Rasmussen's Risk Management Research Articles

The application of a system‐based risk management framework and social network analysis to the Maritime Autonomous Surface Ship system: Who are the decision‐makers in the wider system?

AbstractMaritime Autonomous Surface Ships (MASS) currently have no formal regulations developed specifically for their operation, as their regulatory framework is still under development. Rasmussen's Risk Management Framework has been used to develop an actor map of the current MASS system in the UK, to show who the actors, decision‐makers, and planners are within the wider sociotechnical system and the level at which they sit. From the actor map, two social networks were created, one to show the connections that currently exist between the actors within the MASS system and another to show what a future MASS system could look like if regulations and standards were put in place for MASS. Social Network Analysis was then used to investigate the wider MASS system's dynamics, to understand which actors currently have a high degree of influence within the UK MASS system, and where the shortfalls are in the current MASS system. The analysis showed that the industry and end user levels lacked support from the higher system levels, and the addition of formal regulations and standards in the future MASS system would increase the MASS system's resilience. System recommendations for each level in the Risk Management Framework were then made to suggest ways to increase the influence of the regulators and promote the safe operation of MASS.

Factors contributing to work-related violence: A systematic review and systems perspective

Background & ObjectivesWork-related violence is widespread, occurs across industries / occupations, has detrimental effects on physical and mental health of workers and clear implications for the workplace system. Despite this, there is limited understanding of the broad range of contributing factors. This systematic review identifies factors contributing to WV and adopts a systems thinking framework (Rasmussen's Risk Management Framework, 1997) to map across the workplace system. MethodsA systematic search across 6 databases (MEDLINE, PubMed, AMED, EmCare, SCOPUS, and PsycINFO) was conducted using keywords that specified the setting (workplace), topic (risk factors for WV), and study design of interest. The search was limited to workers > 18 years of age, and articles published in English from 2010 to July 2020. ResultsThe search retrieved 1,286 articles. Following the application of eligibility criteria, a total of 120 articles were included, the majority of which were rated as moderate methodological quality (59%). The vast majority of articles were within healthcare. When mapped across the workplace system the highest percentage of factors were at the Frontline staff level, followed by Governance and Administration, and Operations Management. ConclusionThis study represents the first step in gaining a comprehensive understanding of the system of factors contributing to WV. Findings suggest more attention should be given to sectors outside of healthcare such as the public service, with an identified need for WV intervention. The findings of this study can be used to inform the development of targeted intervention to reduce WV through systemic change.

Sociotechnical view of electric bike issues in China: Structured review and analysis of electric bike collisions using Rasmussen's risk management framework

AbstractFollowing a thriving delivery business and constantly improving road infrastructure and vehicle technologies, electric bicycles (e‐bikes) are becoming one of the most popular modes of road transport in China. Although e‐bikes are flexible and cost efficient, they contribute significantly to on‐road collisions in China. Therefore, this study focuses on the traffic safety of e‐bikes in China. Rather than following conventional engineering approaches, this study applies a sociotechnical analysis of the system, while focusing on the entities that significantly influence e‐bike safety. Applying Rasmussen's risk management framework (RMF) and its associated Accimap methodology shapes the systematic analysis of e‐bike collisions in China. This study identifies and discusses a general pattern of the contribution of social entities to e‐bike collisions. As such, the authors developed a generic model of e‐bike collisions in China. Couriers were considered important in this domain, and their status in the system was discussed. Moreover, recommendations have been proposed to improve e‐bike traffic safety in China.

All in a day's work: Towards improved understanding of safety leadership during regular safety‐related tasks in mining

AbstractThis article examines safety leadership during regular safety‐related tasks conducted across a mining work system. Applying a systems‐thinking methodology, a modified version of the critical decision method (CDM) interview technique was used to examine decision‐making and behavior in association with five safety‐related tasks executed across the work system; hazard identification, inspections, standard operating procedure development, task observation and return to work coordination activities. Data were mapped onto Rasmussen's risk management framework to explore the characteristics of safety leadership decision‐making and behavior which occurred across the work system to support successful task execution. Vertical integration was present and was associated with a core set of decision‐making elements and leadership behaviors that facilitated the communication and exchange of information within and across the work system in association with tasks executed. In addition, different profiles of decision‐making characteristics and behavioral engagement were evident at different system levels, which indicated variability in safety leadership was required to support successful task execution across the work system. Task type was found to influence safety leadership, with structured tasks demonstrating less intensive decision‐making and behavioral engagement requirements than unstructured tasks. The findings add to the knowledge base on safety leadership through improved understanding of the concept, its occurrence across tasks and work system levels, and the factors which influence it to support safe system functioning. Future research endeavors and practical implications are discussed.

