Safety and Health at Work

  • 제12권1호
  • /
  • Pages.10-19
  • /
  • 2021
  • /
  • 2093-7911(pISSN)
  • /
  • 2093-7997(eISSN)
산업안전보건연구원 (Occupational Safety and Health Research Institute, Korea Occupational Safety and Health Agency)
권호 표지
DOI QR코드

DOI QR Code

Safety-II and Resilience Engineering in a Nutshell: An Introductory Guide to Their Concepts and Methods

  • Ham, Dong-Han (Department of Industrial Engineering, Chonnam National University)
  • 투고 : 2020.02.05
  • 심사 : 2020.11.25
  • 발행 : 2021.03.30
PDF 다운로드
⟨ 이전 논문 다음 논문 ⟩

초록

Background: Traditional safety concept, which is called Safety-I, and its relevant methods and models have much contributed toward enhancing the safety of industrial systems. However, they have proved insufficient to be applied to complex socio-technical systems. As an alternative, Safety-II and resilience engineering have emerged and gained much attention for the last two decades. However, it seems that safety professionals have still difficulty understanding their fundamental concepts and methods. Accordingly, it is necessary to offer an introductory guide to them that helps safety professionals grasp them correctly in consideration of their current practices. Methods: This article firstly explains the limitations of Safety-I and how Safety-II can resolve them from the four points of view. Next, the core concepts of resilience engineering and Functional Resonance Analysis Method are described. Results: Workers' performance adjustment and performance variability due to it should be the basis for understanding human-related accidents in socio-technical systems. It should be acknowledged that successful and failed work performance have the same causes. However, they are not well considered in the traditional safety concept; in contrast, Safety-II and resilience engineering have conceptual bases and practical approaches to reflect them systematically. Conclusion: It is necessary to move from a find-and-fix and reactive approach to a proactive approach to safety management. Safety-II and resilience engineering give a set of useful concepts and methods for proactive safety management. However, if necessary, Safety-I methods need to be properly used for situations where they can still be useful as well.

키워드

과제정보

This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (Ministry of Education) (NRF-2020R1I1A3069000).

