A widespread and persistent memory error that people commit on a daily basis is the post-completion error (PCE; i.e., forgetting to complete the final step of a procedural task). PCEs occur in the railroad industry when a locomotive conductor changes the direction of a rail switch but fails to report this change. This particular error could contribute to unsafe conditions as another train traveling on the same track could derail. Although training can help reduce some of the factors leading to unsafe conditions on the rail, research has demonstrated that PCEs are different from other errors of omission in that they cannot be eliminated through training, which makes them a difficult problem to address. Therefore, there is a need to explore new remedial actions designed to reduce PCEs. The current study investigated the effectiveness of a theoretically motivated intervention at reducing PCEs in trainyard operations, where making these errors could be life-threatening. Twenty-eight undergraduates completed trainyard tasks within a high-fidelity simulator. Each participant received the behavioral intervention in one block and no intervention in another. Specifically, participants were required to perform an additional task designed to remind participants of the post-completion (PC) step. The intervention significantly reduced PCE rates in the context of trainyard operations, on average, by 65%. We discuss implications of these results on reducing trainyard accidents, and how this outcome can contribute to the literature on the cause of PCEs.

This thesis problematizes the concept of usefulness, in part by taking questions to the extreme. The starting point is the contemporary view of usefulness, a view that remains within a traditional paradigm of technical rationality in which important aspects are disregarded or not perceived because they are not part of the equation. For scrutiny of technological usefulness that is a socially situated phenomenon regarding physical systems, neither interpretivist nor positivist research approaches are sufficient. Both views are required. Critical Realism supports such duality, facilitating the combination of elements from different paradigms, and provides methodological guidelines for doing this. The critical realist approach makes it possible to transcend the boundaries of technical rationality and contribute an alternative definition of usefulness that takes into account also the situated, the contextual, and the unpredictable. The aim is that this definition will contribute to a transformation of society. Concepts related to usefulness, such as predictability, controllability, effectiveness, and safety, are revisited, redefined, or complemented. Underlying aspects and mechanisms are explored and tensions identified, resulting in a theoretical contribution with models and frameworks explaining what is argued to be the true nature of usefulness. Potentiality is suggested as a complementary concept to effectiveness, similar to how resilience complements safety. Situated usefulness is then defined using these four concepts. The phenomenon known as situation awareness is scrutinized as well, and complemented by system awareness and the thesis title concept, edge awareness. Four cases, two airline crashes and two nuclear power plant events, and three future scenarios, constitute the empirical contribution. The analysis shows that the contributed frameworks and redefinition of usefulness facilitate different or extended explanations of all four events, and that future cases lack considerations of situated usefulness. Research implications center on the human role and our responsibilities in relation to the technology that we use, and on the meaning of concepts defining this role. We are situated human beings. Our role is to be involved and responsible, a role requiring awareness and controllability. The escalating ubiquity and the character of computerized technological systems make therefore the quest for edge awareness more important than ever.

