Resilience Engineering has evolved during the recent century and could be a good complement to the prevailing ideas concerning safety within the air traffic industry. The concept of Resilience Engineering stresses the fact that in order to keep up the high standard of safety, there must be greater attention directed to the importance of being proactive, and to implement measures before dangerous situations arises. The purpose of our work was to develop the Resilience Analysis Grid (RAG) to help LFV, the leading Air Navigation Service Provider in Sweden, to identify their ability to deal with disturbances and unexpected events. By testing our RAG on seven active air traffic controllers and operational managers, we were able to produce a final set of assertions, with a total number of 22 items, which LFV (or other similar organisations) can use as a foundation for future RAG studies. As a first attempt we also rated the answers which gave us an opportunity to produce a star diagram, showing the relationship between the areas covered by the RAG. During the interviews we discovered that resilience is already today in many aspects a big part of the everyday work and that the RAG method can therefore be applicable in the industry with some modification. However, there are certain areas within LFV that we believe there is room for improvements. We believe that the RAG could serve as a helpful tool in identifying these areas as well as assisting LFV in their striving to remain one of the safest organisations in the world.

Resilience Engineering has evolved during the recent century and could be a good complement to the prevailing ideas concerning safety within the air traffic industry. The concept of Resilience Engineering stresses the fact that in order to keep up the high standard of safety, there must be greater attention directed to the importance of being proactive, and to implement measures before dangerous situations arises. The purpose of our work was to develop the Resilience Analysis Grid (RAG) to help LFV, the leading Air Navigation Service Provider in Sweden, to identify their ability to deal with disturbances and unexpected events. By testing our RAG on seven active air traffic controllers and operational managers, we were able to produce a final set of assertions, with a total number of 22 items, which LFV (or other similar organisations) can use as a foundation for future RAG studies. As a first attempt we also rated the answers which gave us an opportunity to produce a star diagram, showing the relationship between the areas covered by the RAG. During the interviews we discovered that resilience is already today in many aspects a big part of the everyday work and that the RAG method can therefore be applicable in the industry with some modification. However, there are certain areas within LFV that we believe there is room for improvements. We believe that the RAG could serve as a helpful tool in identifying these areas as well as assisting LFV in their striving to remain one of the safest organisations in the world.

The established approach to safety management has failed to handle socio-technical systems that have become more complex. The main argument is this approach is based on assumptions that systems are protected against accidents by barriers (well-trained people, redundant mechanisms and safety devices, and procedures and safe systems of work). Complex systems, such as maintenance, are actually labour intensive; maintenance staff often works under pressure to finish tasks as rapidly as possible. They continuously adapt and make adjustments using available resources, time, knowledge, and competence to achieve success. Thus, they are accidents prone. Human factors inherent to maintenance accidents are most times difficult to identify. Research in this area in the oil and gas industry in maintenance management is limited in comparison to the aviation and nuclear sectors. Therefore, it has been suggested to overcome this lack by exploring the maintenance system and identifying appropriate methods and tools that lead a system to safety excellence. Resilience engineering (RE) approach has been found the suitable solution. Moreover, four system abilities (cornerstones of RE: ability to respond, to monitor, to anticipate, and to learn) have been identified to characterise the resilience of a system; if these abilities are known and increased, it will make the system As High Resilient As Possible (AHRAP). However, there is a need to bridge between RE theory and practice. Particularly, a tool that measures these abilities lacks in the oil and gas industry, specifically within the maintenance system. In doing so, a framework based on a Gap Analysis (GA) was outlined. A tool, the MAintenance System Resilience Assessment Tool- MASRAT, was developed to assess current system resilience and identify strategies for improvement to achieve safety excellence. The maintenance system of SONATRACH was explored by the analysis of the system documentation and processes, interviews with maintenance staff, questionnaires, field observations, storytelling, and functional analysis. MASRAT has been validated by means of congruency and principal components analysis, PCA (content validity), and Cronbach’s alpha (reliability). An expert panel testing was carried out to test its usability. The exploration of the system came up with a snapshot of daily activities as well as a better understanding of the maintenance system. The study identified the most significant human factors (resources, time pressure, and supervision/coordination) and their probable impact on plant safety. The elements of the system were found tightly