참고문헌

  1. Dekker S. Field guide to human error investigations. Aldershot (UK): Ashgate; 2002.
  2. Leveson N. Engineering a safer world: systems thinking applied to safety. Cambridge: The MIT Press; 2011.
  3. Yoon YS, Ham D-H, Yoon WC. A new approach to analyzing human-related accidents by combined use of HFACS and activity theory-based method. Cognition, Technology & Work 2017;19:759-83. https://doi.org/10.1007/s10111-017-0433-3
  4. Yoon YS, Ham D-H, Yoon WC. Application of activity theory to analysis of human-related accidents: method and case studies. Reliability Eng System Safety 2016;150:22-34. https://doi.org/10.1016/j.ress.2016.01.013
  5. Hollnagel E, Leonhardt J, Licu T, Shorrock S. From Safety-I to Safety-II: a white paper. Brussels (Belgium): EUROCONTROL; 2013.
  6. Hollnagel E. Safety-I and Safety-II: the past and future of safety management. Farnham (UK): Ashgate; 2014.
  7. Hollnagel E. Resilience engineering: a new understanding of safety. J Ergonomics Society of Korea 2016;35:185-91. https://doi.org/10.5143/JESK.2016.35.3.185
  8. Leonhardt J, Hollnagel E, Macchi L, Kirwan B. A white paper on resilience engineering for ATM. Brussels (Belgium): EUROCONTROL; 2009.
  9. Hollnagel E. Understanding accidents-from root causes to performance variability. In: Proceedings of the 2002 IEEE 7th human factors and power plants 2002. p. 1-6.
  10. Underwood P, Waterson P. Systematic accident analysis: examining the gap between research and practice. Accident Analysis Prevention 2013;55:154-64. https://doi.org/10.1016/j.aap.2013.02.041
  11. Underwood P, Waterson P. Systems thinking, the Swiss cheese model and accident analysis: a comparative systemic analysis of the Grayrigg train derailment using the ATSB, Accimap and STAMP models. Accident Analysis Prevention 2014;68:75-94. https://doi.org/10.1016/j.aap.2013.07.027
  12. Wiegmann DA, Shappell SA. A human error approach to aviation accident analysis: the Human Factors Analysis and Classification System. Farnham (UK): Ashgate; 2003.
  13. Reinach S, Viale A. Application of a human error framework to conduct train accident/incident investigations. Accident Analysis Prevention 2006;38:396-406. https://doi.org/10.1016/j.aap.2005.10.013
  14. Sujan MA, Huang H, Braithwaite J. Learning from incidents in health care: critique from a safety-II perspective. Safety Science 2017;99:115-21. https://doi.org/10.1016/j.ssci.2016.08.005
  15. Patterson M, Deutsch E. Safety-I, Safety-II and resilience engineering. Current Problems Pediatric Adolescent Health Care 2015;45:382-9. https://doi.org/10.1016/j.cppeds.2015.10.001
  16. Ferjencik M. An integrated approach to the analysis of incident causes. Safety Science 2011;49:886-905. https://doi.org/10.1016/j.ssci.2011.02.005
  17. Svendung I, Rasmussen J. Graphic representation of accident scenarios: mapping system structure and the causation of accidents. Safety Science 2002;40:397-417. https://doi.org/10.1016/S0925-7535(00)00036-9
  18. Perrow C. Normal accidents-living with high risk technologies. Princeton: Princeton University Press; 1999.
  19. Patriarca R, Bergstrom J, Di Gravio G, Costantino F. Resilience engineering: current status of the research and future challenges. Safety Science 2018;102: 79-100. https://doi.org/10.1016/j.ssci.2017.10.005
  20. Dekker S. Reconstructing human contributions to accidents: the new view on error and performance. Journal of Safety Research 2002;33:371-85. https://doi.org/10.1016/S0022-4375(02)00032-4
  21. Hollnagel E, Woods DD, Leveson N. Resilience engineering: concepts and precepts. Aldershot (UK): Ashgate; 2006.
  22. Hollnagel E, Paries J, Woods DD, Wreathall J. Resilience engineering in practice: a guidebook. Farnham (UK): Ashgate; 2011.
  23. Shorrock S. What Safety-II isn't; 2016. Available from: http://humanisticsystems.com/2014/06/08/what-safety-ii-isnt/.
  24. Ham D-H, Park J. Use of a big data analysis technique for extracting HRA data from event investigation reports based on the Safety-II concept. Reliability Engineering System Safety 2020;194:106232. https://doi.org/10.1016/j.ress.2018.07.033
  25. Hollnagel E, Macleod F. The imperfections of accident analysis. Loss Prevention Bulletin 2019;270:2-6.
