Erik Hollnagel
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View article: Inductive and deductive approaches to modelling of human decision making
Inductive and deductive approaches to modelling of human decision making Open
This paper presents the two conventional approaches to modelling of human decision making. The inductive approach emphasises the anchoring in empirical data. The deductive approach is based on accepted assumtions from formal decision theor…
View article: Self-reference as a problem in the control of complex systems
Self-reference as a problem in the control of complex systems Open
View article: Visualising for Safety or Visualisation of Safety?
Visualising for Safety or Visualisation of Safety? Open
This chapter considers whether it is possible to visualise safety as a word, a construct, or a concept. It analyses both the instrumental approach of visualising for safety (the use of visual means as a help to make systems safe) and the o…
View article: Analyzing human factors and complexities of mining and O&G process accidents using <scp>FRAM</scp>: Copiapó (Chile) and <scp>FPSO CSM</scp> (Brazil) cases
Analyzing human factors and complexities of mining and O&G process accidents using <span>FRAM</span>: Copiapó (Chile) and <span>FPSO CSM</span> (Brazil) cases Open
The study presented in this research is a systematic human factors approach comparing two striking process accidents in Latin America: the Copiapó mining accident (2010), at the San José copper–gold mine, in Chile, and the FPSO CSM acciden…
View article: Reanalysing Deepwater Horizon accident with FRAM - enhancing learning and understanding complexities to improve safety
Reanalysing Deepwater Horizon accident with FRAM - enhancing learning and understanding complexities to improve safety Open
This study presents a reanalysis of Deepwater Horizon platform accident, occurred in April 2010, in offshore Macondo field, based on books, scientific articles and official reports prepared by the companies involved in the accident. The pu…
View article: Modelling complex socio-technical systems
Modelling complex socio-technical systems Open
In a complex system, it is difficult to understand how the system works in order to analyse, manage, or improve it. A common solution to overcome this difficulty is to construct a model of the system. A model should be more than a diagram …
View article: Work-as-Imagined and Work- as-Done
Work-as-Imagined and Work- as-Done Open
Work-as-Imagined (WAI) and Work-as-Done (WAD) are two concepts borrowed from ergonomics. WAI represents how we think work should be done in order to achieve the intended outcomes. WAI covers our ideas about how others do, or should do, the…
View article: Analysing the interactions and complexities of the operations in the production area of an FPSO platform using the functional resonance analysis method (FRAM)
Analysing the interactions and complexities of the operations in the production area of an FPSO platform using the functional resonance analysis method (FRAM) Open
The technological evolution of several productive sectors of society has demanded the same level of evolution for the oil and gas industry, both for energy production and their own systems’ functioning. The production of crude oil and natu…
View article: Reanalyzing the FPSO CSM accident (2015) with a Human Factors approach to understand the contribution of organizational elements and complexities
Reanalyzing the FPSO CSM accident (2015) with a Human Factors approach to understand the contribution of organizational elements and complexities Open
This study presents a reanalysis of FPSO (Floating Production Storage & Offloading) CSM (Cidade de São Mateus) accident, occurred in February 2015, in the post-salt of the Camarupim fields, in the Espírito Santo offshore area, using the FR…
View article: On the brink of disruption: Applying Resilience Engineering to anticipate system performance under crisis
On the brink of disruption: Applying Resilience Engineering to anticipate system performance under crisis Open
View article: A systems analysis of the COVID-19 pandemic response in the United Kingdom – Part 1 – The overall context
A systems analysis of the COVID-19 pandemic response in the United Kingdom – Part 1 – The overall context Open
View article: Safer Systems: People Training or System Tuning?