Acidentes graves em organizações com infraestruturas críticas, como a Usina Hidrelétrica Itaipu Binacional, embora raros, causam importantes impactos sociais e econômicos em sua área de influência. Portanto, eles devem ser evitados mesmo que, seja esperada uma taxa “normal” de acidentes por conta dos fatores de risco e complexidade da sua operação. Essa dissertação apresenta uma investigação das condições que levam a acidentes em casos específicos da operação da Itaipu Binacional sob o enfoque proativo da gestão da Segurança II de acordo com a Engenharia de Resiliência (ER). Ela se baseia na variabilidade da operação normal e, portanto, “no muito que dá certo”, em contraponto à visão tradicional da Segurança I, reativa, baseada na análise retrospectiva de acidentes e “no pouco que dá errado”. Com base em uma revisão da literatura quanto os requisitos, princípios e temas da ER e da Segurança-II e nas opiniões estruturadas de operadores foram desenvolvidos dois estudos: o primeiro traçou preocupações destes operadores em relação ao risco de incêndio em um transformador da Itaipu Binacional para desenvolver indicadores e planos de ação aderentes aos princípios da ER. O objetivo foi suplementar, com elementos de ER, uma análise de risco convencional baseada em árvore de falhas e árvore de eventos, e otimizar o plano de ação de emergência em caso de incêndio em transformador da unidade geradora Os resultados mostraram a oportunidade de melhoria para o desenvolvimento de indicadores proativos para a análise de risco. O segundo estudou, com base no método FRAM, a operação normal e a variabilidade de quatro manobras operacionais típicas selecionadas pelos operadores dentro dos quadrantes da matriz periodicidade-complexidade. Os resultados indicaram que as mesmas variabilidades influenciam nos passos operacionais, não importando a complexidade tampouco a periodicidade da manobra. Um comparativo entre a análise das variabilidades em situação normal e os relatórios das quatro falhas ocorridas entre 2006 e 2015 apontou que o sucesso e a falha advêm da mesma fonte, e que algumas variabilidades como “ambiente de manobra”, a “necessidade de confirmar os passos das manobras” e situações que tiram a atenção do operador atuam de forma decisiva em praticamente todas as manobras. Os resultados foram discutidos com os integrantes da equipe que propuseram adaptações necessárias para aumento da segurança operacional do trabalho normal sob a perspectiva de ER. / Serious accidents in organizations with critical infrastructures, such as the Itaipu Binacional Hydroelectric Power Plant, although rare, cause important social and economic impacts in their area of influence. Therefore, they must be avoided even if a "normal" rate of accidents is expected because of the risk factors and complexity of the operation. This dissertation presents an investigation on the conditions that lead to accidents in the operation of Itaipu Binacional under the proactive approach of Security II management according to Resilience Engineering (RE). It is based on the variability of the normal operation and, therefore, "in the many things that goes right", in contrast to the traditional and reactive view of Safety-I, based on the retrospective analysis of accidents and "the few things that went wrong". After a review of the literature on the requirements, principles and themes of RE and Security-II and on the structured opinions of the operational staff, two studies were developed: the first one brings the concerns of these operators in regard of the risk of fire in a transformer in order to develop indicators and action plans adherent to the RE principles. The objective was to supplement a conventional risk analysis based on fault tree and event trees with RE elements, optimizing the emergency action plan. The results showed the opportunity for improvement of proactive indicators for risk analysis The second one, inspired by the FRAM method, deals with the normal operation and variability of four typical operational maneuvers selected by operators within four quadrants of a periodicity-complexity matrix. The results indicated that the same variabilities influence the operational steps, regardless of the complexity or the periodicity of the maneuver. A comparison between the analysis of the variabilities in normal situation and the reports of the four operational failures occurred between 2006 and 2015 indicated that success and failure come from the same source, and that some variabilities such as “maneuver environment”, “necessity to confirm the maneuver steps” and “situations that take the attention of the operator” act decisively in virtually all maneuvers. The results were discussed with the team members who proposed the necessary adaptations to increase the operational safety of normal work from the RE perspective.

