Functional Resonance Analysis Method Research Articles

Safety Analysis of Aviation Flight-Deck Procedures Using Systemic Accident Model

Abstract: Analyzing the feasibility of procedures is important for ensuring safety when using systems that feature human operations and highly developed automation. This is certainly the case with flight-deck procedures due to their complexity, which sometimes leads to deviation from standard operation procedures (SOPs) and other serious outcomes (e.g., air crash accidents). To analyze the feasibility of procedures, we adopt the functional resonance analysis method (FRAM) (Hollganel, 2004) to examine the safety management of flight-deck procedures. However, FRAM is essentially a theoretic method, and there are currently no specific approaches or supportive tools to bridge the gap between theory and practice. In this paper, we propose an adaptation of the cognitive reliability and error analysis method (CREAM) (Hollnagel (1998)) that we call Fuzzy CREAM for systematic and quantitative FRAM analysis. We applied the proposed method to an actual air crash accident that occurred near Cali Airport, Colombia in 1995 and conclude that the accident was due to deviation from SOPs. On the basis of our analysis, we show that FRAM can identify potential hazardous paths that may lead to an accident. We also propose a new method using FRAM for pre-analysis of the safety of designed procedures.

Applying Systemic Accident Model to Learn from Near-Miss Incidents of Train Maneuvering and Operation

Abstract: This study proposes a novel method for safety management in train operation and maneuvering based upon Hollnagel’s functional resonance analysis method (FRAM), which assumes that components of a system interact mutually and resonantly. According to the original FRAM, the general functions of train drivers’ and conductors’ tasks are defined, and the normal procedure of a common case is represented. Our method first attempts to replay how fluctuations of some of the tasks propagate through the entire system. Then we examine whether a countermeasure found by replaying is valid under various situations. In this way, we demonstrate that our method is able to detect latent hazards of the system as well as to identify how the system is influenced by various external and internal changes.

Developing a Risk-Based Approach for Optimizing Human Reliability Assessment in an Offshore Operation

Human error plays a pivotal rule in all aspects of engineering activities such as operation, maintenance, design, inspection and installation. Industries are faced up to various significant human errors and consequently irrecoverable loss each year, but still there is a lack of heeds to qualify as well as quantify such errors. This paper tries to estimate the probability of failure in lifting of light structures in sea by considering human errors. To do this, a strong qualifying tool such as Functional Resonance Analysis Method (FRAM) is applied to develop high risk accident scenario by considering non-linear socio-technical interaction in system. Afterwards, human error probability is calculated for each activity using the Success Likelihood Index Method (SLIM) based on resonance that is carried out in FRAM network. Then Event Tree (ET) is conducted to assess consequences. The present study is aimed to interpret the importance of attentions to qualitative methods in implementing quantitative risk analyses to consider human error in calculation. The final outcome depicts that considering human error in the process of risk assessment will result in more accuracy and reliability in final Risk Probability Number (RPN). The developed methodology has been applied to a case study of an offshore installation.

機能共鳴分析手法を用いた鉄道運転操縦のリスク評価

機能共鳴分析手法を用いた鉄道運転操縦のリスク評価

Where the rubber meets the road: using FRAM to align work-as-imagined with work-as-done when implementing clinical guidelines.

BackgroundUptake of guidelines in healthcare can be variable. A focus on behaviour change and other strategies to improve compliance, however, has not increased implementation success. The contribution of other factors such as clinical setting and practitioner workflow to guideline utilisation has recently been recognised. In particular, differences between work-as-imagined by those who write procedures, and work-as-done—or actually enacted—in the clinical environment, can render a guideline difficult or impossible for clinicians to follow. The Functional Resonance Analysis Method (FRAM) can be used to model workflow in the clinical setting. The aim of this study was to investigate whether FRAM can be used to identify process elements in a draft guideline that are likely to impede implementation by conflicting with current ways of working.MethodsDraft guidelines in two intensive care units (ICU), one in Australia and one in Denmark, were modelled and analysed using FRAM. The FRAM was used to guide collaborative discussion with healthcare professionals involved in writing and implementing the guidelines and to ensure that the final instructions were compatible with other processes used in the workplace.ResultsProcesses that would have impeded implementation were discovered early, and the guidelines were modified to maintain compatibility with current work processes. Missing process elements were also identified, thereby, avoiding the confusion that would have ensued had the guideline been introduced as originally written.ConclusionsUsing FRAM to reconcile differences between work-as-imagined and work-as-done when implementing a guideline can reduce the need for clinicians to adjust performance and create workarounds, which may be detrimental to both safety and quality, once the guideline is introduced.

