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Publications (10 of 27) Show all publications
Maia Franca, J. E. & Hollnagel, E. (2023). Analyzing human factors and complexities of mining and O&G process accidents using FRAM: Copiapo (Chile) and FPSO CSM (Brazil) cases. Process safety progress, 42(S1), S9-S18
Open this publication in new window or tab >>Analyzing human factors and complexities of mining and O&G process accidents using FRAM: Copiapo (Chile) and FPSO CSM (Brazil) cases
2023 (English)In: Process safety progress, ISSN 1066-8527, E-ISSN 1547-5913, Vol. 42, no S1, p. S9-S18Article in journal (Refereed) Published
Abstract [en]

The study presented in this research is a systematic human factors approach comparing two striking process accidents in Latin America: the Copiapo mining accident (2010), at the San Jose 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&G-more similarities than differences were observed in the treatment of process safety anomalies, especially those related to major accidents. The intense interactions between workers, equipment and processes, in both industries, have been making significant developments in the edge of innovation and technology, however increasing the complexity of risks in the workplaces. Furthermore, the differences between the preparation and handling of emergency situations show how complex, and critical, process safety is in these industrial areas. Aiming to adequately evidence how this complexity is intrinsically part of the various system that form the entire process, the FRAM (Functional Resonance Analysis Method) was utilized to model and analyses both accidents, under a human factors approach. Interactions and interrelations between LOPC, nontechnical skills, resilience and technical procedures were noticed as crucial for process safety and productivity of daily operations, as well as the preparedness for emergency situations.

Place, publisher, year, edition, pages
John Wiley & Sons, 2023
Keywords
FRAM, human factors, mining, offshore, safety
National Category
Mineral and Mine Engineering Production Engineering, Human Work Science and Ergonomics
Identifiers
urn:nbn:se:hj:diva-58853 (URN)10.1002/prs.12428 (DOI)000873845500001 ()2-s2.0-85141412892 (Scopus ID)
Available from: 2022-11-10 Created: 2022-11-10 Last updated: 2024-01-03Bibliographically approved
Maia França, J. E. & Hollnagel, E. (2023). Human Factors Approach to Assess Risks and Reliability in Offshore Operations with FRAM (Functional Resonance Analysis Method). In: Offshore Technology Conference Brasil: . Paper presented at 2023 Offshore Technology Conference Brasil, OTCB 2023 Rio de Janeiro 24 October 2023 through 26 October 2023. Offshore Technology Conference
Open this publication in new window or tab >>Human Factors Approach to Assess Risks and Reliability in Offshore Operations with FRAM (Functional Resonance Analysis Method)
2023 (English)In: Offshore Technology Conference Brasil, Offshore Technology Conference , 2023Conference paper, Published paper (Refereed)
Abstract [en]

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 emerging risks. In addition, it is necessary to meet the regulatory requirements, which in Brazil are determined by ANP (Agência Nacional do Petróleo, Gás Natural e Biocombustíveis). In view of the Human Reliability regulatory requirements, a dedicated study was developed, seeking to align the expectations of the regulator, the company’s resources and the validated methodologies of analysis, a requirement of the ANP itself. As a result, following HSE publications and ANP guidance, it was observed that the FRAM (Functional Resonance Analysis Method) methodology, simultaneously, can meet both the demands of Human Reliability and Human Factors. From the activities performed onboard offshore units that present the most complex combination of risks, the operations with nitrogen (generation and freezing storage) and the operation of the gas dehydration unit, were selected to be analyzed with FRAM. The results of these analyses, in addition to failures, it was also perceived that human adaptive behavior, a building element of system resilience, promotes safe operational continuity, even with the partial or complete loss of intrinsic safety barriers.