Acidentes graves em organizações com infraestruturas críticas, como a Usina Hidrelétrica Itaipu Binacional, embora raros, causam importantes impactos sociais e econômicos em sua área de influência. Portanto, eles devem ser evitados mesmo que, seja esperada uma taxa “normal” de acidentes por conta dos fatores de risco e complexidade da sua operação. Essa dissertação apresenta uma investigação das condições que levam a acidentes em casos específicos da operação da Itaipu Binacional sob o enfoque proativo da gestão da Segurança II de acordo com a Engenharia de Resiliência (ER). Ela se baseia na variabilidade da operação normal e, portanto, “no muito que dá certo”, em contraponto à visão tradicional da Segurança I, reativa, baseada na análise retrospectiva de acidentes e “no pouco que dá errado”. Com base em uma revisão da literatura quanto os requisitos, princípios e temas da ER e da Segurança-II e nas opiniões estruturadas de operadores foram desenvolvidos dois estudos: o primeiro traçou preocupações destes operadores em relação ao risco de incêndio em um transformador da Itaipu Binacional para desenvolver indicadores e planos de ação aderentes aos princípios da ER. O objetivo foi suplementar, com elementos de ER, uma análise de risco convencional baseada em árvore de falhas e árvore de eventos, e otimizar o plano de ação de emergência em caso de incêndio em transformador da unidade geradora Os resultados mostraram a oportunidade de melhoria para o desenvolvimento de indicadores proativos para a análise de risco. O segundo estudou, com base no método FRAM, a operação normal e a variabilidade de quatro manobras operacionais típicas selecionadas pelos operadores dentro dos quadrantes da matriz periodicidade-complexidade. Os resultados indicaram que as mesmas variabilidades influenciam nos passos operacionais, não importando a complexidade tampouco a periodicidade da manobra. Um comparativo entre a análise das variabilidades em situação normal e os relatórios das quatro falhas ocorridas entre 2006 e 2015 apontou que o sucesso e a falha advêm da mesma fonte, e que algumas variabilidades como “ambiente de manobra”, a “necessidade de confirmar os passos das manobras” e situações que tiram a atenção do operador atuam de forma decisiva em praticamente todas as manobras. Os resultados foram discutidos com os integrantes da equipe que propuseram adaptações necessárias para aumento da segurança operacional do trabalho normal sob a perspectiva de ER. / Serious accidents in organizations with critical infrastructures, such as the Itaipu Binacional Hydroelectric Power Plant, although rare, cause important social and economic impacts in their area of influence. Therefore, they must be avoided even if a "normal" rate of accidents is expected because of the risk factors and complexity of the operation. This dissertation presents an investigation on the conditions that lead to accidents in the operation of Itaipu Binacional under the proactive approach of Security II management according to Resilience Engineering (RE). It is based on the variability of the normal operation and, therefore, "in the many things that goes right", in contrast to the traditional and reactive view of Safety-I, based on the retrospective analysis of accidents and "the few things that went wrong". After a review of the literature on the requirements, principles and themes of RE and Security-II and on the structured opinions of the operational staff, two studies were developed: the first one brings the concerns of these operators in regard of the risk of fire in a transformer in order to develop indicators and action plans adherent to the RE principles. The objective was to supplement a conventional risk analysis based on fault tree and event trees with RE elements, optimizing the emergency action plan. The results showed the opportunity for improvement of proactive indicators for risk analysis The second one, inspired by the FRAM method, deals with the normal operation and variability of four typical operational maneuvers selected by operators within four quadrants of a periodicity-complexity matrix. The results indicated that the same variabilities influence the operational steps, regardless of the complexity or the periodicity of the maneuver. A comparison between the analysis of the variabilities in normal situation and the reports of the four operational failures occurred between 2006 and 2015 indicated that success and failure come from the same source, and that some variabilities such as “maneuver environment”, “necessity to confirm the maneuver steps” and “situations that take the attention of the operator” act decisively in virtually all maneuvers. The results were discussed with the team members who proposed the necessary adaptations to increase the operational safety of normal work from the RE perspective.

No description available.