Applying systems ergonomics methods in sport: A systematic review

IntroductionAs sports systems become increasingly more complex, competitive, and technology-centric, there is a greater need for systems ergonomics methods to consider the performance, health, and safety of athletes in context with the wider settings in which they operate. Therefore, the purpose of this systematic review was to identify and critically evaluate studies which have applied a systems ergonomics research approach in the context of sports performance and injury management. Material and methodsFive databases (PubMed, Scopus, ScienceDirect, Web of Science, and SPORTDiscus) were searched for the dates 01 January 1990 to 01 August 2017, inclusive, for original peer-reviewed journal articles and conference papers. Reported analyses were underpinned by a recognised systems ergonomics method, and study aims were related to the optimisation of sports performance (e.g. communication, playing style, technique, tactics, or equipment), and/or the management of sports injury (i.e. identification, prevention, or treatment). ResultsA total of seven articles were identified. Two articles were focussed on understanding and optimising sports performance, whereas five examined sports injury management. The methods used were the Event Analysis of Systemic Teamwork, Cognitive Work Analysis (the Work Domain Analysis Abstraction Hierarchy), Rasmussen's Risk Management Framework, and the Systems Theoretic Accident Model and Processes method. The individual sport application was distance running, whereas the team sports contexts examined were cycling, football, Australian Football League, and rugby union. ConclusionsThe included systems ergonomics applications were highly flexible, covering both amateur and elite sports contexts. The studies were rated as valuable, providing descriptions of injury controls and causation, the factors influencing injury management, the allocation of responsibilities for injury prevention, as well as the factors and their interactions underpinning sports performance. Implications and future directions for research are described.

Ending on a positive: Examining the role of safety leadership decisions, behaviours and actions in a safety critical situation

Safety leadership is an important factor in supporting safe performance in the workplace. The present case study examined the role of safety leadership during the Bingham Canyon Mine high-wall failure, a significant mining incident in which no fatalities or injuries were incurred. The Critical Decision Method (CDM) was used in conjunction with a self-reporting approach to examine safety leadership in terms of decisions, behaviours and actions that contributed to the incidents' safe outcome. Mapping the analysis onto Rasmussen's Risk Management Framework (Rasmussen, 1997), the findings demonstrate clear links between safety leadership decisions, and emergent behaviours and actions across the work system. Communication and engagement based decisions featured most prominently, and were linked to different leadership practices across the work system. Further, a core sub-set of CDM decision elements were linked to the open flow and exchange of information across the work system, which was critical to supporting the safe outcome. The findings provide practical implications for the development of safety leadership capability to support safety within the mining industry.

Understanding safe performance in rapidly evolving systems: a risk management analysis of the 2010 US financial market Flash Crash with Rasmussen's risk management framework

ABSTRACTSystemic events or widespread disruptions in financial markets like the Flash Crash are a public concern as they jeopardise investors’ confidence in financial markets and result in financial losses for market participants. Federal regulations for financial markets do not keep pace with the evolution and growth of financial technology including advances in algorithmic and high-frequency trading (HFT). We report an analysis of the Flash Crash which occurred on 6 May 2010 using Rasmussen's 1997 risk management framework. While the framework has been validated on a number of well-documented accidents, our work examines the framework in the context of a large-scale adverse event associated with complex technologies and automated systems capable of evolving over time. Our contribution is a set of implications of the Flash Crash associated with Rasmussen's propositions. These implications would inform regulators and risk assessment methods for rapidly evolving complex socio-technical systems.

A systemic analysis of South Korea Sewol ferry accident – Striking a balance between learning and accountability

The South Korea Sewol ferry accident in April 2014 claimed the lives of over 300 passengers and led to criminal charges of 399 personnel concerned including imprisonment of 154 of them as of Oct 2014. Blame and punishment culture can be prevalent in a more hierarchical society like South Korea as shown in the aftermath of this disaster. This study aims to analyse the South Korea ferry accident using Rasmussen's risk management framework and the associated AcciMap technique and to propose recommendations drawn from an AcciMap-based focus group with systems safety experts. The data for the accident analysis were collected mainly from an interim investigation report by the Board of Audit and Inspection of Korea and major South Korean and foreign newspapers. The analysis showed that the accident was attributed to many contributing factors arising from front-line operators, management, regulators and government. It also showed how the multiple factors including economic, social and political pressures and individual workload contributed to the accident and how they affected each other. This AcciMap was presented to 27 safety researchers and experts at ‘the legacy of Jens Rasmussen’ symposium adjunct to ODAM2014. Their recommendations were captured through a focus group. The four main recommendations include forgive (no blame and punishment on individuals), analyse (socio-technical system-based), learn (from why things do not go wrong) and change (bottom-up safety culture and safety system management). The findings offer important insights into how this type of accident should be understood, analysed and the subsequent response.

Rasmussen's legacy in the great outdoors: A new incident reporting and learning system for led outdoor activities

Jens Rasmussen's seminal risk management framework and accompanying Accimap method have become highly popular in safety science circles. Despite this, widespread adoption of the model and method in practice has not yet been achieved. This paper describes a project involving the development and implementation of an incident reporting and learning system underpinned by Rasmussen's risk management framework and Accimap method. The system was developed for the led outdoor activity sector in Australia to enable reporting and analysis of injuries and near miss incidents, with the aim of supporting the development of more effective countermeasures. An analysis of the data derived from the first 3 months use of the system by 43 organisations is presented. The outputs provide an in-depth Accimap-based analysis of all incidents reported by participating organisations over the 3 month period. In closing, the importance of developing usable domain specific tools to support translation of Ergonomics theory and methods in practice is discussed.

