. While these vehicles offer cost reduction, operational efficiency, and environmental sustainability benefits, they also pose challenges in terms of safety, reliability, decision-making, and societal acceptance. ...
... The Functional Resonance Analysis Method (FRAM), developed by Hollnagel (2004;, emerges as an effective tool for understanding interdependencies and relationships within highly complex and integrated systems. The method provides a clear view of how each variable acts within a function (whether as input, prerequisite, control, resource, or temporal parameter) and how variability in each can impact the function in question. ...
This article explores the application of the Functional Resonance Analysis Method (FRAM) in assessing the operational concept of Electric Vertical Takeoff and Landing (eVTOL) vehicles in urban environments. The study investigates the challenges and risks associated with urban mobility, focusing particularly on the potential impact of eVTOLs as an innovative mode of transportation. The increasing interest in autonomous or piloted aerial vehicles stems from the growing demand for air transport and the imperative to reduce CO2 emissions. The article aims to provide qualitative analysis of operational risks associated with eVTOLs in urban settings. By adopting the FRAM methodology proposed by Hollnagel (2004; 2012), the study seeks to comprehensively understand interactions within sociotechnical systems and identify emerging failures that could compromise safety and operational efficiency. While these vehicles offer cost reduction, operational efficiency, and environmental sustainability benefits, they also pose challenges in terms of safety, reliability, decision-making, and societal acceptance. Studies underscore the need to balance the advantages of aerial vehicles with the complexities of urban infrastructure and existing air traffic management systems. The Concept of Operations (CONOPS) was defined through literature review. Using a standardized scenario, the operation was modeled using FRAM and function abstraction at different hierarchical levels. Findings highlight the importance of integrating diverse stakeholders and addressing uncertainties in urban air mobility planning. In conclusion, applying FRAM to assess the operational concept of eVTOLs provides a holistic perspective on the challenges and opportunities of integrating advanced aerial vehicles into urban transportation systems. By comprehending the intricate interactions within sociotechnical systems, stakeholders can make informed decisions to enhance safety, efficiency, and sustainability in future urban air mobility initiatives
... is of great value for any complex sociotechnical system. According to Hollnagel [1], a sociotechnical 28 system is a composition of numerous subsystems with multiple functions. Despite the expectation 29 that their operations are standardized and predictable, the infinite interactions among the 30 components of this system yield variable outcomes and consequences, both positively and 31 ...
... methods, systemic approaches consider the various layers of the hierarchical structure of a complex 256 sociotechnical system. Notable methods include Accimap [9][25], CAST [26], FRAM [1], and others. ...
This study addressed the complexity of sociotechnical systems through an investigative analysis of 11 the accident involving a Boeing F/A-18F Super Hornet and KC-130J during an in-flight refueling 12 procedure conducted by the US Marine Corps in 2018. The event was investigated using 13 Rasmussen's Accimap and Leveson's STAMP/CAST methodologies, identifying the main 14 contributing factors, their correlations, and control failures that led to the critical event. The study 15 emphasizes the demanding nature of in-flight refueling, highlighting the dependence on pilot 16 expertise and the absence of safety systems during critical phases. Conclusions underscore the 17 significance of human factors, such as fatigue and stress, in accidents of this nature, advocating for 18 ongoing research in ergonomics. The limitations and strengths of the methodologies are discussed, 19 with a suggestion for future studies to incorporate Neisser's Perceptual Cycle Model to better 20 understand human factors influencing decision-making in such events. 21 22
... FRAM analysis, which is used to create potential accident scenarios that may occur in work environments, was introduced by Hollnagel (2016) and developed in the following years (Hollnagel, 2016). FRAM is a systemic analysis method that tries to explain the non-linear relationships and interactions between different functions in a system. ...
The commercialization of liquefied natural gas (LNG) offers significant benefits to various industries; however, its chemical properties pose substantial risks, potentially resulting in catastrophic incidents. The transportation, storage, and utilization of flammable substances like LNG can lead to industrial accidents, such as fires and explosions, if not adequately controlled. To mitigate these risks, conducting a comprehensive hazard and risk analysis at the worksite and implementing appropriate safety measures are essential. This study focuses on analyzing potential fire and explosion scenarios that may arise in a port area engaged in LNG operations, employing the Functional Resonance Analysis Method (FRAM). Accident processes are examined through functional analysis, identifying 20 distinct functions. Of these, 7 functions were categorized as high risk, 5 as medium risk, and 8 as low risk. Based on the findings, this study provides recommendations for safety measures aimed at safeguarding both occupational health and environmental integrity.
... While certain risk assessment methods, such as STPA and the Functional Resonance Accident Method (FRAM), are rooted in systems thinking, their complexity and the time required for effective application have limited their widespread adoption (Dallat et al. 2018;Hollnagel 2016;Leveson 2011). This has led to a demand for new approaches that embody systems thinking principles while remaining user-friendly. ...
