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  • 1.
    Arcuri, R.
    et al.
    Oswaldo Cruz Foundation – FIOCRUZ. Av. Brasil, 4036/10° Andar, Prédio da Expansão, Manguinhos, Rio de Janeiro, 21040-361, Brazil.
    Bellas, H. C.
    Oswaldo Cruz Foundation – FIOCRUZ. Av. Brasil, 4036/10° Andar, Prédio da Expansão, Manguinhos, Rio de Janeiro, 21040-361, Brazil.
    Ferreira, D. D. S.
    Production Engineering Program, Federal University of Rio de Janeiro – COPPE/UFRJ. Av. Horácio Macedo, 2030 - Bloco G - Sala 207 - Centro de Tecnologia, Cidade Universitária - Ilha do Fundão, Rio de Janeiro, 21941-914, Brazil.
    Bulhões, B.
    Oswaldo Cruz Foundation – FIOCRUZ. Av. Brasil, 4036/10° Andar, Prédio da Expansão, Manguinhos, Rio de Janeiro, 21040-361, Brazil.
    Vidal, M. C. R.
    Production Engineering Program, Federal University of Rio de Janeiro – COPPE/UFRJ. Av. Horácio Macedo, 2030 - Bloco G - Sala 207 - Centro de Tecnologia, Cidade Universitária - Ilha do Fundão, Rio de Janeiro, 21941-914, Brazil.
    Carvalho, P. V. R. D.
    Nuclear Engineering Institute – IEN/CNEN. R. Hélio de Almeida, 75, Cidade Universitária - Ilha do Fundão, Rio de Janeiro, 21941-614, Brazil.
    Jatobá, A.
    Oswaldo Cruz Foundation – FIOCRUZ. Av. Brasil, 4036/10° Andar, Prédio da Expansão, Manguinhos, Rio de Janeiro, 21040-361, Brazil.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    On the brink of disruption: Applying Resilience Engineering to anticipate system performance under crisis2022In: Applied Ergonomics, ISSN 0003-6870, E-ISSN 1872-9126, Vol. 99, article id 103632Article in journal (Refereed)
    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.

  • 2. Braithwaite, Jeffrey
    et al.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Hunte, Garth S.
    Discussion, integration and concluding remarks2019In: Working across boundaries: Resilient health care, volume 5 / [ed] J. Braithwaite, E. Hollnagel & G. S. Hunte, London: CRC Press, 2019, , p. 192p. 165-172Chapter in book (Other academic)
  • 3. Braithwaite, Jeffrey
    et al.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Hunte, Garth S.
    Introduction: The journey to here and what happens next2019In: Working across boundaries: Resilient health care, volume 5 / [ed] J. Braithwaite, E. Hollnagel & G. S. Hunte, London: CRC Press, 2019, , p. 192p. 3-8Chapter in book (Other academic)
  • 4. Braithwaite, Jeffrey
    et al.
    Hollnagel, ErikJönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.Hunte, Garth S.
    Working across boundaries: Resilient health care, volume 52019Collection (editor) (Other academic)
  • 5. Braithwaite, Jeffrey
    et al.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Wears, Robert L.
    Bon voyage: Navigating the boundaries of resilient health care2019In: Working across boundaries: Resilient health care, volume 5 / [ed] J. Braithwaite, E. Hollnagel & G. S. Hunte, London: CRC Press, 2019, , p. 192p. 9-14Chapter in book (Other academic)
  • 6.
    Chuang, S.
    et al.
    Graduate Institute of Data Science, Taipei Medical University, Taipei, Taiwan.
    Ou, J. -C
    Department of Emergency Medicine, Shuang-Ho Hospital, Taipei Medical University, Taipei, Taiwan.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Hou, S. -K
    Department of Emergency Medicine, Taipei Medical University Hospital, TaipeiMedical University, Taipei, Taiwan.
    Measurement of resilience potential: development of a resilience assessment grid for emergency departments2020In: PLOS ONE, E-ISSN 1932-6203, Vol. 15, no 9, article id e0239472Article in journal (Refereed)
    Abstract [en]