Place, publisher, year, edition, pages
Offshore Technology Conference, 2023
Keywords
Behavioral research, Factor analysis, Human engineering, Offshore oil wells, Offshore technology, Reliability analysis, Risk assessment, Analysis method, Business needs, Functional resonance, Human reliability, Integrated management systems, Offshore oil platform, Offshore operations, Oil and natural gas, Regulatory requirements, Resonance analysis, Offshore oil well production
National Category
Occupational Health and Environmental Health
Identifiers
urn:nbn:se:hj:diva-62885 (URN)10.4043/32873-MS (DOI)2-s2.0-85175546331 (Scopus ID)978-1-959025-02-3 (ISBN)
Conference
2023 Offshore Technology Conference Brasil, OTCB 2023 Rio de Janeiro 24 October 2023 through 26 October 2023
Available from: 2023-11-15 Created: 2023-11-15 Last updated: 2024-02-07Bibliographically approved
Slater, D., Hollnagel, E., MacKinnon, R., Sujan, M., Carson-Stevens, A., Ross, A. & Bowie, P. (2022). A systems analysis of the COVID-19 pandemic response in the United Kingdom: Part 1 - The overall context. Safety Science, 146, Article ID 105525.
Open this publication in new window or tab >>A systems analysis of the COVID-19 pandemic response in the United Kingdom: Part 1 - The overall context
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2022 (English)In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 146, article id 105525Article in journal (Refereed) Published
Abstract [en]

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, 2019). On the other hand, a more constructive approach, is to capture and understand the work that was actually done.This would include normal activities, as well as positive adaptations to challenges and failures that may have occurred. Such an approach aimed at improving what worked, rather than blaming people for what went wrong, has the potential to contribute more successfully to controlling the consequences of the current crisis. Such an approach should thus be aimed at detecting and feeding back lessons from emerging and probably unexpected behaviours and helping to design the system to adapt better to counter the effects. The science and discipline of Human Factors (HF) promotes system resilience. This can be defined as an organisation's ability to adjust its functioning before, during or after significant disturbances (such as a pandemic), enabling adaptation and operation under both anticipated and unanticipated circumstances. A "functional" approach methodology enables the identification of where the system and its various interdependent functions (an activity or set of activities that are required to give a certain output), could be improved and strengthened; if not immediately, at least for the future. Along these lines, suggestions for adding key resilience functions are additionally identified and outlined. The application and insights gained from this functional approach to the 2015 MERS-Cov pandemic in South Korea has been seen as contributing substantially to the effective response to the current crisis in that country (min, submitted for publication). In this paper, we present an overarching framework for a series of projects that are planned to carry out focussed systems-based analysis to generate learning from key aspects of the COVID-19 pandemic response in the United Kingdom.

Place, publisher, year, edition, pages
Elsevier, 2022
Keywords
Systems thinking, COVID 19, Complex adaptive systems, FRAM
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:hj:diva-55078 (URN)10.1016/j.ssci.2021.105525 (DOI)000707816700005 ()34658531 (PubMedID)
Available from: 2021-11-15 Created: 2021-11-15 Last updated: 2021-11-15Bibliographically approved
Franca, J. E. M., Hollnagel, E. & Praetorius, G. (2022). Analysing the interactions and complexities of the operations in the production area of an FPSO platform using the functional resonance analysis method (FRAM). Arabian Journal of Geosciences, 15(7), Article ID 573.
Open this publication in new window or tab >>Analysing the interactions and complexities of the operations in the production area of an FPSO platform using the functional resonance analysis method (FRAM)
2022 (English)In: Arabian Journal of Geosciences, ISSN 1866-7511, E-ISSN 1866-7538, Vol. 15, no 7, article id 573Article in journal (Refereed) Published
Abstract [en]

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 onboard activities and risks, notably FPSO units; it is necessary to have adequate recognition of the elements that can support these activities and manage these risks, enabling productive and safe operations. In this sense, this article aims to increase the understanding of the complex interactions and inherent safety issues that arise in the operations of FPSOs, observing and analysing the work done onboard such platforms. The FRAM methodology has been chosen because it allows for the recognition and analysis of the complex interactions involving workers, equipment, system and offshore environment, focusing on the oil treatment area of the process plant. The results demonstrated some interesting findings regarding onboard safety and the relationship between human competences, work demands and process safety.