Human factors methods, as a systems discipline, can be applied across various areas of working systems. Risk assessment methods are particularly useful for identifying risks that may impact the performance of overall working systems, groups, and individuals. The emergency evacuation process in hospitals involves multiple risks that can significantly affect its performance. This study applied a systems thinking‐based risk assessment method to identify risks associated with hospital emergency evacuations. The Networked Hazard Analysis and Risk Management System (Net‐HARMS) method was utilized to identify all credible risks in the hospital evacuation process during emergencies that could degrade optimal performance. Some of the key risks identified in the hospital emergency evacuation process included delays in assessing risks associated with evacuation procedures, failures or delays in forming and appointing an emergency evacuation and command team, and inadequate intra‐ and interorganizational coordination. Additionally, emerging risks were identified, such as delays in the evacuation process due to staff lacking sufficient information about the evacuation and incident command team members, as well as delays in receiving assistance from external organizations like the fire department and Red Crescent due to inadequate interorganizational coordination processes. These risks arose from the interactions between activities. The study concludes that the Net‐HARMS method is effective in forecasting systemic and emergent risks in the hospital evacuation process, as well as identifying risks associated with specific activities and emergent risks in this critical process.
... Accidents may happen anytime. As a matter of fact, it probably happened even during caveman age (Hollnagel, 2016). Since the development of automobile as a mode of transportation has increased over the past decades, it has been an important part of our daily lives. ...
Since the development of automobile as a mode of transportation has increased, it has been an important part of our daily lives. However, vehicle-related road accidents worldwide have also increased. Even with the efforts of government and non-government institutions to at least solve these problems, accident may happen no matter what. Lives could have been saved if the information related to the accident is reported on time. Literature review shows that there has not been a published research and patented device in Asian countries that automatically notifies the police and rescue team if there is an accident. This research study developed a device that automatically notifies the Philippine National Police (PNP) office if there is an accident occurred. The device is comprised of different sensors such as ultrasonic and vibration, and modules such as Global System for Mobile communication (GSM) and Global Positioning System(GPS). The sensors detect objects and vibration and will evaluate the gathered data using decision matrix if it is an accident or not. If the device detects an accident, it will automatically get the GPS location of the vehicle using the GPS module and sends a notification message to the nearby PNP office via SMS using the GSM module. This study followed the Agile methodology with ISO 9126 - based questionnaire and interview as a mode to gather data. A pilot of 45 respondents were used in this study, divided into two categories, 1) Police Officers and 2) Motorcycle Riders. Overall, the respondents evaluated the device as acceptable in terms of its functionality, usability, efficiency, maintainability and portability. For future works, further improvement and implementation of the device is highly recommended.
... IoT-based vehicle accident detection and rescue information system detects car accidents and sends location information to the vehicle owner, nearest hospital, and police station via a web service [9]. Intelligent reflecting surface (IRS) is implemented on the road, in which the two big-size road reflectors can be utilized as a communication medium with Low Earth Orbit (LEO) satellite [10]. A Smart Road Stud (SRS) is implemented for vehicle speed detection technique with two identical three-axis geomagnetic sensors, wireless communication, selfpowering module, and controlled light-based traffic direction [11], [12]. ...
The Internet of things (IoT) has been proven as an efficient technology for real-time monitoring of physical things through the Internet from any location. With the advancement in sensors and communication technologies, the implementation of IoT is adopted in wide extensions. Road reflectors on highway roads need to be automated and also powered with intelligence. With this motivation, we have proposed and implemented IoT and long range (LoRa) based architecture for the realization of smart road reflectors on the highway. To realize the proposed architecture, the hardware of the smart reflector and gateway is implemented on the university campus. During our implementation of the hardware, we observed the light intensity values that are sensed by smart reflectors on the server through LoRa and internet connectivity. In the future, we will be integrating additional sensors and also power the smart reflector with artificial intelligence to predict the fog status of a particular road.
... Il peut permettre d'anticiper ainsi une défaillance possible. Cette anticipation permet l'élaboration de différentes « barrières » pour bloquer l'apparition de différentes conditions nécessaires à l'apparition des défaillances (Hollnagel, 2016). ...
Analyse systémique et organisationnelle des violences en entreprise à des fins de prévention : le modèle systémique d'analyse des situations de violence au travail (MSVT)
... FRAM is a method for system analysis with a focus on process functions and how they depend on one another. 64 Each function is characterized in terms of six attributes: (1) input, (2) output, (3) precondition (necessary state before the function can begin), (4) resource, (5) control (instructions for execution), and (6) time (temporal considerations for execution). One of the principles underlying FRAM is that functions can interact to produce outsized variability in outcome, that is, functional resonance. ...