    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 assessment grid (RAG) into a custom-made RAG (ED-RAG) to support resilience management in EDs. Methods The study approach had three parts: 1) translation of Hollnagel’s RAG into Chinese version, followed by generation of a tailored set of ED-RAG questions adapted to EDs; 2) testing and revising the tailored sets until to achieve satisfactory validity for application; 3) design of a new rating scale and scoring method. The test criteria of the ED-RAG questionnaire adopted the modified three-level scoring criteria proposed by Bloom and Fischer. The study setting of the field test is a private regional hospital. Results The fifth version of ED-RAG was acceptable after a field test. It has three sets of open structured questions for the potentials to respond, monitor, and anticipate, and a set of structured questions for the potential to learn. It contained 38 questions corresponding to 32 foci. A new 4-level rating scale along with a novel scaling method can improve the scores conversion validity and communication between team members and across investigations. This final version is set to complete an interview for around 2 hours. Conclusions The ED-RAG represents a snapshot of EDs’resilience under specific conditions. It might be performed multiple times by a single hospital to monitor the directions and contents of improvement that can supplement conventional safety management toward resilience. Some considerations are required to be successful when hospitals use it. Future studies to overcome the potential methodological weaknesses of the ED-RAG are needed.

  • 7.
    Franca, Josue E. M.
    et al.
    Linnaeus Univ, Vaxjo, Sweden..
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Praetorius, Gesa
    Univ South Eastern Norway, Notodden, Norway..
    Analysing the interactions and complexities of the operations in the production area of an FPSO platform using the functional resonance analysis method (FRAM)2022In: Arabian Journal of Geosciences, ISSN 1866-7511, E-ISSN 1866-7538, Vol. 15, no 7, article id 573Article in journal (Refereed)
    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.

  • 8.
    Frani§a, J. E. M.
    et al.
    Linnaeus University, Kalmar, Sweden, Petrobras, Rio de Janeiro, Brazil.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Process Safety Analysis Considering Human Factors in High Tech Industries2021In: 2021 Spring Meeting and 17th Global Congress on Process Safety, GCPS 2021, American Institute of Chemical Engineers, 2021Conference paper (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.

  • 9.
    França, Josué E. M.
    et al.
    UFF (Universidade Federal Fluminense), Rio de Janeiro, Brazil.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    dos Santos, Isaac J. A. L.
    IEN (Instituto de Energia Nuclear), Rio de Janeiro, Brazil.
    Haddad, Assed N.
    UFRJ (Universidade Federal do Rio de Janeiro), Rio de Janeiro, Brazil.
    Analysing human factors and non-technical skills in offshore drilling operations using FRAM (functional resonance analysis method)2021In: Cognition, Technology & Work, ISSN 1435-5558, E-ISSN 1435-5566, Vol. 23, no 3, p. 553-566Article in journal (Refereed)
    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.

  • 10.
    França, Josué E.M.
    et al.
    UFF (Universidade Federal Fluminense), Rio de Janeiro, Brazil.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Dos Santos, Isaac José Antonio Luquetti
    IEN (Instituto de Energia Nuclear), Rio de Janeiro, Brazil.
    Haddad, Assed N.
    UFRJ (Universidade Federal do Rio de Janeiro), Rio de Janeiro, Brazil.
    FRAM AHP approach to analyse offshore oil well drilling and construction focused on human factors2020In: Cognition, Technology & Work, ISSN 1435-5558, E-ISSN 1435-5566, Vol. 22, p. 653-665Article in journal (Refereed)
    Abstract [en]

    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 needs, especially in developed and growing countries, the technology used by the O&G industry has evolved significantly, not only to increase production and profit levels, but also to reduce the risks of these activities, using reliable automation and other barriers to worker protection. However, despite all this investment, accidents such as the Deepwater Horizon, in 2010, and Odebrecht NS-32, in 2017, shown that there are still gaps in this process of evolution of protection systems, especially those used in highly complex systems such as offshore oil rigs. In addition, inevitably, the technological contribution implemented in offshore drilling systems increases their complexity and, consequently, also increases the complexity of the relationship between workers, systems, machines, and environment, definitively characterizing oil rigs as complex socio-technical systems. Keeping that in mind, a FRAM model was developed to understand the levels of complexity and show the relevant human factors that are critical for the safe operations of these workplaces, considering the natural and variability that emerges from these labour scenarios. Some functions of the FRAM model built presented significant variability, as function “Perform drilling operations”, where the most significant variabilities were observed in its 10 outputs, causing a large resonance within the model, once their couplings, mostly in their control aspects, can vary in terms of time and precision.