Place, publisher, year, edition, pages
Springer, 2022
Keywords
FPSO, Production, FRAM, Safety, Human factors, Non-technical skills
National Category
Production Engineering, Human Work Science and Ergonomics
Identifiers
urn:nbn:se:hj:diva-56141 (URN)10.1007/s12517-022-09801-0 (DOI)000770770200005 ()HOA;intsam;804211 (Local ID)HOA;intsam;804211 (Archive number)HOA;intsam;804211 (OAI)
Available from: 2022-04-01 Created: 2022-04-01 Last updated: 2022-04-01Bibliographically approved
Hollnagel, E. & Clay-Williams, R. (2022). Modelling complex socio-technical systems: The Functional Resonance Analysis Method (FRAM). In: F. Rapport, R. Williams and J. Braithwaite (Ed.), Implementation Science: The Key Concepts (pp. 110-112). Taylor & Francis
Open this publication in new window or tab >>Modelling complex socio-technical systems: The Functional Resonance Analysis Method (FRAM)
2022 (English)In: Implementation Science: The Key Concepts / [ed] F. Rapport, R. Williams and J. Braithwaite, Taylor & Francis, 2022, p. 110-112Chapter in book (Other academic)
Abstract [en]

In a complex system, it is difficult to understand how the system works in order to analyse, manage, or improve it. A common solution to overcome this difficulty is to construct a model of the system. A model should be more than a diagram illustrating components of the system and how they are connected. The real purpose of a model is to represent the essential characteristics of something in a way that is amenable to analysis and manipulation. Currently, the leading method to develop a functional model is the Functional Resonance Analysis Method (FRAM). The FRAM provides a way to describe functions that can be used to develop a model of how a system performs. This method is based on four principles: 1) work that goes well and work that doesn’t happen in essentially the same way, 2) performance on all levels of an organization is variable because it must be adjusted to meet existing resources and demands, 3) acceptable and unacceptable outcomes both emerge from variability due to the everyday adjustments, which 4) can lead to functional resonance and non-linear consequences. 

Place, publisher, year, edition, pages
Taylor & Francis, 2022
National Category
Production Engineering, Human Work Science and Ergonomics
Identifiers
urn:nbn:se:hj:diva-58767 (URN)10.4324/9781003109945-32 (DOI)2-s2.0-85140188977 (Scopus ID)9780367626112 (ISBN)9780367626136 (ISBN)
Available from: 2022-11-01 Created: 2022-11-01 Last updated: 2022-11-01Bibliographically approved
Arcuri, R., Bellas, H. C., Ferreira, D. D., Bulhões, B., Vidal, M. C., Carvalho, P. V., . . . Hollnagel, E. (2022). On the brink of disruption: Applying Resilience Engineering to anticipate system performance under crisis. Applied Ergonomics, 99, Article ID 103632.
Open this publication in new window or tab >>On the brink of disruption: Applying Resilience Engineering to anticipate system performance under crisis
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2022 (English)In: Applied Ergonomics, ISSN 0003-6870, E-ISSN 1872-9126, Vol. 99, article id 103632Article in journal (Refereed) Published
Abstract [en]

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 Brazilian Upper Amazon River region. To do so, we present two studies that by using a Resilience Engineering approach aimed to predict the functioning of the Brazilian Mobile Emergency Medical Service (SAMU) for riverside and coastal areas during the COVID-19 pandemic, based on the normal system functioning. Study I, carried out before the pandemic, applied ethnographic methods for data collection and the Functional Resonance Analysis Method - FRAM for data analysis in order to develop a model of the mobile emergency care in the region during typical conditions of operation. Study II then estimated how changes in variability dynamics would alter system functioning during the pandemic, arriving at three trends that could lead the service to collapse. Finally, the accuracy of predictions is discussed after the pandemic first peaked in the region. Findings reveal that relatively small changes in variability dynamics can deliver strong implications to operating care and safety of expeditions aboard water ambulances. Also, important elements that add to the resilient capabilities of the system are extra-organizational, and thus during the pandemic safety became jeopardized as informal support networks grew fragile. Using FRAM for modelling regular operation enabled prospective scenario analysis that accurately predicted disruptions in providing emergency care to riverine population.

Place, publisher, year, edition, pages
Elsevier, 2022
Keywords
FRAM, Mobile emergency care, Resilience engineering, Risk assessment, Safety management, Emergency services, Ferroelectric RAM, Amazon river, Emergency care, Emergency healthcares, Healthcare systems, Remote regions, Resilience engineerings, Risks assessments, Systems performance
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:hj:diva-55082 (URN)10.1016/j.apergo.2021.103632 (DOI)000720479600007 ()34740073 (PubMedID)2-s2.0-85118342683 (Scopus ID)
Available from: 2021-11-16 Created: 2021-11-16 Last updated: 2021-12-02Bibliographically approved
Hollnagel, E. & Clay-Williams, R. (2022). Work-as-Imagined and Work-as-Done. In: F. Rapport, R. Williams and J. Braithwaite (Ed.), Implementation Science: The Key Concepts (pp. 175-177). Taylor & Francis
Open this publication in new window or tab >>Work-as-Imagined and Work-as-Done
2022 (English)In: Implementation Science: The Key Concepts / [ed] F. Rapport, R. Williams and J. Braithwaite, Taylor & Francis, 2022, p. 175-177Chapter in book (Other academic)
Abstract [en]