This review article aims to provide an overview of accident models and incident analysis techniques in the context of radiation oncology. Accident models conceptualize the mechanisms through which accidents occur. Chain‐of‐event models and systemic models are two main categories of accident models and differ in how accident causation is portrayed. Chain‐of‐event models focus on the linear sequence of events leading up to an accident, whereas systemic models emphasize the nonlinear relationships between the components in a complex system. The article then introduces various incident analysis techniques, including root cause analysis (RCA), London Protocol, AcciMap, and Causal Analysis Based on Systems Theory (CAST), which are based on these accident models. The techniques based on the chain‐of‐event model can be effective in identifying causal factors, safety interventions, and improving safety. The other techniques based on the systemic models inherently facilitate an examination of how the influence of personal conditions, environmental conditions, and information exchange between different aspects of a system contributed to an accident. To improve incident analysis, it is essential to translate unsafe human behavior into decision‐making flaws and the underlying contextual factors. Where resources allow, it is also crucial to systematically link frontline contributions to organizational and societal aspects of the system and incorporate expertise in safety science and human factors into the analysis team. The article also touches on related concepts such as Perrow's Normal Accident Theory (NAT), Functional Resonance Analysis Method (FRAM), and Bowtie Analysis, which are not based on specific accident models but have been used for safety improvement in radiation oncology. Overall, different incident analysis techniques have strengths and weaknesses. Taking a systems approach to incident analysis requires a shift from linear thinking to a more nuanced understanding of complex systems. However, the approach also brings unique value and can help improve safety as radiation oncology further gains complexity.
... "estaba evaluación de riesgos facilita la toma de decisiones ya que ofrece una visualización transparente de los riesgos más críticos que deben ser atendidos con el juicio" (6), por lo que la aplicación de dicha matriz, en coordinación y combinación con los análisis anteriores, garantiza una evaluación integral y una priorización efectiva de los riesgos en esta empresa. ...
Este estudio evaluó los riesgos de seguridad en Diflopes S.A., empresa de reparación y mantenimiento de embarcaciones. Los objetivos fueron identificar y priorizar los riesgos mediante herramientas tales como el Análisis de Peligros y Operabilidad (HAZOP), Evaluación de Riesgos en el Lugar de Trabajo (JSA) y una matriz de evaluación de riesgos. Los resultados mostraron desviaciones críticas en procesos clave, riesgos asociados a tareas y una priorización efectiva de los riesgos en función de su probabilidad e impacto; y las conclusiones dejan ver lo necesario que es el implementar medidas de control con rigurosidad y la importancia de una cultura de seguridad participativa.
... The analysis of actual accidents is essential for the formulation of inferences aimed at accident prevention [8]. In other words, accidents can only be prevented when they are correctly defined and understood [9,10]. At this juncture, the analysis of past accidents is of paramount importance for the development of strategic measures to prevent potential future accidents. ...
... Rasio efektivitas sebesar 26% memberikan gambaran bahwa dari rata-rata pengendalian kritikal yang terimplementasi sebesar 73% hanya sedikit yang bisa mengintervensi insiden secara menghilangkan penyebab ataupun mengurangi eskalasi (ICMM, n.d.) sehingga insiden terjadi. (Hollnagel, 2016 ...
Penelitian ini bertujuan untuk menganalisis kehandalan pengendalian kritikal dalam mengurangi risiko tabrakan alat berat di PT X selama periode 2019-2023. Metode penelitian ini menggunakan analisis deskriptif analitik dengan pendekatan kualitatif dan kuantitatif, menggunakan data sekunder dari laporan insiden selama periode tersebut. Hasil penelitian menunjukkan bahwa meskipun tingkat implementasi pengendalian kritikal relatif tinggi (73%), efektivitasnya dalam mencegah insiden masih rendah (26%). Temuan ini mengindikasikan perlunya perbaikan implementasi dan evaluasi rutin terhadap pengendalian kritikal untuk meningkatkan keselamatan operasional di tambang.
... The Functional Resonance Analysis Method (FRAM) is a systemic, nonlinear approach to analyze complex sociotechnical systems (Hollnagel, 2013). Developed by Hollnagel, FRAM seeks to understand not only how systems work under normal conditions but also how interactions between system components can lead to accidents when variability is introduced (Hollnagel, 2016). Unlike traditional linear accident analysis methods, which focus on cause-and-effect relationships, FRAM views accidents as emergent outcomes resulting from the interaction of multiple, interdependent functions (Hollnagel and Goteman, 2004). ...
... The majority of the generators at the BSs are noisy, according to the results, which suggests the necessity for barriers. However, this research proposes the use of zoning in physical planning because of the diversity of barriers, including physical, procedural, instructions, and behaviors [15]. Accessibility to base stations for accurate positioning may have affected the results. ...
The installation of base stations in Accra and other urban centers meant to expand mobile phone network coverage has met opposition from the public. This study was carried out to assess the noise levels of generators utilized at the mobile telecommunication base stations focusing on noise levels from mobile telecommunication base stations in residential zonings only at the night (2200-0600). The methodology for data collection involved a quantitative approach using simple compliance coefficient data analysis. The study results showed that noise levels from generator sets at base stations in residential areas were not always below the Environmental Protection Agency’s (EPA) threshold of 48dB within the hours of 2200 to 0600 at a distance of 50m from base stations. There is, therefore, noise pollution in this perimeter which has been classified as a residential area with negligible or infrequent transportation. In this regard, district assemblies ought to strictly implement a minimum setback distance of not less than 50m of telecommunication BSs from the closest residential structure.