  • 11.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    FRAM. Metodo de Analisi della Risonanza Funzionale per costruire modelli di sistemi socio-tecnici e spiegare l'accadimento di eventi2019Book (Other academic)
  • 12.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Managing for security2021In: 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.

  • 13.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Safety-II の実践 ―レジリエンスポテンシャルを強化する2019Book (Other academic)
  • 14.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    The gilded age?2019In: Safety science research: Evolution, challenges and new directions / [ed] J.-C. Le Coze, Boca Raton: CRC Press, 2019Chapter in book (Other academic)
    Abstract [en]

    This chapter describes the world as black or white and uses that as the basis of explanations and communication. A strategy of depth-before-breadth makes it possible to pursue a single idea until the objective has been achieved, while at the same time limiting the mental effort required. The main issue with safety – and the reason why it is an ever-growing problem – is that the lack of safety is neither due to a single factor, nor can it be comprehended by a single view. A contemporary approach to safety should recognise that; it should try to embrace multiple perspectives in a comprehensible way. Since the focus of safety is on the negative, on what goes wrong or fails, the efforts focus on how to eliminate the causes. New perspectives and new approaches are brought on to solve the old problems, but the problems are understood in the same way, at times with a sprinkle of complexity added.

  • 15.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Vad händer när ingenting händer?2019In: Säker vård - nya perspektiv på patientsäkerhet / [ed] Synnöve Ödegård, Stockholm: Liber, 2019, p. 75-86Chapter in book (Other academic)
  • 16.
    Hollnagel, Erik
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Clay-Williams, R.
    Australian Institute of Health and Innovation (AIHI), Macquarie University, Sydney, Australia.
    Modelling complex socio-technical systems: The Functional Resonance Analysis Method (FRAM)2022In: 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. 

  • 17.
    Hollnagel, Erik
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Clay-Williams, R.
    Australian Institute of Health and Innovation (AIHI), Macquarie University, Sydney, Australia.
    Work-as-Imagined and Work-as-Done2022In: 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.

  • 18.
    Hollnagel, Erik
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Macleod, Fiona
    The imperfections of accident analysis2019In: Loss Prevention Bulletin, ISSN 0260-9576, E-ISSN 1744-358X, no 270, p. 2-6Article in journal (Refereed)
    Abstract [en]

    Determining the cause of an accident is a psychological(social) rather than logical (rational) process and can never becompletely free of bias.

  • 19.
    Hollnagel, Erik
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Sujan, M.
    Human Reliability Associates Ltd, United Kingdom.
    Braithwaite, J.
    Macquarie University, Australia.
    Resilient Health Care – Making steady progress2019In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 120, p. 781-782Article in journal (Other academic)
  • 20.
    Jonassen, Jan R.
    et al.
    Western Norway University of Applied Sciences, Haugesund, Norway.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    License to intervene: the role of team adaptation in balancing structure and flexibility in offshore operations2019In: WMU Journal of Maritime Affairs (JoMA), ISSN 1651-436X, E-ISSN 1654-1642, WMU Journal of Maritime Affairs, Vol. 18, no 1, p. 103-128Article in journal (Refereed)
    Abstract [en]

    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 towards this balance seems to be a process of team adaptation, including adjustments and corrections, when performing operations. The multi-teams operate in an open climate with a commonly accepted allowance to stop any safety-threatened operational activity. In practice, this gives the operational teams a “license” to intervene and adjust or adapt to suddenly occurring anomalies. The operations are in turn based on a period of planning and preparing. During the actual balancing, the teams relied on communication and information sharing, coordination and cooperation, and anticipation (proactive behavior) and empowerment/autonomy as effective enablers of team adaptation. 