Safer Systems: People Training or System Tuning? Open
Safety is usually seen as a problem when it is absent rather than when it is present, where accidents, incidents, and the like represent a lack of safety rather than the presence of safety. To explain this lack of safety, one or more cause…
View article: A novel approach to explore Safety-I and Safety-II perspectives in in situ simulations—the structured what if functional resonance analysis methodology
A novel approach to explore Safety-I and Safety-II perspectives in in situ simulations—the structured what if functional resonance analysis methodology Open
View article: Safety-II Approach in the O&G Industry: Human Factors and Non-Technical Skills Building Safety
Safety-II Approach in the O&G Industry: Human Factors and Non-Technical Skills Building Safety Open
The Evolution of Technology in the workplace in the O&G industry carry this segment to a present dilemma, where ingiven situations, there is so much complexity that the system operability became quite complex too. In this context, thetradi…
View article: Measurement of resilience potential - development of a resilience assessment grid for emergency departments
Measurement of resilience potential - development of a resilience assessment grid for emergency departments Open
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 managemen…
View article: Safety-II and the Future of Safety Management
Safety-II and the Future of Safety Management Open
安全マネジメントにおけるレジリエンスエンジニアリングの重要性を説かれるエリック・ホルナゲル教授をお招きし,Safety-IIと呼ばれる新しい考え方から安全マネジメントの過去・現在・未来についてご講演いただきます。
View article: A nexus of necessary knowledge
A nexus of necessary knowledge Open
View article: Historical reasons for the fragmented view
Historical reasons for the fragmented view Open
View article: Fundamentals of change management
Fundamentals of change management Open
View article: Synetic change management
Synetic change management Open
View article: Psychological reasons for the fragmented view
Psychological reasons for the fragmented view Open
View article: A fragmented view
A fragmented view Open
View article: Fragmented change management
Fragmented change management Open
View article: Framing the FRAM: A literature review on the functional resonance analysis method
Framing the FRAM: A literature review on the functional resonance analysis method Open
The development of the Functional Resonance Analysis Method (FRAM) has been motivated by the perceived limitations of fundamentally deterministic and probabilistic approaches to understand complex systems' behaviour. Congruent with the pri…
View article: RECOGNITION AND ANALYSIS OF HUMAN FACTORS AND NON-TECHNICAL SKILLS USING THE FUNCTIONAL RESONANCE ANALYSIS METHOD - FRAM
RECOGNITION AND ANALYSIS OF HUMAN FACTORS AND NON-TECHNICAL SKILLS USING THE FUNCTIONAL RESONANCE ANALYSIS METHOD - FRAM Open
This study presents a Human Factors and non-technical skills recognition and analysis in the operations activities of an offshore drilling platform, using the FRAM (Functional Resonance Analysis Method) to build a model of how the work is …
View article: Resilient Health Care
Resilient Health Care Open
Contents: Preface: on the need for resilience in health care, Erik Hollnagel, Jeffrey Braithwaite and Robert L. Wears. Part I Health Care as a Multiple Stakeholder, Multiple Systems Enterprise: Making health care resilient: from safety-I t…
View article: Staff acting resiliently at two hospital wards
Staff acting resiliently at two hospital wards Open
Purpose The purpose of this paper is to understand how the hospital staff (nurses and physicians) at two hospital wards have coped with everyday work having leaders in conflict or longer periods without one or the other leader and whether …
View article: Hospital accreditation: staff experiences and perceptions
Hospital accreditation: staff experiences and perceptions Open
Purpose The purpose of this paper is to understand how staff at various levels perceive and understand hospital accreditation generally and in relation to quality improvement (QI) specifically. Design/methodology/approach In a newly accred…
View article: Leadership set-up: wishful thinking or reality?
Leadership set-up: wishful thinking or reality? Open
Purpose The purpose of the study is to determine whether one leader set-up is better than the others according to interdisciplinary cooperation and leader legitimacy. Design/methodology/approach The study is a qualitative study based on se…
View article: Learn from what goes right: A demonstration of a new systematic method for identification of leading indicators in healthcare
Learn from what goes right: A demonstration of a new systematic method for identification of leading indicators in healthcare Open