  26. Havinga J, Dekker S, Rae A. Everyday work investigations for safety. Theoretical Issues Ergonomics Science 2017;19:213-28. https://doi.org/10.1080/1463922X.2017.1356394
  27. de Carvalho PV, Righi AW, Huber GJ, Lemos C, Jatoba A, Gomes JO. Reflections on work as done (WAD) and work as imagined (WAI) in an emergency response organizations: a study on firefighters training exercises. Applied Ergonomics 2018;68:28-41. https://doi.org/10.1016/j.apergo.2017.10.016
  28. Woltjer R, Pinska-Chauvin E, Laursen T, Josefsson B. Towards understanding work-as-done in air traffic management safety assessment and design. Reliability Engineering System Safety 2015;141:115-30. https://doi.org/10.1016/j.ress.2015.03.010
  29. Wachs P, Saurin TA, Righi AW, Wears RL. Resilience skills as emergent phenomena: a study of emergency departments in Brazil and the United States. Applied Ergonomics 2016;56:227-37. https://doi.org/10.1016/j.apergo.2016.02.012
  30. Wachs P, Saurin TA. Modelling interactions between procedures and resilience skills. Applied Ergonomics 2018;68:328-37. https://doi.org/10.1016/j.apergo.2017.12.013
  31. Hollnagel E. The ETTO principle: efficiency-thoroughness trade-off. Farnham (UK): Ashgate; 2009.
  32. Xiao T, Sanderson P, Clayton S, Venkatesh B. The ETTO principle and organizational strategies: a field study of ICU bed and staff management. Cognition, Technology & Work 2010;12:143-52. https://doi.org/10.1007/s10111-010-0147-2
  33. Salmon PM, Stanton NA, Lenne M, Jenkins DP, Rafferty LA, Walker GH. Human factors methods and accident analysis: practical guidance and case study applications. Farnham (UK): Ashgate; 2011.
  34. Salmon PM, Cornelissen M, Trotter MJ. Systems-based accident analysis methods: a comparison of Accimap, HFACS, and STAMP. Safety Science 2012;50:1158-70. https://doi.org/10.1016/j.ssci.2011.11.009
  35. Hulme A, Stanton NA, Walker GH, Waterson P, Salmon PM. What do applications of systems thinking accident analysis methods tell us about accident causation? A systematic review of applications between 1990 and 2018. Safety Science 2019;117:164-83. https://doi.org/10.1016/j.ssci.2019.04.016
  36. Lundberg J, Rollenhagen C, Hollnagel E. What you find is not always what you fix-how other aspects than causes of accidents decide recommendations for remedial actions. Accident Analysis and Prevention 2010;42:2132-9. https://doi.org/10.1016/j.aap.2010.07.003
  37. Hollnagel E. FRAM: the functional resonance analysis method. Farnham (UK): Ashgate; 2012.
  38. Hollnagel E, Hounsgaard J, Colligan L. FRAM-the Functional Resonance Analysis Method-a handbook for the practical use of the method. Center for Quality; 2014.
  39. Anderson JE, Ross A, Back J, Duncan M, Snell P, Walsh K, Jaye P. Implementing resilience engineering for healthcare quality improvement using the CARE model: a feasibility study protocol. Pilot Feasibility Studies 2016;2:61. https://doi.org/10.1186/s40814-016-0103-x
  40. Hollnagel E. Safety-II in practice: developing the resilience potentials. London (UK): Routledge; 2018.
  41. Patriarca R, Gravio GD, Costantino F, Falegnami A, Bilotta F. An analytic framework to assess organizational resilience. Safety and Health at Work 2018;9:265-76. https://doi.org/10.1016/j.shaw.2017.10.005
  42. Shirali G, Shekari M, Angali KA. Assessing reliability and validity of an instrument for measuring resilience safety culture in sociotechnical systems. Safety Health Work 2018;9:296-307. https://doi.org/10.1016/j.shaw.2017.07.010
  43. Lundberg J, Johansson B. Systemic resilience model. Reliability Engineering System Safety 2015;141:22-32. https://doi.org/10.1016/j.ress.2015.03.013
  44. Hoffman RR, Hancock PA. Measuring resilience. Human Factors 2017;59:564-81. https://doi.org/10.1177/0018720816686248
  45. Arpansa. Regulatory guide: holistic safety. Australian Radiation Protection and Nuclear Safety Agency; 2017.
  46. Arpansa. Regulatory guide: holistic safety-sample questions. Australian Radiation Protection and Nuclear Safety Agency; 2017.
  47. Raben DC, Viskum B, Mikkelsen KL, Hounsgaard J, Bogh SB, Hollnagel E. Application of a non-linear model to understand healthcare processes: using the functional resonance analysis method on a case study of the early detection of sepsis. Reliability Engineering and System Safety 2018;177:1-11. https://doi.org/10.1016/j.ress.2018.04.023