  • 21.
    Maia Franca, Josue Eduardo
    et al.
    Kalmar Maritime Academy, Linnaeus University, Kalmar, Sweden; Academia UP de SMS, Petrobras, Rio de Janeiro, Brazil.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Analyzing human factors and complexities of mining and O&G process accidents using FRAM: Copiapo (Chile) and FPSO CSM (Brazil) cases2023In: Process safety progress, ISSN 1066-8527, E-ISSN 1547-5913, Vol. 42, no S1, p. S9-S18Article in journal (Refereed)
    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.

  • 22.
    Maia França, J. E.
    et al.
    Petrobras University, Petrobras, Rio de Janeiro, Brazil.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Human Factors Approach to Assess Risks and Reliability in Offshore Operations with FRAM (Functional Resonance Analysis Method)2023In: Offshore Technology Conference Brasil, Offshore Technology Conference , 2023Conference 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.

  • 23.
    Maia França, J. E.
    et al.
    Kalmar Maritime Academy, Linnaeus University, Kalmar, Sweden.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Human factors approach to process safety in the offshore area using FRAM2020In: 2020 AIChE Virtual Spring Meeting and 16th Global Congress on Process Safety, American Institute of Chemical Engineers, 2020Conference paper (Refereed)
    Abstract [en]

    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, extremely remote from the 6.500 meters in offshore area of Brazil Pre-Salt. To drill a subsea well and raise the crude oil to a platform, by itself, presents a series of risks that compromise the Process Safety of the entire plant. Avoiding a loss of containment, in addition to being inherent to safety itself, is also in the interest of the environment, production control and workers' health. In this sense, understand the safety barriers, as well as comprehend the Human Factors involved in Process Safety, not only brings operational reliability to the plant, but also meets the requirements of the legislation and increases productivity. In this research, a FRAM was developed to analyze a loss of containment of an FPSO storage tank, showing the importance of a systemic understanding of Human Factors in Process Safety, acting as an effective barrier to the security of the entire process.

  • 24.
    Patriarca, R.
    et al.
    Sapienza Univ Rome, Dept Mech & Aerosp Engn, Via Eudossiana 18, I-00184 Rome, Italy..
    Di Gravio, G.
    Sapienza Univ Rome, Dept Mech & Aerosp Engn, Via Eudossiana 18, I-00184 Rome, Italy..
    Woltjer, R.
    Uppsala Univ, Dept Informat Technol, Uppsala, Sweden..
    Costantino, F.
    Sapienza Univ Rome, Dept Mech & Aerosp Engn, Via Eudossiana 18, I-00184 Rome, Italy..
    Praetorius, G.
    Linnaeus Univ, Kalmar Maritime Acad, Kalmar, Sweden.;Univ South Eastern Norway, Dept Maritime Operat, Borre, Norway..
    Ferreira, P.
    Univ Lisbon, CENTEC Ctr Marine Technol & Ocean Engn, Inst Super Tecn, Lisbon, Portugal..
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jonkoping Acad, Jonkoping, Sweden.;Macquarie Univ, Sydney, NSW, Australia..
    Framing the FRAM: A literature review on the functional resonance analysis method2020In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 129, article id UNSP 104827Article, review/survey (Refereed)
    Abstract [en]

    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 terms, and increasingly adopted in industrial environments with reportedly successful results. Nevertheless, a wide literature review focused on the method is currently lacking. On these premises, this paper aims to summarise all available published research in English about FRAM. More than 1700 documents from multiple scientific repositories were reviewed through a protocol based on the PRISMA review technique. The paper aims to uncover a number of characteristics of the FRAM research, both in terms of the method's application and of the authors contributing to its development. The systematic analysis explores the method in terms of its methodological aspects, application domains, and enhancements in qualitative and quantitative terms, as well as proposing potential future research directions.

  • 25.
    Slater, David
    et al.
    Cardiff Univ, Sch Engn, Cardiff, Wales..
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Univ Jonkoping, Jonkoping, Sweden..
    MacKinnon, Ralph
    Manchester Metropolitan Univ, Fac Hlth Psychol & Social Change, Manchester, Lancs, England..
    Sujan, Mark
    Carson-Stevens, Andrew
    Cardiff Univ, Sch Med, Patient Safety & Qual Improvement, Cardiff, Wales..
    Ross, Alistair
    Univ Glasgow, Human Factors Healthcare, Dent Sch, Glasgow, Lanark, Scotland..
    Bowie, Paul
    NHS Educ Scotland, Aberdeen, Scotland..
    A systems analysis of the COVID-19 pandemic response in the United Kingdom: Part 1 - The overall context2022In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 146, article id 105525Article in journal (Refereed)
    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.