Work-as-Imagined (WAI) and Work-as-Done (WAD) are two concepts borrowed from ergonomics. WAI represents how we think work should be done in order to achieve the intended outcomes. WAI covers our ideas about how others do, or should do, their work and also how we prepare our own work. In contrast, WAD represents the direct experience of those who actually do the work. Their understanding is detailed and precise, and their priorities are directly related to the work at hand, first and foremost to meet the goals of the activities for which they are responsible. The concepts of WAI and WAD make it possible to consider the difference between what people are expected to do and what they actually do without insisting that one is right and the other is wrong. The recognition of this difference is essential both for how work is managed and for how changes are planned and implemented. Managing work and changes to work must be grounded in a solid understanding of what actually goes on. When considering the gap between WAI and WAD, the solution should never be to make WAD comply with WAI. It is important, rather, to acknowledge the gap and to find ways to overcome it.

Place, publisher, year, edition, pages
Taylor & Francis, 2022
National Category
Production Engineering, Human Work Science and Ergonomics
Identifiers
urn:nbn:se:hj:diva-58769 (URN)10.4324/9781003109945-52 (DOI)2-s2.0-85140173326 (Scopus ID)9780367626112 (ISBN)9780367626136 (ISBN)
Available from: 2022-11-01 Created: 2022-11-01 Last updated: 2022-11-01Bibliographically approved
França, J. E. M., Hollnagel, E., dos Santos, I. J. A. & Haddad, A. N. (2021). Analysing human factors and non-technical skills in offshore drilling operations using FRAM (functional resonance analysis method). Cognition, Technology & Work, 23(3), 553-566
Open this publication in new window or tab >>Analysing human factors and non-technical skills in offshore drilling operations using FRAM (functional resonance analysis method)
2021 (English)In: Cognition, Technology & Work, ISSN 1435-5558, E-ISSN 1435-5566, Vol. 23, no 3, p. 553-566Article in journal (Refereed) Published
Abstract [en]

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 emerged. Managing them requires a methodology capable of understanding and recognising how this entire sociotechnical system works. This research uses the FRAM to model the activities performed by drillers, from the perspective of their workplace, inside the drilling unit of an offshore oil rig—a complex sociotechnical system. The interviews, on-board observations and data gathering performed as part of this study provided information that was used to build a FRAM model capable of representing the real work done by drillers inside the doghouses on offshore oil rigs. Through this model, the variability of human behaviour could be analysed in the context of the different situations that may happen, enabling researchers to understand the specific demands of the work and the correlation between WAI and WAD that naturally emerges. This FRAM-based analysis acknowledges that human factors and non-technical skills are responsible for the productive and safe execution of the work in both normal and critical operations situations, and identifies the impact of this variability—positive or negative—in the execution of daily tasks. It shows that workers’ varied responses can properly deal with complex system demands both in normal situations and in emergencies.

Place, publisher, year, edition, pages
Springer, 2021
Keywords
Drilling, FRAM, Human factors, Non-technical skills, Offshore, Safety, Behavioral research, Drilling equipment, Factor analysis, Ferroelectric RAM, Human engineering, Infill drilling, Large scale systems, Offshore oil well production, Offshore oil wells, Complex sociotechnical systems, Critical operations, Functional resonance, Offshore drilling operations, Offshore facilities, Offshore oil rigs, Sociotechnical systems, Offshore drilling
National Category
Environmental Engineering Production Engineering, Human Work Science and Ergonomics
Identifiers
urn:nbn:se:hj:diva-50232 (URN)10.1007/s10111-020-00638-9 (DOI)000541405300001 ()2-s2.0-85087082835 (Scopus ID);intsam;1458220 (Local ID);intsam;1458220 (Archive number);intsam;1458220 (OAI)
Available from: 2020-08-14 Created: 2020-08-14 Last updated: 2021-12-12Bibliographically approved
Hollnagel, E. (2021). Managing for security. In: G. Jacobs, I. Suojanen, K. E. Horton, P. S. Bayerl (Ed.), International Security Management: New Solutions to Complexity (pp. 43-53). Springer
Open this publication in new window or tab >>Managing for security
2021 (English)In: International Security Management: New Solutions to Complexity / [ed] G. Jacobs, I. Suojanen, K. E. Horton, P. S. Bayerl, Springer, 2021, p. 43-53Chapter in book (Refereed)
Abstract [en]