The Leading Edge: A Systems Thinking Methodology for Assessing Safety Leadership

Leadership is progressively being recognized as a key factor in supporting successful performance across a range of domains. This is particularly important when considered within the context of safety, with the now widespread acceptance that safety is an emergent property of overall work systems. As such, the decisions and actions that characterize safety leadership thus become important emergent properties in the prevention of incidents, which should be considered within the context of the broader organizational system and not merely constrained to understanding events or conditions that shape performance at the ‘sharp end’. This paper presents a first-of-its-kind test application of a methodological approach, underpinned by systems thinking, to the examination of safety leadership. A case study incident is examined using the Critical Decision Method, Rasmussen's Risk Management Framework and corresponding Accimap method to identify safety leadership decisions and actions, and their contribution to the incidents important safe outcome (no injuries or fatalities were incurred). The merits of the methodological approach utilized are discussed.

Systems-based accident analysis in the led outdoor activity domain: application and evaluation of a risk management framework

Safety-compromising accidents occur regularly in the led outdoor activity domain. Formal accident analysis is an accepted means of understanding such events and improving safety. Despite this, there remains no universally accepted framework for collecting and analysing accident data in the led outdoor activity domain. This article presents an application of Rasmussen's risk management framework to the analysis of the Lyme Bay sea canoeing incident. This involved the development of an Accimap, the outputs of which were used to evaluate seven predictions made by the framework. The Accimap output was also compared to an analysis using an existing model from the led outdoor activity domain. In conclusion, the Accimap output was found to be more comprehensive and supported all seven of the risk management framework's predictions, suggesting that it shows promise as a theoretically underpinned approach for analysing, and learning from, accidents in the led outdoor activity domain. Statement of Relevance: Accidents represent a significant problem within the led outdoor activity domain. This article presents an evaluation of a risk management framework that can be used to understand such accidents and to inform the development of accident countermeasures and mitigation strategies for the led outdoor activity domain.

A test of Rasmussen's risk management framework in the food safety domain: BSE in the UK

In 1986, bovine spongiform encephalopathy (BSE) was identified in the UK. Millions of BSE-infected cows were slaughtered and over 150 people contracted variant Creutzfeldt–Jakob disease, an inevitably fatal human form of BSE. Tragic incidents such as this provide valuable opportunities to understand and improve the safety of complex socio-technical systems. By studying accidents, knowledge can be gained that can improve system safety. The purpose of this article is to test the usefulness of Rasmussen's risk management framework for explaining how and why accidents occur in the food production domain. This was accomplished by using the framework to retrospectively investigate how and why BSE was transmitted through the human and animal food supply in the UK from 1986 to 1996. More specifically, an AcciMap and Conflict Map were constructed to represent contributing factors of the epidemic according to the structure of Rasmussen's framework. These factors were used to test the seven predictions made by the framework. All seven predictions were supported by the evidence, indicating that Rasmussen's risk management framework shows promise as a theoretically driven explanation of how and why accidents happen in complex socio-technical systems, particularly in the food production domain.

Computed tomography of the body

As sports systems become increasingly more complex, competitive, and technology-centric, there is a greater need for systems ergonomics methods to consider the performance, health, and safety of athletes in context with the wider settings in which they operate. Therefore, the purpose of this systematic review was to identify and critically evaluate studies which have applied a systems ergonomics research approach in the context of sports performance and injury management.Five databases (PubMed, Scopus, ScienceDirect, Web of Science, and SPORTDiscus) were searched for the dates 01 January 1990 to 01 August 2017, inclusive, for original peer-reviewed journal articles and conference papers. Reported analyses were underpinned by a recognised systems ergonomics method, and study aims were related to the optimisation of sports performance (e.g. communication, playing style, technique, tactics, or equipment), and/or the management of sports injury (i.e. identification, prevention, or treatment).A total of seven articles were identified. Two articles were focussed on understanding and optimising sports performance, whereas five examined sports injury management. The methods used were the Event Analysis of Systemic Teamwork, Cognitive Work Analysis (the Work Domain Analysis Abstraction Hierarchy), Rasmussen's Risk Management Framework, and the Systems Theoretic Accident Model and Processes method. The individual sport application was distance running, whereas the team sports contexts examined were cycling, football, Australian Football League, and rugby union.The included systems ergonomics applications were highly flexible, covering both amateur and elite sports contexts. The studies were rated as valuable, providing descriptions of injury controls and causation, the factors influencing injury management, the allocation of responsibilities for injury prevention, as well as the factors and their interactions underpinning sports performance. Implications and future directions for research are described.