  • 26.
    Sujan, M.
    et al.
    Human Reliability Associates, United Kingdom.
    Furniss, D.
    Human Reliability Associates, United Kingdom.
    Anderson, J.
    King's College, London, United Kingdom.
    Braithwaite, J.
    Macquarie University, Australia.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Towards a syllabus for resilient health care2020In: Proceedings of the 29th European Safety and Reliability Conference, ESREL 2019 / [ed] M. Beer and E. Zio, Research Publishing Services, 2020, p. 1412-1416Conference paper (Refereed)
    Abstract [en]

    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 that could form the basis for a resilient health care syllabus. An online survey eliciting free text responses was completed by 11 anonymous participants. There was agreement that topics should cover tools for understanding work-as-done, and that concepts should focus on emergence and complex systems. Teaching should promote a mindset that safety “belongs” to all stakeholders (including clinicians and patients) rather than being the domain of safety engineers. As a result, constructivist pedagogical principles were favored, which emphasize peer learning and sharing of experiences. We found conflicting views about whether traditional methods such as bow-tie analysis should be included in a resilient health care curriculum.

  • 27.
    Sujan, Mark Alexander
    et al.
    Human Reliability Associates, Dalton, United Kingdom.
    Furniss, Dominic
    Human Reliability Associates, Dalton, United Kingdom.
    Anderson, Janet E.
    King's College London, United Kingdom.
    Braithwaite, Jeffrey
    Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Resilient Health Care as the basis for teaching patient safety – A Safety-II critique of the World Health Organisation patient safety curriculum2019In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 118, p. 15-21Article in journal (Refereed)
    Abstract [en]

    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 Health Organisation (WHO) patient safety curriculum, released ten years ago. However, it is well established that patient safety thinking in healthcare has been driven largely by Safety-I principles, and this is reflected in the WHO curriculum. The aim of this paper is to review and to provide a critique of the WHO patient safety curriculum from a Safety-II perspective, in order to assess to what extent RHC principles are already incorporated, and to identify areas where RHC might make contributions to the WHO curriculum. Based on this analysis, we argue that RHC thinking could be added in modular fashion to the WHO curriculum, but that in the future a broader curriculum should be developed that integrates RHC thinking throughout. 

  • 28.
    Thude, Bettina Ravnborg
    et al.
    Department of Centre for Quality, Region Syddanmark Center for Kvalitet, Middelfart, Denmark.
    Juhl, Andreas Granhof
    Institute for Communications, Århus Universitet, Aarhus, Denmark.
    Stenager, Egon
    Department of Neurology, Hospital of Southern Jutland, Focused Research Unit in Neurology, Aabenraa, Denmark.
    von Plessen, Christian
    Department of Regional Health Research, University of Southern Denmark, Sønderborg, Denmark.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Staff acting resiliently at two hospital wards2019In: Leadership in Health Services, ISSN 1751-1879, E-ISSN 1751-1887, Vol. 32, no 3, p. 445-457Article in journal (Refereed)
    Abstract [en]

    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-structured interviews with the staff at the two wards, the authors analysed how the staff were working, if they had cooperation and interdisciplinary cooperation, how they would handle uncertainties and how they coped with the absence of their leaders.

    FINDINGS: The staff at both wards were handling the everyday work in a resilient way. The authors argue that to increase the resilience in an organisation, leaders should acknowledge the need to establish strong emotional ties among staff and at the same time ensure role structures that make sense in the everyday work.

    ORIGINALITY/VALUE: This study reports on original work and shows what decision makers could do to increase resilience in an organisation. This paper shows that the organisational context is important for the staff to act resiliently. As leaders come and go, it can be important for the stability of the organisation to promote the staff in acting resiliently independent of the leader situation.

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