... The World Health Organization (WHO) defined road crashes as an epidemic [3] and, a posteriori, as a pandemic [4]. Generally speaking, a road crash is an unplanned and uncontrolled event in which the action, or reaction of an object, substance, person, or radiation, resulted in injury or the probability of injury to persons [5] or a brief, sudden, and unexpected event or fact that results in an undesirable result and is due, directly or indirectly, to human activity rather than a natural event [6]. ...
Driving a vehicle, whether motorized or not, is a risky activity that can lead to a traffic accident and directly or indirectly affect all road users. In particular, road crashes involving pedestrians have caused the highest number of deaths and serious injuries in recent years. In order to prevent and reduce the occurrence of these types of traffic accidents and to optimize the use of the available resources of the administrations in charge of road safety, an updatable predictive model using Markov chains is proposed in this work. Markov chains are used in fields as diverse as hospital management or electronic engineering, but their application in the field of road safety is considered innovative. They are prediction and decision techniques that allow the estimation of the state of a given system by simulating its stochastic risk level. To carry out this study, the available information on traffic accidents involving pedestrians in the database of the Local Police of Badajoz (a medium-sized city in the southwest of Spain) in the period 2016 to 2023 were analyzed. These data were used to train a predictive model that was subsequently used to estimate the probability of occurrence of a traffic crash involving pedestrians in different areas of this city, information that could be used by the authorities to focus their efforts in those areas with the highest probability of a road crash occurring. This model can improve the identification of high-risk locations, and urban planners can optimize decision making in designing appropriate preventive measures and increase efficiency to reduce pedestrian crashes.
... In other words, safety means (the safety of the individual from accidents and avoiding them). (18) Health, It means protecting human resources from physical and psychological diseases that may be contracted in the workplace, which are caused by either the general physical climate, the individual, or the nature of the work (job) itself, and these diseases do not occur immediately but rather over time, as they are contracted as a result of continuous exposure to their causes, which means that their occurrence is not instantaneous but occurs cumulatively, in other words, the concept of health means (the individual being free from physical and psychological diseases). (19) 2. ...
The issue of human resources management, the physical and psychological work environment in order to provide health, safety and environment for the human element in the workplace, is an important part of the human resources management strategy, because this issue has a direct impact on the most important thing that a person has, which is his health and life, and at the same time it is of great economic importance for the organization and society, because the high rate of work injuries and diseases in organizations costs them huge amounts of money spent on treatment, in addition to the fact that it disrupts work in them. As for society, the increase in these expenses negatively affects the national product and leads to the loss of part of the country's productive capacity. The concept of human resources management is an activity that includes a set of technical and administrative works and procedures, concerned with studying the climatic and psychological conditions prevailing in the places where work is carried out within organizations in general and industrial organizations in particular, and designing specialized programs in order to control/remove the sources and causes of potential accidents and diseases that human resources may suffer from while performing their work, resulting from the nature of this work, or from the surrounding climatic and psychological conditions, in order to work on providing the means of protection capable of avoiding these risks and their negative effects on the safety and health of human resources in the workplace, or at least mitigating these effects, and creating a sound and healthy physical and psychological work environment and climate that protects these resources from any danger.
... Most accidents in recent years have been the result of the interaction of multiple aspects (e.g., technological, human, or organizational) present in socio-technical systems [1] . Traditional safety engineering methods such as fault tree analysis, event tree analysis, failure mode and impact analysis are unable to explain how multiple causes can lead to accidents [2] Erik Hollnagel first proposed the Functional Resonance Accident Model (FRAM) in 2004 [3] , where he describes the Functional Resonance Accident Model (FRAM) content and Functional Resonance Theory (FRT). The model can be used both to explain complex accidents and to identify risks in dynamic systems. ...
The community evacuation process is a complex system, coupled and linked by multiple interactions, and traditional safety engineering methods are unable to explain how multiple causes can lead to an incident. By introducing the concept of mediated centrality and constructing the BC-FRAM critical risk factor identification model for residential evacuation, the Betweeness Centrality- Functional Resonance Accident Model (BC-FRAM) solves the problem that traditional functional resonance methods can ignore risk modules with low performance fluctuations but high impact levels in complex networks. The ability of the BC-FRAM model to identify key risk factors in community evacuation is improved by a factor of 1 and the ability to identify failed functional connections is improved by 44.4% over the traditional FRAM model.
... En el ámbito de la seguridad industrial, los enfoques tradicionales como Safety I (Reason, 1990;Hollnagel, 2004) se han centrado principalmente en la prevención de accidentes y la reducción de errores humanos. Este paradigma, basado en la identificación de causas directas y la implementación de controles específicos para evitar accidentes, presupone una visión mecanicista del mundo en la que los accidentes son vistos como fenómenos evitables mediante la eliminación de sus causas inmediatas. ...
