Showing papers by "Erik Hollnagel published in 2020"

FRAM AHP approach to analyse offshore oil well drilling and construction focused on human factors

Abstract: 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.

Measurement of resilience potential - development of a resilience assessment grid for emergency departments.

Abstract: 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.