Assessing risk in sustainable construction using the Functional Resonance Analysis Method (FRAM)

Traditional tools found in occupational risk assessments are a preliminary hazard analysis and checklists, both based on the isolation of a particular activity from the entire process and created for application in specific environments of manufacture. This strategy makes the results of such evaluations distant from real situations. Construction is a complex endeavor and can involve multiple contractors and groups working under each contractor. Work occurs under constant change and varying demands. In this context, as workers move through their daily journey, their health and safety are often are threatened by activities carried out by other contractors or groups. The study utilizes the Functional Resonance Analysis Method (FRAM), which aims to describe how function couplings may be combined in such a way that variability of performance, rather than failure or poor functioning, creates an occupational risk. The study also contributes to the evolution of FRAM, by proposing the application of the analytic hierarchy process, to investigate the relative importance of the criteria and alternatives for the identification of phenotypes of performance variability, as well as the aggregation of variability.

Extended FRAM by Integrating with Model Checking to Effectively Explore Hazard Evolution

Functional Resonance Analysis Method (FRAM), which defines a systemic framework to model complex systems from the perspective of function and views accidents as emergent phenomenon of function’s variability, is playing an increasingly significant role in the development of systemic accident theory. However, as FRAM is typically taken as a theoretic method, there is a lack of specific approaches or supportive tools to bridge the theory and practice. To fill the gap and contribute to the development of FRAM, (1) function’s variability was described further, with the rules of interaction among variability of different functions being determined and (2) the technology of model checking (MC) was used for the analysis of function’s variability to automatically search the potential paths that could lead to hazards. By means of MC, system’s behaviors (normal or abnormal) are simulated and the counter example(s) that violates the safety constraints and requirements can be provided, if there is any, to improve the system design. The extended FRAM approach was applied to a typical air accident analysis, with more details drawn than the conclusions in the accident report issued officially by Agenzia Nazionale per la Sicurezza del Volo (ANSV).

Functional resonance analysis method and its application on Zagreb mid-air collision

Functional resonance analysis method and its application on Zagreb mid-air collision

Improvisation at Workplace and Accident Causation - An Exploratory Study

This paper presents an application of functional resonance analysis method for an exploratory study of accidents at workplace where some type of improvisation took place. Improvisation, along with creativity, can be seen as a basis for advancements in virtually all knowledge areas. The necessity to overcome a barrier, a difficulty, a discomfort, or any constraint is a driving force for mankind to improvise - it is a natural act, a product of intelligence under unplanned circumstances and a way to cope with resource constraints. Despite the improvements improvisation can bring to the society, it can also result in unwanted outputs, mainly when it is performed at the workplace, in the presence of hazardous situations and unknown situations. The main problem with improvisation occur when its consequences are ignored and cannot be predictable, once it can lead to devastating events. So, why firms improvise? The basic response is to have the work done in the face of a demand for lacking resources. This research is essentially a exploratory study and was conducted to provide a better understanding of accidents resulting from improvisation at work. Three accident reports were selected from open databases in Brazil and are presented to provide an overview of the role of improvisation at work on accident causation. In order to study the accidents resulting from improvisation, this study applied the Functional Resonance Analysis Method (FRAM). All cases had in common the lack of hazards recognition, lack of planning, lack of supervision, and the pressure for productivity firms imposed to workers.

Hospital discharge of the elderly--an observational case study of functions, variability and performance-shaping factors.