Submitted by Izabel Franco (izabel-franco@ufscar.br) on 2016-09-23T13:28:36Z No. of bitstreams: 1 DissFTM.pdf: 1884333 bytes, checksum: 6d73a357db41241d350b7ce7605a8dbb (MD5) / Approved for entry into archive by Marina Freitas (marinapf@ufscar.br) on 2016-09-26T20:38:44Z (GMT) No. of bitstreams: 1 DissFTM.pdf: 1884333 bytes, checksum: 6d73a357db41241d350b7ce7605a8dbb (MD5) / Approved for entry into archive by Marina Freitas (marinapf@ufscar.br) on 2016-09-26T20:38:51Z (GMT) No. of bitstreams: 1 DissFTM.pdf: 1884333 bytes, checksum: 6d73a357db41241d350b7ce7605a8dbb (MD5) / Made available in DSpace on 2016-09-26T20:38:57Z (GMT). No. of bitstreams: 1 DissFTM.pdf: 1884333 bytes, checksum: 6d73a357db41241d350b7ce7605a8dbb (MD5) Previous issue date: 2011-08-17 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / The Safety and Health at Work (SHW) management is recognized as one of the main factors so the enterprises may be able to fulfill their basic goals of coast, term and quality. One of the latest management strategies is the Resilience Engineering (RE) approach that considers the presence of four main principles for appliance: Top Management Commitment, Apprenticeship, Flexibility and Consciousness. Considering the intensive use of the concrete precast building systems it becomes substantial to study this section about the SHW aspects on the RE focus and record the good practices held by the companies. This work is based on the proposal elaborated by Costella (2008) which presents an Evaluation Method of the Safety and Health at Work based on the safety management principles and the RE. The case study method was adopted, a concrete precast producer enterprise was searched, which had a qualified management system, and it accepted to collaborate with the research. It was concluded that the researched Enterprise presents evidence of the application of the RE principles, mainly due to the existence of the SHW management. It was verified that there are ordinary and complementary concerns, such as the operation of critical sectors and the maintenance of the equipment currently used in factories and construction sites. / A gestão da Segurança e Saúde do Trabalho (SST) é reconhecida como um dos elementos essenciais para que os empreendimentos cumpram suas metas básicas de custo, prazo e qualidade. Uma das estratégias mais modernas de gestão é a abordagem da Engenharia de Resiliência (ER) que considera a presença de quatro princípios para aplicação: Comprometimento da Alta Direção, Aprendizagem, Flexibilidade e Consciência. Dado o uso intensivo dos sistemas construtivos pré-fabricados de concreto torna-se importante estudar este setor sobre os aspectos de SST sobre o enfoque da ER e registrar as boas práticas realizadas pelas empresas. Este trabalho se baseia na proposta elaborada por Costella (2008) que apresenta um Método de Avaliação da Segurança e Saúde do Trabalho, com base nos princípios de gestão da segurança e da ER. Foi adotado o método de estudo de caso e pesquisada uma empresa fabricante do setor de pré-fabricados de concreto que se prontificou a colaborar com a pesquisa e possuía sistema de gestão de qualidade certificado. Concluiu-se que a Empresa pesquisada apresenta indícios de aplicação dos princípios da ER, devido principalmente ao fato de haver a gestão da SST. Verificou-se que existem preocupações em comuns e complementares, como a operação de setores críticos e a manutenção dos equipamentos em uso nas fábricas e canteiros. Palavras chave: Construção Civil. Segurança e Saúde do Trabalho. Engenharia de Resiliência.

In recent years, the research approach known as Resilience Engineering (RE) has offered a promising new way of understanding safety-critical organizations, but less in the way of empirical methods for analysis. In this master’s thesis, an extensive comparison was made between RE and two different research approaches on cognitive systems: Distributed Cognition (DC) and Cognitive Systems Engineering (CSE) with the aim of exploring whether these approaches can contribute to the analysis and understanding of resilience. In addition to a theoretical comparison, an ethnographic healthcare case study was conducted, analyzing the patient safety at a pediatric emergency department using the Three-Level Analytical Framework from DC and the Extended Control Model from CSE, then conducting an RE analysis based on the former two analyses. It was found that while the DC and CSE approaches can explain how an organization adapts to current demands, neither approach fully addresses the issue of future demands anticipation, central to the RE perspective. However, the CSE framework lends itself well as an empirical ground providing the entry points for a more thoroughgoing RE analysis, while the inclusion of physical context in a DC analysis offers valuable insights to safety-related issues that would otherwise be left out in the study of resilience.

During the spring of 2020, COVID-19 rapidly started to spread within Sweden, causing a crisis that affected the entire society, and in particular, the health care sector. What makes the COVID-19 pandemic a unique crisis is that it did not appear as a complete surprise when it reached Sweden. Partly because pandemics are expected to happen and therefore anticipated, partly because reports of COVID-19 and its effects were available before the disease caused a crisis in Sweden. This makes the phase before the crisis, known as the pre-crisis phase, quite long. For this study, it is argued that the pre-crisis phase encompasses actions taken before COVID-19 was known, predominantly in the form of the development of pandemic preparedness plans, as well as the actions taken when COVID-19 was known before it reached Sweden. However, due to the decentralisation of the Swedish political system, the twenty-one regions being responsible for the health care sector, and the uneven geographical transmission of the virus, the pre-crisis phase most likely differed across the country. In this study, it is the pre-crisis phase of Region Östergötland which has been examined and evaluated as a part of the Center for Disaster Medicine and Traumatology’s general evaluation of the COVID-19 pandemic in Östergötland. The study has aimed to answer the research questions related to how the pre-crisis phase was conducted, and how three different theories can contribute to the understanding of the pre-crisis phase. The theories used were Conflicting Objectives Perspective, High Reliability Organisation, and Resilience Engineering. To answer the research questions, semi-structured interviews with eight employees of Region Östergötland involved in the pre-crisis phase were conducted. The interviews were analysed using the thematic analysis approach. The thematic analysis showed that the pre-crisis phase was mainly characterised by organisational changes within the regular organisational structures, different challenges predominately related to acquiring personal protective equipment, a lack of information from the national agencies, and a slight underestimation. These themes were used to answer the first research question. To answer the second research question, the aforementioned theories were applied to the themes. This application showed that there are aspects of the three theories that can contribute to the understanding of the pre-crisis phase. These aspects can also be used during future pre-crisis phases. Furthermore, based on the contributions of the three theories and the thematic analysis, a new model was developed which can be used to describe the different phases of the pre-crisis phase. The application of the theories and the new model resulted in general guidelines highlighting the important processes during a pre-crisis phase, including the processes of monitoring, anticipating, planning, and preparing.