coupled, hence the system complex. Stories describing the continuous adaptations of people to achieve assigned objectives were collected. On the other hand, MASRAT was validated. All items were rated above 0.75 in congruency test. The results of PCA for the three selected factors confirmed the items may be clustered after extraction into four components which interpretation represents the four cornerstones of RE. The analysis showed MASRAT is reproducible. Cronbach’s alpha results were found higher than what is required (0.7). MASRAT was found usable by maintenance expert panel. It was used to measure the maintenance department resilience. Strategies that may lead the system from current maturity level to excellence were identified. Eventually, recommendations were made to management to be implemented both at corporate and department levels. For the first time, the maintenance department resilience of petroleum assets was measured to fill in the gap between RE theory and practice. Besides, this can be of benefit to the petroleum industry by a better knowledge of the maintenance working environment and human factors impact on safety and by profiles determination and improvement strategies identification.

Serviços de saúde são reconhecidamente sistemas socio-técnicos complexos (SSTC) tendo em vista sua dinamicidade, diversidade, incerteza e interações entre os diversos elementos que os compõe. Outra característica importante dos SSTC é a resiliência, fundamental para manter os sistemas em funcionamento. Estudar a resiliência em SSTC é objetivo da Engenharia de Resiliência (ER), novo paradigma para gestão de segurança, com enfoque na análise do trabalho real. Esta tese explora o papel complementar de duas práticas com influência na resiliência em SSTC: o desenvolvimento de habilidades de resiliência (HR) e os procedimentos operacionais padronizados (POPs). Há um entendimento que, mesmo com procedimentos operacionais padronizados, existe uma variabilidade inerente ao SSTC, tornando impossível que o procedimento atenda a todas as situações. Este estudo tem como principal questão de pesquisa: como integrar a gestão de procedimentos operacionais padronizados ao desenvolvimento de HR em serviços de emergência hospitalar? E como objetivo principal: propor um modelo para integração entre gestão de POP e desenvolvimento de HR, enfatizando serviço de emergência hospitalar Os objetivos específicos são: (a) identificar, analisar e traçar um panorama sobre estudos na área da saúde com a ótica da ER; (b) identificar a origem das HR. A abordagem norteadora da tese é o Design Science Research que, com sua natureza prescritiva, busca desenvolver o conhecimento por meio da construção de artefatos. A tese está estruturada em três fases, que resultam em três artigos: (i) ―Contribuições da Engenharia de Resiliência para a Saúde: uma Revisão Sistemática‖, tem como principal objetivo identificar e entender como os conceitos de ER vem sendo utilizados na área da saúde; (ii) ―Habilidades de resiliência como fenômeno emergente: um estudo em departamentos de emergência no Brasil e nos Estados Unidos‖, tem como objetivo responder ao questionamento ―de onde emergem as habilidades de resiliência‖; (iii) ―Procedimentos e capacitação: recursos para ação trabalhando em conjunto para apoiar a resiliência de sistemas sócio-técnicos complexos‖, que responde a pergunta ―como integrar melhoria de POP e desenvolvimento de HR?‖. Assim, o último artigo atende o principal objetivo da tese ao propor modelo de integração entre POP e capacitações em HR. / Health services are admittedly complex socio-technical systems (CSS) considering their dynamism, diversity, uncertainty and interactions between the various elements that compose them. Another important feature of the CSS is resilience. It is critical to keep systems running. The goal of Resilience Engineering is to study resilience, the new paradigm for safety management, focusing on the analysis of current work. This thesis approaches the complementary role of two practices that influence the resilience CSS: the development of resilience skills (RS) and standard operational procedures (SOPs). There is an understanding that even with the use of SOPs, there is variability in the CSS, making it impossible for the procedure to meet all situations. This study's main research question is: how to integrate the SOP management and RS development in hospital emergency room services? The main objective of the study is: to suggest a model to integrate SOP management and RS development, with emphasis in hospital emergency room. The specific objectives are: (a) identify, analyze and give an overview of studies in health care according to Resilience Engineering; (b) identify the origens of the RS The guiding approach of this thesis is the Design Science Research which, due to its prescriptive nature, seeks to develop knowledge by building artifacts. The thesis is structured in three phases, resulting in three items: (i) ―A Systematic Review on Resilience Engineering contributions for Health Care‖ aims to identify and understand how concepts of Resilience Engineering have been used in health services (ii) "Resilience skills as emergent phenomena: a study of emergency departments in Brazil and the United States" aims to answer the question "where do resilience skills come from"; (iii) ―Procedures and training: resources for action working together to support the resilience in CSS‖, which answers the question "how to integrate SOP improvement and resilience skills development?". Thus, the last article serves the main objective of the thesis that is to suggest an integration model between SOP and RS training.