Las corrientes teóricas de las ciencias de seguridad se han dedicado a pensar la prevención de siniestros y la mitigación de riesgos desde un enfoque que predominantemente identifica las causas subyacentes de los accidentes en factores humanos o factores técnicos. Sin embargo, estos paradigmas pueden ser insuficientes para capturar la complejidad de la gran cantidad de variables que entran en juego al momento en que se produce un accidente. Este artículo propone una alternativa teórico-metodológica para la gestión de la seguridad industrial fundamentada en la integración de la Ontología Orientada a Objetos (OOO) y la Teoría del Actor-Red (TAR). Por tanto, se propone una aproximación a una "Seguridad Orientada a Objetos" que considera la interdependencia y el impacto de todos los actantes en un entorno industrial, permitiendo desarrollar sistemas de seguridad más sólidos y robustos al reconfigurar el proceso cognitivo de identificación y mapeo de actores que intervienen en un accidente.
... These findings align with studies in European, American, or Australian contexts. These insights parallel studies conducted in European, American, or Australian contexts Hollnagel, 2016;Klei, 2017;Stefan Van, 2016;Dalvie et al., 2014;Barnes and White, 2020) . ...
... The definition encompasses barriers that form part of a sequence of activities embodying the conventional MORT barrier notion, yet may be insufficient to protect the target independently [20,23]. This is achieved by introducing the concept of defence-in-depth of the fault and event tree [24][25][26]. ...
In accident causation, the interaction between human involvement and organizational factors plays a crucial role, often leading to deviations at the organizational level before affecting humans and equipment. Taking a proactive approach to identify and address these organizational-level deviations holds promise in preventing subsequent human and equipment failures. However, traditional risk assessment methods like PHA, HAZOP, FMEA, LOPA, and QRA, while foundational, lack the sufficient capacity to assess safety barrier performance and quantify Risk Influence Factors (RIFs). This gap results in overlooking the impact of organizational factors on the overall risk profile. This chapter aims to fill this gap by exploring models of safety incident origins explicitly designed to integrate RIFs, addressing critical gaps in root cause analysis. These methodologies, mindful of RIFs, provide a comprehensive view covering short- and long-term factors influencing technological systems and human behavior. The modeling of RIFs becomes crucial, offering insights essential for identifying risk prevention and mitigation strategies, along with relevant indicators. The utilization of these indicators for monitoring RIF states is instrumental in uncovering fluctuations directly linked to shifts in the risk scenario. The chapter examined various models and methodologies, including Barrier and Operational Risk Analysis (BORA), Causal Modeling of Air Transportation System (CATS), Hybrid Causal Logic Model (HCL), Accidental Risk Assessment Methodology for Industries (ARAMIS), Integrated Risk (I-Risk) method, Accident Causation using Hierarchical Influence Network (MACHINE), Operational Condition Safety (OTS), and Risk Modeling—Integration of Organizational, Human, and Technical factors (Risk-OMT). It also highlights hybrid methodologies, incorporating diverse tools like Bayesian networks into accident causation modeling. This exploration serves as a guide for an adaptive approach in complex sociotechnical systems. Emphasizing the pivotal role of organizational and management factors in shaping accident dynamics and risk assessments, this work offers a scholarly yet accessible insight into risk assessment methodologies considering RIFs.
... Initiated by Hollnagel in the 2000s and described in 2004, FRAM is a qualitative method for the functional analysis of complex systems, modeling functions and their variability (Hollnagel, 2004;Anvarifar et al., 2017). According to Benyettou and Megnounif (2022), FRAM is one of many methods developed over the last 30 years, such as Functional Block Diagrams (FDB), Structured Analysis and Design Technique (SADT), and the Functional Tree (FT). ...
Health and Safety Committees (HSC) play a crucial role in preventing accidents
in the workplace and improving working conditions and well-being. The
presence of these committees should considerably reduce occupational risks in
companies. However, the number of accidents at work and occupational
illnesses is still on the increase, despite the existence of these committees,
whose functions have not been thoroughly evaluated.
This study examines the functional variability of the HSCs, more specifically
the Algerian Joint Health and Safety Committee (CPHS), using the Functional
Resonance Analysis Method (FRAM). The aim is to identify CPHS functions,
the interactions, the variability and the functional resonance, as well as the
underlying causes of the variability of these functions. This will make it
possible to draw up a prevention policy and a national action plan for effective
implementation of these committees in Algerian companies, enhancing the
well-being and safety of workers. This study is the first to apply the FRAM
method to the emergence of CPHSs, offering a new perspective for other
countries to assess the functions of their HSCs, despite the limitations
associated with the qualitative nature of the FRAM method.
... For example, in the work (Hollnagel, 2004), for the application in IT the author divides P-Y techniques into three types: ...
It is widely acknowledged that the expenses associated with substandard quality constitute a significant portion of a company's overall costs. Consequently, organizations adopt quality management systems and implement corrective and preventive measures to reduce these expenses. Within these implementations, Poka-Yoke techniques are notably prominent. Theoretically, these techniques are designed to prevent mistakes that lead to costs, especially quality-related costs associated with nonconforming products. This study proposes a classification of Poka-Yoke techniques and a methodology for evaluating the effectiveness of these techniques. The methodology was applied in the evaluation of selected techniques implemented in various assembly tasks. This assessment relies on objective characteristics of the techniques. The value of this method lies in its ability to easily evaluate techniques to implement in areas where interventions are needed to increase the reliability of the production system. Thus, it serves as a simple tool to help design new and improve existing workplace organizations.