The maritime industry is vital to the Swedish trade and economy. Shipping has less environmental impact per ton transported goods than other transport modes. Furthermore, ships use the sea as their roads, thus not requiring additional impact on the environment in the form of building roads or tracks to be able to transport goods or people. The aim of this thesis is to identify the characteristics of the safety management approach and safety management systems (SMS) in five Swedish companies operating in the Swedish shipping industry. It furthermore explores whether a new approach to safety management such as Safety II and resilience engineering can offer a complementary view to the current safety management. The study design of this thesis has been a multiple case study. A literature review has been performed to gain insights into the domain and safety management in the domain in specific. Data has been gathered through semi-structured interviews with 10 respondents working within shipping or crew management companies. Five of the respondents work ashore with safety management and five of the respondents work onboard as Chief Officers or Chief Engineer. Chief Officers as well as Chief Engineers have responsibilities regarding safety for their respective department and thus have management positions within the operations. The results show that the participating companies’ safety management and SMSs are of the reactive kind. There is furthermore a gap between work as imagined, WAI, and work as done, WAD, that affects the suitability of the routines, procedures and equipment used in operations. Complexity of a system is also a contributing factor when it comes to safety management, and in the participating companies, aspects regarding complexity were identified at a regulatory, organisational and operational level. This affects the possibility to create routines and procedures that correspond to the demands, variations and situations encountered in operations. It is suggested in this thesis that a Safety II approach to safety management, along with the use of resilience engineering to develop and enhance the domain’s adaptability, can serve as a complement to the current safety management approach. Being able to adapt, respond and manage various unforeseen situations is a way of ensuring safety in operations even in complex socio-technical systems. The resilience assessment grid, RAG, is suggested as a tool to be developed to be usable in the participating companies. The RAG could serve as a tool to taper the gap between WAI and WAD, as well as to provide input to the development of indicators other than accidents for improving safety. Furthermore, it could also facilitate learning from everyday operations and what is going well – the everyday successes in everyday execution of tasks involved in operations.

Each year people are injured and even die in crowd related accidents, often during planned events. Recent studies have emphasized the need for using a systems approach to study these events. In this study the systems approach of resilience theory is combined with the crowd psychology-models Extended Social Identity Model and the Aggravation and Mitigation Model to examine event safety at a music festival, a domain previously largely unexplored by these perspectives. By using an ethnographic approach as well as interviewing visitors the study set out to answer questions about when and how the safety organization adjusted itself under conditions relating to crowds. Another goal was to study the social identity of the visitors as well as the interaction between the safety organization and the visitors at the festival to explain the presence or absence of crowd conflict. Using thematic analysis several situations were identified where the safety organization adjusted itself, as well as the strategies that the organization used in these different circumstances. It was also concluded that the absence of crowd conflict could best be explained by three factors. First of all, no history of crowd conflict existed between the safety organization and the visitors, secondly, there were no groups present with the goal of creating conflict, and thirdly, the social processes taking place between the safety organization and the visitors were all mitigating in nature. The mitigating nature of the social processes was partly attributable to the strategies identified for adjusting to crowd conditions.