<p>Responsinsatser vid extra ordinära händelser såsom kriser och katastrofer karakteriseras av höga risker och stor tidspress i en föränderlig och komplex miljö. Vissa händelser går till viss del att förutse men dessvärre inte att hindra, exempelvis översvämningar eller orkaner, medan andra händelser kan vara svåra att förutse, exempelvis jordbävningar eller tsunamis. Kraven på prestation av de involverade responsorganisationerna vid sådana extrema händelser är höga samtidigt som kunskapen om situationen ofta är begränsad. Improviserat arbete och anpassning efter rådande situation är därför en förutsättning för en lyckad insats (Medonça, 2006).</p><p>Tidigare forskning har visat att en rad svårigheter kan uppstå med att ha flexibla och improviserade roller under en insats, exempelvis en annan befattning eller funktion än den man vanligtvis har. Genom att studera en ledningsövning för Svenska Stödstyrkans samordningsstab där deltagare fått ta på sig en roll de inte är utbildade för syftar denna studie till att närmare undersöka förutsättningar och förmågor som ligger till grund för ett lyckat improviserat arbete.</p><p>En kvalitativ fallstudie av den genomförda ledningsövningen gjordes. Det insamlade materialet från övningen, i form av bland annat telefon- och videoinspelningar, har analyserats med hjälp av episodanalys. Resultaten visar att en tydlig organisationsstruktur krävs i det initiala ledningsarbetet, inte minst för att motverka och fånga upp missuppfattningar. Resultaten visar även att en välutvecklad återkopplingsmetod är viktigt för att skapa en medvetenhet hos stabsmedlemmar om positiva och negativa aspekter av deras arbete. Att studera improvisation och dess förhållande till kontexten kan vara ett viktigt verktyg för att bättre förstå arbetet med improviserade och icke-improviserade roller, vilket på sikt kan leda till bättre stödsystem för ledningsarbetet vid responsinsatser.</p>

Safety is very important for our society. In contrast, it is hard to define what this term really means. Nevertheless, one area that is considered important for safety involves accident prevention. Many methods exist within this area which aims at preventing accidents from happening. One accident prevention method is called ‘The Safety Scanning Tool (SST)’. The study conducted in this thesis aimed at exploring whether the SST could improve the safety understanding of experts from the domain of aviation. The term ‘safety understanding’, as it is used in this thesis, refers to the understanding of central scientific concepts underlying safety. These concepts relate to the area of accident prevention and they were the results of a literature study on safety. Thus, the safety understanding was addressed on two levels of abstraction. The first general abstraction level concerned the basic assumptions for studying an organization’s safety culture relating to Schein’s (1992) framework cited by Guldenmund (2000). This relates to the area of accident prevention in a more general way. The second more specific abstraction level regarded 21 different safety issues important for accident prevention. These originated from the area of resilience engineering. Furthermore, this study was structured as a field experiment using a pre-post test and a within-group design.  In order to measure the different experts’ safety understanding, the data were gathered with the help of two surveys before and after the experts’ used the SST. The SST was applied to two groups of experts. In the first group, they were six people, and, in the second 16. The questions in the surveys were created with the help of the above mentioned literature study on safety. The results were analyzed with the help of the statistics program SPSS. In addition, the results were analyzed with the help of sources from academic literature. These were used in order to determine whether there was an improvement of the safety understanding or not. Based on the results from this study, it can be concluded that undergoing the SST caused several improvements of the experts’ safety understanding. These improvements were found in both groups of experts and on both abstraction levels of the safety understanding. However, one result relating to the basic assumption level in the second group of experts could be interpreted both as an improvement and as a decrease of the safety understanding. The results of this study indicate not only that the SST has the ability to detect safety problems in an early state, before they can develop to the outcome of an accident. It has also the ability to enhance its user’s safety understanding relating to factors important for accident prevention.