... For decades, safety researchers have been developing accident causation models, beginning with the Domino theory (Heinrich et al., 1980(Heinrich et al., , origin. 1931) and including Turner's theory of man-made disasters (1978) and the idea of the incubation period, Perrow's theory of normal accidents (Perrow, 1984), Reason's Swiss cheese model and barriers (1997), the idea of drifting into failure and sacrificing decisions (Rasmussen, 1997) and so forth, up to recent even more complex non-linear models (Hollnagel, 2004;Leveson, 2004). Researchers as well as safety experts in organizations have been chasing the root cause of accidents and the prevalent and latent conditions related to accidents, and have offered explanations with the aim of understanding -and preventing -the factors contributing to accidents. ...
... The high accident and fatality rates suggest that there is an urgent need to design and implement accident prevention measures in the construction industry. As an accident prevention strategy, analyzing accident case studies is a crucial approach to understanding the patterns of accident occurrence and identifying potential risk factors [9][10][11]. Thus far, several effective accident prevention strategies have been developed by analyzing case studies, and the Korean government has taken measures based on the results, such as establishing public health and safety management guidelines and prohibiting hazardous subcontracting work [12][13][14]. ...
Before starting any construction work, providing workers with awareness about past similar accident cases is effective in preventing mishaps. Based on construction accident reports, this study developed two models to identify past accidents at sites with similar site information. The site information includes 16 parameters, such as type of work, type of accident, the work in which the accident occurred, weather conditions, contract conditions, type of work, etc. The first model, the site information classification model, uses named entity recognition tasks to classify site information, which is extracted from accident reports. The second model, the similar-site accident retrieval model, which finds the most similar accidents that occurred in the past from input site information, uses a semantic textual similarity task to match the classified information with it. A total of 17,707 accident reports from South Korean construction sites were found; these models were trained to use Korean Language Understanding Evaluation–Bidirectional Encoder Representations from Transformers (KLUE-BERT) for processing. The first model achieved an average accuracy of 0.928, and the second model was precisely matched, with a mean cosine similarity score exceeding 0.90. These models could identify and provide workers with similar past accidents, enabling proactive safety measures, such as site-specific hazard identification and worker education, thereby allowing recognition of construction safety risks before starting work. By integrating site information with historical data, the models offer an effective approach to improving construction safety.
The aim of this chapter is to highlight the potential of collaboration between logistics players for sustainable road safety. Such collaboration could be effective in better assessing the level of road insecurity and proceeding with the planning of road safety countermeasures. The approach adopted for this analysis is based on the exploitation of research work and cross-referenced data on road insecurity collected by official bodies. Emphasis is placed on the collaboration of stakeholders in identifying the main road safety problems and discussing appropriate countermeasures likely to solve specific road safety problems. The practices of the players who have sought to optimize road safety are numerous, and the tools mobilized are varied. Many players have collaborated on road safety issues in research fields such as engineering (automotive, infrastructure...), economics (accident statistics, planning...), decision-makers ...etc, but they do not agree on a precise approach, so much so that there are as many players as there are approaches.
This project presents the study of the safe procedures of LNG loading and unloading operation in port. The purpose of this study is to maintain the safety record of LNG operation for this roughly forty years. The study is carried out by performing ‘one to one interview’ with the port’s safety officer. Then, the collected data from the personal interview is analyzed using Hazard Identification (HAZID) approach. The detail procedures, technical data, and explanation from port’s safety as an expertise in LNG handling field could be needed to determine the potential improvement that could trigger the idea to develop a generic safety model which is refined and improved of the existent holistic model that being reviewed in this study. The model developed in this study is to be applied onto either loading or unloading LNG terminal all over the world. This model is expected to meet the aim of minimizing the unsafe act and near miss which is always be the initiation point of harmful incident and accident. Model which has been developed is an improved and refined version of a generic safety model. The model developed describes the integration of technologies within the system of working competency which also reconsidering the individual performance. In the same time, it aimed to reduce the probabilities of the crews or operators to engage with unsafe act which always introduce the consequence of near miss, which is to be minimized in this research. The model developed in this study is called ‘H-T-D’ safety model, which stand for human factor, technical handling, and design element.
Several types of accidents, such as exposure to toxic gases, fires, or explosions, are encountered in process industries which are highly risk systems. To reduce risks and the consequences of disruptive events, resilience is recognized as one of the most important aspects of safety management, and resilience assessment in complex process systems plays an important role. This study examines methods for resilience assessment in process industries, by reviewing the published studies. Given the transient changes in resilience and performance variability due to complexity, it is examined which methods are more commonly applied for quantitative resilience assessments. As a result of the review of published literature, the most commonly used method to assess resilience in process industries is Dynamic Bayesian Network (DBN). DBN may be used for the estimation of uncertainty and probability of resilience in chemical processes. The resilience of complex process systems, which consider some aspects of resilience like absorption, adaptation, and recovery, is addressed and modeled by DBN. This review provides information on the use of quantitative methods to assess the resilience of complex process systems, the estimation of failure probability, the determination of performance variability under complex conditions, and the model of interactions between the components of a complex process system.