BackgroundUnderstanding and improving hospital discharge has assumed major importance since it represents an error-prone transition in care. One barrier to improvement is the lack of detailed understanding of how hospital discharge is organized, including its interdependencies and influential performance-shaping factors (PSFs). This study examines the discharge of elderly patients using the Functional Resonance Analysis Method, developed to analyze performance variability in complex systems. Our main aim was to identify hospital discharge functions, variability, and PSFs that may explain the variability and different outcomes in discharge practices by incorporating multiple-stakeholder perceptions (health-care providers, patients, next of kin).MethodsThe data consisted of moderate participant observations of 20 elderly patients (>75) discharged from hospital to primary health care. The data comprised 90 hours’ observations at hospital wards, including 173 conversations with patients, next of kin, and health-care personnel involved in discharge.ResultsWe identified 10 common functions in the discharge of elderly patients to primary health care. We found substantial variability in terms of timing, duration, and precision. Duration is a significant source of variability, primarily determined by the time of day the patient was determined medically fit for discharge. Precision issues related to (1) decision-making criteria concerning the medical fitness decision and appropriate level of care, (2) quality of discharge planning, (3) degree of patient involvement, and (4) quality of information transfer. PSFs were temporal conditions (degree of time pressure), individual and team characteristics, patient factors, organizational factors (unit, specialization, leadership, institutionalized routines), work environment factors (bed availability, availability in municipal services, quality of discharge planning, familiarity with the patient, pressure from next of kin, doctor’s specialization) and regulatory influences (financial incentives).ConclusionsThe study provides a detailed understanding of the discharge of elderly patients by describing common functions and variability in performance caused by multiple PSFs. Our findings indicate the necessity for studying multiple factors related to discharge, interdependencies, and their effects on a range of discharge outcomes incorporating a multiple-stakeholder perspective. We argue that the existing sequential approaches to the complexity surrounding hospital discharge are inadequate. Given the interdependencies among functions, there is a need for corresponding multi-factorial interventions.Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6963-14-365) contains supplementary material, which is available to authorized users.

FRAM: the functional resonance analysis method, modelling complex socio-technical systems

FRAM: the functional resonance analysis method, modelling complex socio-technical systems

The use of Functional Resonance Analysis Method (FRAM) in a mid-air collision to understand some characteristics of the air traffic management system resilience

The Functional Resonance Analysis Model (FRAM) defines a systemic framework to model complex systems for accident analysis purposes. We use FRAM in the mid-air collision between flight GLO1907, a commercial aircraft Boeing 737-800, and flight N600XL, an executive jet EMBRAER E-145, to investigate key resilience characteristics of the Air Traffic Management System (ATM). This ATM system related accident occurred at 16:56 Brazilian time on September 29, 2006 in the Amazonian sky. FRAM analysis of flight monitoring functions showed system constraints (equipment, training, time, and supervision) that produce variability in system behavior, creating demand resources mismatches in an attempt to perceive and control the developing situation. This variability also included control and coordination breakdowns and automation surprises (TCAS functioning). The analysis showed that under normal variability conditions (without catastrophic failures) the ATM system (pilots, controllers, supervisors, and equipment) was not able to close the control loops of the flight monitoring functions using feedback or feedforward strategies to achieve an adequate control of an aircraft flying in the controlled air space. Our findings shed some light on the resilience of Brazilian ATM system operation and indicated that there is a need of a deeper understanding on how the system is actually functioning.

Comparing a multi-linear (STEP) and systemic (FRAM) method for accident analysis

Accident models and analysis methods affect what accident investigators look for, which contributory factors are found, and which recommendations are issued. This paper contrasts the Sequentially Timed Events Plotting (STEP) method and the Functional Resonance Analysis Method (FRAM) for accident analysis and modelling. The main issue addressed in this paper is the comparison of the established multi-linear method STEP with the new systemic method FRAM and which new insights the latter provides for accident analysis in comparison to the former established multi-linear method. Since STEP and FRAM are based on a different understandings of the nature of accidents, the comparison of the methods focuses on what we can learn from both methods, how, when, and why to apply them. The main finding is that STEP helps to illustrate what happened, involving which actors at what time, whereas FRAM illustrates the dynamic interactions within socio-technical systems and lets the analyst understand the how and why by describing non-linear dependencies, performance conditions, variability, and their resonance across functions.