Responsinsatser vid extra ordinära händelser såsom kriser och katastrofer karakteriseras av höga risker och stor tidspress i en föränderlig och komplex miljö. Vissa händelser går till viss del att förutse men dessvärre inte att hindra, exempelvis översvämningar eller orkaner, medan andra händelser kan vara svåra att förutse, exempelvis jordbävningar eller tsunamis. Kraven på prestation av de involverade responsorganisationerna vid sådana extrema händelser är höga samtidigt som kunskapen om situationen ofta är begränsad. Improviserat arbete och anpassning efter rådande situation är därför en förutsättning för en lyckad insats (Medonça, 2006). Tidigare forskning har visat att en rad svårigheter kan uppstå med att ha flexibla och improviserade roller under en insats, exempelvis en annan befattning eller funktion än den man vanligtvis har. Genom att studera en ledningsövning för Svenska Stödstyrkans samordningsstab där deltagare fått ta på sig en roll de inte är utbildade för syftar denna studie till att närmare undersöka förutsättningar och förmågor som ligger till grund för ett lyckat improviserat arbete. En kvalitativ fallstudie av den genomförda ledningsövningen gjordes. Det insamlade materialet från övningen, i form av bland annat telefon- och videoinspelningar, har analyserats med hjälp av episodanalys. Resultaten visar att en tydlig organisationsstruktur krävs i det initiala ledningsarbetet, inte minst för att motverka och fånga upp missuppfattningar. Resultaten visar även att en välutvecklad återkopplingsmetod är viktigt för att skapa en medvetenhet hos stabsmedlemmar om positiva och negativa aspekter av deras arbete. Att studera improvisation och dess förhållande till kontexten kan vara ett viktigt verktyg för att bättre förstå arbetet med improviserade och icke-improviserade roller, vilket på sikt kan leda till bättre stödsystem för ledningsarbetet vid responsinsatser.

