Filtyp
Recent accidents such as the Macondo blowout actualize the issue of offshore safety. Accidents do occur in spite of actions taken to prevent them from happening. The energy-barrier philosophy is the governing principle within the Norwegian offshore industry. The paradox with that philosophy is that the construction of additional barriers may increase complexity within the system. Risk may be seen
Improving teamwork has become a major safety goal for healthcare organizations. Audit tools currently available are useful, but they remain inadequate because they are reactive and fail to provide context for “the interaction between people and the operational context (i.e., organizational, regulatory and environmental factors) within which people discharge their operational duties” (Maurino, 2005
The Aviation industry is ultra-safe. Rules and procedures have been attributed as a contributory factor for attaining this high level of safety. The complexity of the aviation system has risen dramatically in the last few decades due to the development and introduction of modern aircraft and on-board technological innovations. Every day pilots encounter situations they did not expect. During those
This report presents a protocol for assessing team performance in terms of control based on cognitive systems engineering theories. The protocol changes the focus of team performance assessment from good and bad behaviours towards the team’s activity. By using Hollnagel’s contextual control model (COCOM) a protocol is developed so that team activity can be categorised into four control modes. Data
This master thesis deals with how an effective risk communication between the county administrative board and the public can be conducted. The master thesis starts with a summary of the current literature on the subject after which interviews were conducted with three individuals who work with these issues at the county administrative board in Kalmar and a number of questions were sent to a few mu
In this study, principles of Cognitive Systems Engineering are used to better understand the human–machine interaction manifesting in the use of anaesthesia alarms. The hypothesis is that the design of the machine incorporates built-in assumptions of the user that are discrepant with the anaesthesiologist's self-assessment, creating ‘user image mismatch’. Mismatch was interpreted by focusing on th
Resilience is becoming a prevalent agenda in safety research and organisational practice. In this study we examine how the peer-reviewed safety science literature (a) formulates the rationale behind the study of resilience; (b) constructs resilience as a scientific object; and (c) constructs and locates the resilient subject. The results suggest that resilience engineering scholars typically motiv
System-thinking and related systemic methods enhance traditional risk and hazard assessments and accident analysis, as well as system design. The Functional Resonance Analysis Method (FRAM) is a recently developed method for systemic analysis. FRAM facilitates descriptions of the functional relations among system elements. In case of large systems (e.g. several agents, multiple procedures, many te
In this study, the duality of adaptive capacity in aviation safety is examined, where the need for resilience of frontline workers conflicts with the expectations and assumptions of upstream entities, leading to system brittleness. We explore three critical categories: responsibilization, the application of practical wisdom in navigating challenging situations, and the unrecognized sacrifices that
The aim of the thesis was to study the information retrieval and seeking of an on-scene commander on the incident site. Also, to systematize the information to further improve the decision-making condition for all all of the commanding officers. By studying literature, analysing collected recorded material from helmet-mounted cameras and conducting interviews, the study has shown that commanders,
Recent high-visibility disasters have fueled public and political awareness of the importance of managing and mitigating their consequences effectively. In response, various countries have enacted legislation that demands the evaluation of emergency responses so that lessons for improvement can be learned. A series of field and experimental studies were conducted from 2005 to 2007 to assess the ab
This paper questions the correspondance between resilience engineering theory and the theoretical fundaments of traditional CRM training, with its related behavior assessments. Reviewing the theoretical roots of CRM it is concluded that such concepts are rather founded in the information processing paradigm hiding the complexities of adaption to rapidly changing situations. An alternative approach
Following an adverse event in a Swedish university hospital in 2010, three separate investigations seeking causal factors were conducted. We here review each of the analyses to see whether they together generate the kind of epistemological pluralism that could contribute to a systemic understanding of, and learning from, the event. Our content analysis shows that, while using vastly different amou
Swedish legislation requires that any owner or user of a building maintain a reasonable level of fire protection measures to ensure the safety of all people located in the building. If a building, in the wake of a fire, in court is determined not to have had a reasonable fire protection, the blame will likewise be assigned to the building owner or user. Using the perspective of risk governance, th
We pursued the following three interconnected points: (1) there are unexplored opportunities for resilience scholars from different disciplines to cross-inspire and inform, (2) a systems perspective may enhance understanding of human resilience in health and social settings, and (3) resilience is often considered to be fractal, i.e., a phenomenon with recognizable or recurring features at a variet
An increasingly heterogeneous demography in society demands for a shift of attitude towards crisis communication. With a population where one in five has got a foreign background it is important that governments and decision makers continuously evaluate the current crisis management plans, and take measures through updates where so is considered to be needed. This report aims to evaluate the curre
This article presents a protocol for assessing team performance in terms of control based on cognitive systems engineering theory. The protocol changes the focus of team performance assessment from good and bad behaviours towards team activity. By using Hollnagel’s contextual control model (COCOM), a protocol is developed so that team activity can be described as four control modes. Data is collec
Growing concerns regarding the vulnerability of communities to natural disasters and climate-related hazards and risks have caused attention to be increasingly directed towards adaptation and resilience as important policy prescriptions. These two concepts are commonly becoming normative when used in this context and seen as intrinsically linked to each other, i.e. adaptation leads to resilience a
In society, accidents happen on a daily basis. To investigate these accidents is part of preventing them from happening at all. The investigations are carried out by different reasons and with different focus as well as by varying methods and extent. This contributes to that the finding of causes of the event varies with the investigator as well as with what the purpose of the investigation is as