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 security by design, by prevention and by protection. Security, however, differs significantly from safety both because security breaches are intentional rather than haphazard, and because the secondary effects are more serious than the primary. This chapter considers these differences and concludes that security is not something that can be managed by itself or in isolation. The challenge is instead to manage for security so that a system or an organisation remains secure. © Springer Nature Switzerland AG 2021.

Place, publisher, year, edition, pages
Springer, 2021
Series
Advanced Sciences and Technologies for Security Applications, ISSN 1613-5113, E-ISSN 2363-9466
Keywords
Control, Resilience potentials, Safety, Security, Security by design, Security by prevention, Security by protection
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:hj:diva-50921 (URN)10.1007/978-3-030-42523-4_4 (DOI)2-s2.0-85093902570 (Scopus ID)978-3-030-42522-7 (ISBN)978-3-030-42523-4 (ISBN)
Available from: 2020-11-02 Created: 2020-11-02 Last updated: 2020-11-02Bibliographically approved
Frani§a, J. E. & Hollnagel, E. (2021). Process Safety Analysis Considering Human Factors in High Tech Industries. In: 2021 Spring Meeting and 17th Global Congress on Process Safety, GCPS 2021: . Paper presented at 2021 Spring Meeting and 17th Global Congress on Process Safety, GCPS 2021, Virtual, Online, 18 April 2021 through 23 April 2021. American Institute of Chemical Engineers
Open this publication in new window or tab >>Process Safety Analysis Considering Human Factors in High Tech Industries
2021 (English)In: 2021 Spring Meeting and 17th Global Congress on Process Safety, GCPS 2021, American Institute of Chemical Engineers, 2021Conference paper, Oral presentation with published abstract (Other academic)
Abstract [en]

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 safety strategies,including human factors approach,is a way to promote process safety in the design of the projects,construction,operation,and maintenance,in land,air and space. Although NASA had implemented several safety barriers in their operations since its beginning,some major accidents occurred,notably Columbia (2003) and Challenger (1986). At the same time,workplaces in the oil and gas (O&G) industry have evolved to become part of the modern complex sociotechnical system that characterizes onshore and offshore facilities today. The intense interactions between workers,systems,equipment,and processes have made companies in this sector more productive,but significant and complex risks have also emerged. This industry has a history of several accidents,such as Piper Alpha (1988),Texas City Refinery (2005) and Deepwater Horizon (2010),causing heavy losses and global geopolitical changes. All these accidents,in aerospace and O&G industries,involved machines and system that are operating in the very limit of engineering,specially in the sharp end of the operations. Having both industries as background,this study presents a human factor approach to assess two relevant accidents,using the FRAM (Functional Resonance Analysis Method) to perform this analysis.

Place, publisher, year, edition, pages
American Institute of Chemical Engineers, 2021
Keywords
Accident prevention, Accidents, Aerospace industry, Chemical analysis, Factor analysis, Ferroelectric RAM, Human engineering, NASA, Offshore oil well production, Analysis method, Functional resonance, Functional resonance analyse method, High tech industry, LOPC, Oil and Gas Industry, Oil-rigs, Process safety, Resonance analysis, Safety analysis, Space shuttles, FRAM, Human Factors, oil rig, space shuttle
National Category
Production Engineering, Human Work Science and Ergonomics
Identifiers
urn:nbn:se:hj:diva-58164 (URN)2-s2.0-85135227078 (Scopus ID)
Conference
2021 Spring Meeting and 17th Global Congress on Process Safety, GCPS 2021, Virtual, Online, 18 April 2021 through 23 April 2021
Available from: 2022-08-11 Created: 2022-08-11 Last updated: 2022-08-11Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0003-1666-7507

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