Essa dissertação é formada por três artigos que versam sobre o Serviço de Atendimento Móvel de Urgência – SAMU, da Região Metropolitana de Porto Alegre. O primeiro artigo analisa a extensão na qual o SAMU opera como um sistema sociotécnico, considerando os 19 princípios propostos por Clegg (2000), tendo ficado claro que o sistema atende a 4, parcialmente a 3 e não atende a 12 deles. O segundo artigo foca o sistema de regulação do SAMU à luz dos quatro subsistemas do sistema sociotécnico: o pessoal, do projeto de trabalho, o tecnológico e do ambiente externo. O método utilizado para análise foi a Análise Macroergonômica do Trabalho – AMT (GUIMARÃES, 2010), que viabilizou a identificação de demanda ergonômica dos envolvidos no sistema, a partir de entrevistas e/ou questionários com 118 pessoas, sendo 41 trabalhadores da regulação e 77 das bases.Os resultados mostraram que os ítens de maior impacto para o desenvolvimento do serviço advém do ambiente externo, principalmente o despreparo da população para o uso do serviço (os trotes chegam a 69% das chamadas) e o risco de omissão de socorro. O terceiro artigo avalia o SAMU como um sistema complexo sob a ótica da Engenharia de Sistemas Cognitivos (ESC), que considera os fatores de coordenação, resiliência e “affordance” que emergem nas interações entre tecnologia e pessoas que compõem um sistema de trabalho. Concluiu-se que o SAMU possui diversas características de um sistema sociotécnico complexo, e que o sistema é descoordenado e clumssy, pois não possui artefatos e procedimentos de trabalho que agilizem o processo de trabalho. As características de resiliência são pró ativas e emergentes, pois os agentes diretos estão em constante adaptação para contornar os obstáculos encontrados no sistema de trabalho. Foram feitas algumas sugestões para melhoria do serviço, que poderão ser efetivadas a longo prazo, tendo em vista as dificuldades impostas pelo ambiente externo (legislação e questões políticas e sócio-culturais). / This dissertation consists of three articles that focus on the Mobile Emergency Service – SAMU of the Metropolitan Region of Porto Alegre. The first article examines the extent to which the SAMU operates as a sociotechnical system, considering the 19 principles proposed by Clegg (2000), it was clear that the system meets the 4, 3 and partially does not meet 12 of them. The second article focuses on the system of regulation of SAMU in the light of the four subsystems of the socio-technical system: staffing, project work, the technological and the external environment. The method of analysis was the Macroergonomic Work Analysis - MWA (GUIMARÃES, 2010), which enabled the identification of ergonomic demands of those involved in the system, based on interviews and / or questionnaires to 118 people, including 41 employees of regulation and 77 bases. The results showed that the items of greatest impact on service development comes from the external environment, especially the unpreparedness of the population using the service (hazing reach 69% of calls) and the risk of failure to save. The third article assesses the SAMU as a complex system from the perspective of Cognitive Systems Engineering (CSE), which considers the factors of coordination, resilience and "affordance" that emerge in the interactions between technology and people that make a system work. It was concluded that the SAMU has several characteristics of a complex socio-technical system and the system is patchy and clumssy as it has no artifacts and work processes that streamline the work process. The characteristics of resilience are clear, as the direct agents are constantly adapting to bypass the obstacles encountered in the work. There have been some suggestions for improving the service, which could take effect in the long term, in view of the difficulties imposed by the external environment (legislation and policy issues and socio-cultural).

Os sistemas de medição de desempenho em segurança e saúde no trabalho (SMDSST) contribuem para identificar e caracterizar os riscos de acidentes, sendo um elemento fundamental da gestão da SST em qualquer setor industrial e também uma base para a melhoria contínua. O presente trabalho propõe um conjunto de critérios para avaliar SMDSST no setor da construção civil. Os critérios desenvolvidos foram estabelecidos a partir de três tipos de requisitos: (a) consistência do SMDSST com uma filosofia de gestão da SST, denominada engenharia de resiliência; (b) conformidade dos SMDSST com requisitos gerais de sistemas de medição de desempenho, tais como o grau de definição dos indicadores, a sua incorporação na rotina organizacional e o alinhamento das medidas com as estratégias; e (c) contribuição para a identificação e monitoramento dos principais fatores causais de acidentes, classificando-os em falhas relacionadas aos subsistemas pessoal, tecnológico, organizacional e do ambiente externo. A aplicação dos critérios é ilustrada por meio de dois estudos de caso, realizados em duas construtoras. Os resultados indicaram que tais critérios contribuem para a identificação de oportunidades de melhoria nos SMDSST tradicionais no setor da construção civil, tais como o desenvolvimento de novos indicadores e adaptações naqueles já existentes. / Performance measurement systems in occupational health and safety (SMDSST) help to identify risks of accidents, and play a key role in the management of occupational health and safety in any industry, establishing a basis for continuous improvement. This research work proposes a set of criteria for assessing SMDSST in the construction industry. This set of criteria was devised by taking into account three groups of requirements: (a) consistency of the SMDSST with an occupational health and safety management philosophy, known as resilience engineering; (b) compliance of the SMDSST with general performance measurement system, such as the definition of indicators, their incorporation into the organizational routine, and alignment of measures with strategies; and (c) contribution for the identification and control the main accident causal factors, classifying them in failures related to personnel, technological, organizational and external environment subsystems. The application of criteria is illustrated in two case studies carried out in different construction companies. Results indicated that the proposed criteria help to identify opportunities for improvement in SMDSST, such as development of new indicators and improvement in the existing ones.