Le thème de la sécurité a un statut particulier dans les travaux de Jacques Leplat puisqu’il est transversal à toute sa carrière (Leplat, 1985, 2011; Leplat & Cuny, 1974). À partir des années 80, il s’est lié à celui de complexité, devenu indispensable pour décrire le monde qui nous entoure (Leplat & De Terssac, 1990; Morin, 2008; Woods, 1988). Les travaux de Leplat sur la complexité (1988) sont directement liés à son modèle-guide pour l’analyse de l’activité à partir du couplage (Leplat, 1997, 2000b). Cette modélisation met l'accent sur la manière dont les individus traitent les tâches complexes, intégrant les caractéristiques des sujets. Elle a ouvert d’importantes voies de recherche et de nouvelles perspectives de prévention centrées sur les compétences (Leplat, 2000a, 2008; Leplat & de Montmollin, 2001). Alors que de nouveaux courants et modèles ont émergé (en particulier autour de l’ingénierie de la résilience , par exemple Hollnagel, Woods, & Leveson, 2006), cet article propose de revisiter l’apport singulier des travaux de Jacques Leplat dans ce paysage mouvant et parfois divisé des sciences de la sécurité. C’est un article programmatique et théorique qui ouvre des perspectives pour tracer de futures recherches.
Our study was carried out in winegrowing in France and relates to the prevention of pesticide exposure situations. During treatments, the sprayer is a technical determinant directly responsible for these situations because of its design. The objective of our study is to gain a better understanding of pesticide exposure situations during the use of sprayers, by identifying the design of these machinery and the regulations that apply to it as a chain of determinants. Focusing on activity-centred ergonomics, this qualitative study formulates ergonomic (video recorded observations and interviews) and legal (content regulation) analyses at each level of this chain (treatments activities, sprayer design activities, regulation, and regulation development activities). The results highlight the role of design and regulation in the emergence of pesticide exposure situations, due to a little consideration of the real work of winegrowers. This means that design and regulation are relevant change levers for sustainable preventive action.
The rising frequency of heavy truck accidents in China poses a significant public safety risk, endangering lives and property. However, current research based on data from heavy truck accidents in China remains limited, making it challenging to support the formulation of traffic management measures. To mitigate the severity of these accidents, this study analyzed five years of heavy truck accident data from a specific region in China and developed logistic regression models for different road conditions. The aim was to identify the key factors influencing accident severity and understand the underlying mechanisms. The findings revealed that, under urban road conditions, the severity of heavy truck accidents is significantly impacted by factors such as lighting conditions, road safety attributes, driver age, and vehicle driving status. On highways, accident severity is largely influenced by visibility, roadside protection measures, intersection and section types, vehicle driving status, inter-vehicle accident types, and road safety features. On expressways, critical factors include inter-vehicle accident types, driver violations, visibility, and road alignment. In conclusion, the factors contributing to the severity of heavy truck accidents vary according to road conditions, which necessitates tailored traffic management strategies. The study’s findings offer theoretical support for more targeted approaches to preventing and controlling heavy truck traffic accident severity under different road conditions in China.
The scientific and practical potential of behavioral economics and behavioral design in Russia is underutilized, and the use of their methods can be significantly expanded, both in the scientific field and in practice. One of the promising areas of their application, with significant experience accumulated in the West, is healthcare. Behavioral design in healthcare is an example of an effective synthesis of the achievements of the humanities and technical sciences with an interdisciplinary approach that constructively combines economic, psychological, and technological methods of scientific knowledge. The use of behavioral design technologies, including digital and neural interfaces, is a promising direction for creating competitive products and services in healthcare. The theory of solving inventive problems can help speed up the process of implementation in practice. Behavioral design technologies in healthcare can be considered from such positions as physical design – the design of medical equipment, devices, and drug labels – as well as design for error-proofing in organizing processes based on reducing the negative impact of the human factor. The behavioral design of error-proofing systems in healthcare is implemented through functions such as forced control, error failure, warning, and touch alert.
Authors: This study investigates the impact and implications of passenger mobility through crowdshipping on customer satisfaction and environmental degradation. A questionnaire was used to collect data from customers who have been aeroplane passengers at Hang Nadim Airport in Batam, Indonesia. SmartPLS software was used to evaluate the quality of the questionnaire data and test the research hypotheses. The SmartPLS path model analysis results show that passenger mobility affects Crowdshipping, customer satisfaction, and environmental degradation; Crowdshipping affects passenger mobility and environmental degradation, and customer satisfaction affects environmental degradation. The findings of this study help understand and quantify potential strategies for logistics delivery by utilizing aeroplane passenger crowd shipping. Consequently, it can help policymakers and air transport companies develop air transport-based crowd shipping models to estimate the possible impacts from an economic and environmental point of view as well as environmental utilization.
