Human error risk management for engineering systems: a methodology for design, safety assessment, accident investigation and training

The objective of this paper is to tackle methodological issues associated with the inclusion of cognitive and dynamic considerations into Human Reliability methods. A methodology called Human Error Risk Management for Engineering Systems is presented that offers a ‘roadmap’ for selecting and consistently applying Human Factors approaches in different areas of application and contains also a ‘body’ of possible methods and techniques of its own. Two types of possible application are discussed to demonstrate practical applications of the methodology. Specific attention is dedicated to the issue of data collection and definition from specific field assessment.     

Fuzzy-logic-based network for complex systems risk assessment: Application to ship performance analysis

In this paper, a new interpretation of intuitionistic fuzzy sets in the advanced framework of the Dempster–Shafer theory of evidence is extended to monitor safety-critical systems’ performance. Not only is the proposed approach more effective, but it also takes into account the fuzzy rules that deal with imperfect knowledge/information and, therefore, is different from the classical Takagi–Sugeno fuzzy system, which assumes that the rule (the knowledge) is perfect. We provide an analytical solution to the practical and important problem of the conceptual probabilistic approach for formal ship safety assessment using the fuzzy set theory that involves uncertainties associated with the reliability input data. Thus, the overall safety of the ship engine is investigated as an object of risk analysis using the fuzzy mapping structure, which considers uncertainty and partial truth in the input–output mapping. The proposed method integrates direct evidence of the frame of discernment and is demonstrated through references to examples where fuzzy set models are informative. These simple applications illustrate how to assess the conflict of sensor information fusion for a sufficient cooling power system of vessels under extreme operation conditions. It was found that propulsion engine safety systems are not only a function of many environmental and operation profiles but are also dynamic and complex.     

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.     

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.     

Identification, ranking, and management of risks in a major system acquisition

Risk management is essential to protect the quality of a large-scale engineering effort. It should be a well-defined process that builds on an encompassing and detailed understanding of the purpose, elements, and contexts of the system. It should accommodate qualitative and quantitative information in understanding sources of risk. In an application paper, we use hierarchical holographic modeling (HHM) to identify sources of risk in the acquisition of a large ($1 billion US) software and database system. HHM provides a framework to integrate the perceptions by managers and analysts of what could go wrong in the acquisition. In addition, we filter and prioritize the identified sources of risk based on their likelihoods and potential consequences. Finally, we generate and evaluate alternatives for risk management, focusing on potential impacts to the acquisition schedule.     

Addressing the road trauma burden in China: Exploring attitudes,behaviours, risk perceptions and cultural uniqueness

As China continues to motorise rapidly, solutions are needed to reduce the burden of road trauma that is spread inequitably across the community. Little is currently known about how new drivers are trained to deal with on-road challenges, and little is also known about the perceptions, behaviours and attitudes of road users in China. This paper reports on a pilot study conducted in a driver retraining facility in one Chinese city where people who have had their licence suspended for accrual of 12 demerit points in a one year period must attend compulsory retraining in order to regain their licence. A sample of 239 suspended drivers responded to an anonymous questionnaire that sought information about preferred driving speeds and perceptions of safe driving speeds across two speed zones. Responses indicated that speeds higher than the posted limits were commonly reported, and that there was incongruence between preferred and safe speeds, such that a greater proportion of drivers reported preferred speeds that were substantially faster than what were reported as safe speeds. Participants with more driving experience reported significantly fewer crashes than newly licensed drivers (less than 2 years licensed) but no differences were found in offences when compared across groups with different levels of driving experience. Perceptions of risky behaviours were assessed by asking participants to describe what they considered to be the most dangerous on-road behaviours. Speeding and drink driving were the most commonly reported by far, followed by issues such as fatigue, ignoring traffic rules, not obeying traffic rules, phone use while driving, and non-use of seatbelts, which attracted an extremely low response which seems consistent with previously reported low belt wearing rates, unfavourable attitudes towards seatbelt use, and low levels of enforcement. Finally, observations about culturally specific considerations are made from previous research conducted by the authors and others. Specifically, issues of saving face and the importance and pervasiveness of social networks and social influence are discussed with particular regard to how any future countermeasures need to be informed by a thorough understanding of Chinese customs and culture.