Tendo em vista a crescente disseminação de sistemas de gestão da segurança e saúde no trabalho (SGSST), torna-se cada vez mais relevante a necessidade de instrumentos de avaliação da sua eficiência e eficácia. Nesse contexto, esta tese apresenta a proposta de um método de avaliação de sistemas de gestão de segurança e saúde no trabalho (MASST), o qual apresenta duas características inovadoras: a) a conciliação das abordagens estrutural (sistema prescrito), operacional (o que está acontecendo na prática) e por desempenho (resultados de indicadores); b) a adoção do enfoque da engenharia de resiliência (ER) sobre a segurança e saúde. O MASST foi desenvolvido a partir das contribuições da literatura, na qual foram identificados quatro princípios da ER (comprometimento da alta direção, flexibilidade, aprendizagem e consciência), bem como de um estudo de caso exploratório realizado em uma empresa de implementos agrícolas. Com base nisso, foram propostos vinte e sete itens distribuídos ao longo de sete critérios. Cada item possui um conjunto de requisitos que são avaliados com base em três fontes de evidências básicas: entrevistas, análise de documentos e observação direta. O MASST foi validado em um estudo de caso em uma empresa da cadeia automotiva. Os principais resultados revelaram que, no estudo de caso, em uma escala de pontuação de 0% a 100%, nove dentre quatorze itens relacionados à ER obtiveram pontuação entre 0% e 10%. Além disso, o MASST possibilitou a identificação dos pontos positivos do SGSST, a identificação das causas sistêmicas da falta de segurança e a identificação das prioridades de ação em termos de SST. Dentre as limitações do MASST percebidas durante o estudo de caso, salienta-se a necessidade de experiência do auditor acerca de conceitos e princípios da ER, os quais ainda não são amplamente aplicados de modo sistemático no meio industrial. / Due to the increasing dissemination of health and safety management systems (HSMS), both academics and practitioners have paid more attention to the assessment of their effectiveness and efficacy. This thesis introduces a method for assessing health and safety management systems (MASST) that has two innovative characteristics: a) it takes into account simultaneously the structural approach (prescribed system), the operational approach (what is really happening on the shop floor) and the performance approach (results of performance indicators); b) it adopts the resilience engineering (RE) perspective on health and safety. The MASST was developed based on both the literature review and an exploratory case study in a heavy machinery manufacturer. The literature review pointed out four major resilience engineering (RE) principles: top management commitment, flexibility, learning and awareness. Then, twenty-seven items grouped into seven major criteria were proposed. Each item encompasses a set of requirements that should be assessed based on three major sources of evidence: interviews, analysis of documents and direct observation. The MASST was tested in a case study that was carried out in a supplier of the automotive industry. The results pointed out that, considering a scale from 0% to 100%, nine out of the fourteen items related to the RE obtained a very low degree, ranging from 0% to 10%. Moreover, the MASST pointed out the positive aspects of the HSMS, identified systemic causes of the lack of safety and identified priorities in terms of health and safety management. The case study results also indicated that one of the main limitations of the MASST concerns the necessity of experienced auditors in terms of RE principles and concepts. This drawback is relevant since the RE perspective on health and safety has not yet been adopted by a large extent in the industry.