  48. Hollnagel E, Pruchnicki S, Woljter R, Etcher S. Analysis of Comair flight 5191 with the functional resonance accident model. In: Proceedings of the 8th international symposium of the Australian aviation psychology association 2008.
  49. Rosa LV, Haddad AN, de Carvalho P. Assessing risk in sustainable construction using the functional resonance analysis method (FRAM). Cognition, Technology & Work 2015;17:559-73. https://doi.org/10.1007/s10111-015-0337-z
  50. Patriarca R, Di Gravio G, Costantino F, Tronci M. The functional resonance analysis method for a systemic risk based environmental auditing in a sinter plant: a semi-quantitative approach. Environmental Impact Assessment Rev 2017;63:72-86. https://doi.org/10.1016/j.eiar.2016.12.002
  51. Patriarca R, Bergstrom J, Di Gravio G, Costantino F. Defining the functional resonance analysis space: combining abstraction hierarchy and FRAM. Reliability Engineering System Safety 2018;165:34-46. https://doi.org/10.1016/j.ress.2017.03.032
  52. Clay-Williams R, Hounsgaard J, Hollnagel E. Where the rubber meets the road: using FRAM to align work-as-imagined with work-as-done when implementing clinical guidelines. Implementation Science 2015;10:125. https://doi.org/10.1186/s13012-015-0317-y
  53. Raben DC, Both SB, Viskum B, Mikkelsen KL, Hollnagel E. Learn from what goes right: a demonstration of a new systematic method for identification of leading indicators in healthcare. Reliability Engineering System Safety 2018;169:187-98. https://doi.org/10.1016/j.ress.2017.08.019
  54. Aguilera M, da Fronseca B, Ferris T, Vidal M, de Carvalho P. Modelling performance variabilities in oil spill response to improve system resilience. J Loss Prevension Process Industries 2016;41:18-30. https://doi.org/10.1016/j.jlp.2016.02.018
  55. Hounsgaard J. Patient safety in everyday work: learning from thigs that go right. University of Southern Denmakr; 2016.
  56. Herrera IA, Woltjer R. Comparing a multi-linear (STEP) and systemic (FRAM) method for accident analysis. Reliability Engineering System Safety 2010;95: 1269-75. https://doi.org/10.1016/j.ress.2010.06.003
  57. de Carvalho P. The use of Functional Resonance Analysis Method (FRAM) in a mid-air collision to understand some characteristics of the air traffic management system resilience. Reliability Engineering System Safety 2011;96: 1482-98. https://doi.org/10.1016/j.ress.2011.05.009
  58. Woltjer R. Resilience assessment based on models of functional resonance. In: Proceedings of the 3rd symposium on resilience engineering 2008.
  59. Tian J, Wu J, Yang Q, Zhao T. FRAMA: a safety assessment approach based on Functional Resonance Analysis Method. Safety Science 2016;85:41-52. https://doi.org/10.1016/j.ssci.2016.01.002
  60. Furniss D, Curzon P, Blandford A. Using FRAM beyond safety: a case study to explore how sociotechnical systems can flourish or stall. Theoretical Issues Ergonomics Science 2016;17:507-32. https://doi.org/10.1080/1463922X.2016.1155238
  61. Patriarca R, Di Gravio G, Costantino F. A Monte Carlo evolution of the Functional Resonance Analysis Method (FRAM0 to assess performance variability in complex systems. Safety Science 2017;91:49-60. https://doi.org/10.1016/j.ssci.2016.07.016
  62. Pereira A. Introduction to the use of FRAM on the effectiveness assessment of a radiopharmaceutical dispatches process. In: Proceedings of 2013 international nuclear atlantic conference 2013.
  63. Praetorius G, Hollnagel E, Dahlman J. Modelling vessel traffic service to understand resilience in everyday operations. Reliability Engineering System Safety 2015;141:10-21. https://doi.org/10.1016/j.ress.2015.03.020
  64. de Vries L. Work as Done? Understanding the practice of sociotechnical work in the maritime domain. J Cognitive Engineering Decision Making 2017;11: 270-95. https://doi.org/10.1177/1555343417707664
  65. Patriarca R, Di Gravio G, Woltjer R, Costantino F, Praetorius G, Ferreira P, Hollnagel E. Framing the FRAM: a literature review on the functional resonance analysis method. Safety Science 2020;129:104827. https://doi.org/10.1016/j.ssci.2020.104827