Functional resonance analysis method (FRAM) is extensively employed in analyzing and managing performance variabilities. Additionally, semi‐quantitative and quantitative methods have been increasingly integrated with the FRAM to analyze complex socio‐technical systems to improve safety levels. This review article presents a comprehensive and updated survey of current literature focused on semi‐quantitative and quantitative methods employed for quantifying performance variabilities and exploring aggregation/propagation rules. A total of 1659 studies published between 2012 and March 2024 from various scientific databases were systematically examined using preferred reporting items for systematic review and meta‐analysis, identifying 29 studies that met inclusion criteria. The identified studies were categorized into four groups based on the quantitative methods employed: Monte Carlo simulation, fuzzy logic, cognitive reliability and error analysis method, and miscellaneous approaches. While different methodologies had unique strengths, they commonly relied on expert judgment for data collection, whether for defining probability distributions in Monte Carlo simulations, membership functions, and fuzzy rule bases in fuzzy inference systems, or selecting common performance conditions, determining their interrelationships, and assigning scores. Addressing bias from expert judgment in assessing performance variabilities can be achieved by using suitable experts' opinions integration techniques, and leading safety indicators in the analysis.
This chapter offers an overview of safety causation models, exploring both simple and complex linear, as well as nonlinear complex models and theories. Commencing with the foundational concepts of Linear Causation Models, the discussion underscores the complexities inherent in sociotechnical systems. The chapter examines into Simple Linear Causation Models, encompassing Heinrich’s Domino Theory and the Loss Causation Model, providing insights into straightforward cause-and-effect paradigms, accompanied by analyses of accident scenarios. Progressing to Complex Linear Causation Models, the chapter examines advanced frameworks such as the Energy-Damage Model, Time Sequence Models, Epidemiological Models, Systemic Models, and Rasmussen’s Risk Management Framework. Subsequently, the chapter introduces the latest nonlinear complex models, including the Normal Accident Theory, Functional Resonance Analysis Method (FRAM), and The Systems-Theoretic Accident Model and Process (STAMP). Each model is evaluated for its capacity to address the intricacies of accidents in complex environments. The critical aspects of validation and reliability are discussed, assessing the applicability of these frameworks in real-world scenarios. The chapter also underlines challenges and limitations, providing practical insights for researchers and practitioners. This concise exploration serves as a valuable resource for those seeking to comprehend safety and accident causation models, bridging the gap between these models and the intricate dynamics of complex sociotechnical systems.
Research facilities such as spallation sources and synchrotrons generate radiation for use in atomic-level or molecular-scale experiments. These facilities can be viewed as complex safety-critical systems. An important aspect of the safety management of such systems is the short safety education and training programme the users are required to undergo in order to gain facility access. As research on the topic is limited, this study aimed to increase the knowledge about current education design and practice using the perspectives of safety science and pedagogy. Study objectives were to identify preconditions that impact the safety education design, to describe current design and practice of the safety education, and to identify weaknesses and possibilities for improvement. Site visits with a total of 20 interviews were performed at three research facilities. The results show the need for sufficient resources to maintain learning activities for users, provide pedagogical continuing education for educators, and maintain safety culture-enhancing activities to meet the challenges of having large numbers of short-term facility users. Increased focus should be placed on safety-related competence needs and the mapping of these to match the competence of individual users. New thinking and innovation can benefit the design and provision of such education activities, based on both socio-technical system and system safety perspectives.
Road traffic accidents pose a significant threat to public safety, particularly in urban city like Antananarivo, capital of Madagascar. This study investigates the characteristics of roads accidents, aiming to analyze existing traffic management strategies and policies. Through comprehensive data analysis and evaluation of accident patterns, this research seeks to propose effective measures and policy enhancements to mitigate accident risks and enhance road traffic safety in the capital.
Specialized households serve as the primary units within specialized villages in China, and their capacity to withstand risks and external influences significantly shapes the future trajectory of specialized villages and the overall vitality of the rural economy. In this study, we established a measurement indicator system based on the definition of specialized households’ resilience, elucidating the logical connection between specialized households’ resilience and rural industrial development in China. The musical instrument industry in Lankao County, Henan Province of China, was employed as a case; survey data, the entropy method, and an obstacle diagnosis model were used to examine how instrument production specialized households responded to the challenges posed by Corona Virus Disease 2019 (COVID-19) and the tightening of national environmental protection policies, yielding the following key findings: 1) there exists substantial variation in the comprehensive resilience levels among different specialized households; 2) the ability to learn and adapt is the most significant contributor to the overall resilience level of specialized households; 3) technological proficiency and access to skilled talent emerge as pivotal factors influencing specialized households’ resilience; 4) the positioning of specialized households within the industrial supply chain and the stability of their income have a direct bearing on their resilience level. The influence of specialized households’ resilience on industrial development primarily manifests in the following ways: stronger resilience correlates with increased stability in production and sales, fostering a more proactive approach to future actions. However, heightened exposure to the external macroeconomic environment can lead to a higher rate of export reduction. To enhance the development resilience of entities like specialized households and family farms, and to invigorate rural economic development, escalating investments in rural science and technology and prioritizing the training of technical talent become imperative.
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