The investigation and modelling of aviation accident causation is dominated by linear models. Aviation is, however, a complex system and as such suffers from being artificially manipulated into non-complex models and methods. This thesis addresses this issue by developing a new approach to investigating aviation accident causation through information networks. These networks centralise communication and the flow of information as key indicators of a system‟s health and risk. The holistic approach focuses on the system itself rather than any individual event. The activity and communication of constituent elements, both human and non-human agents, within that system is identified and highlights areas of system failure. The model offers many potential developments and some key areas are studied in this research. Through the centralisation of barriers and information nodes the method can be applied to almost any situation. The application of Bayesian mathematics to historical data populations provides scope for studying error migration and barrier manipulation. The thesis also provides application of these predictions to a flight simulator study in an attempt of validation. Beyond this the thesis also discusses the applicability of the approach to industry. Through working with a legacy airline the methods discussed are used as the basis for a new and forward-thinking safety management system. This holistic approach focuses on the system environment, the activity that takes place within it, the strategies used to conduct this activity, the way in which the constituent parts of the system (both human and non-human) interact and the behaviour required. Each stage of this thesis identifies and expands upon the potential of the information network approach maintaining firm focus on the overall health of a system. It is contended that through the further development and application of this approach, understanding of aviation risk can be improved.

Neste estudo analisou-se e comparou-se o sistema de medicação quanto ao processo de prescrição, dispensação, preparo e administração de medicamentos em unidades de psiquiatria de um hospital geral e de um hospital psiquiátrico, do interior paulista; identificaram-se e compararam-se erros de medicação nas unidades em estudo, identificaram-se e compararam-se tipos, causas, providências e sugestões para prevenção dos erros, na perspectiva dos profissionais e identificou-se o conhecimento dos mesmos sobre aspectos relevantes do sistema de medicação. Trata-se de estudo transversal, do tipo survey exploratório, que utilizou a abordagem quantitativa. Foi realizado em duas enfermarias de psiquiatria de hospital geral e em quatro enfermarias de hospital psiquiátrico e nas farmácias desses hospitais. A amostra total constou de 12 médicos, 17 enfermeiros, 68 auxiliares ou técnicos de enfermagem, 13 farmacêuticos e 37 auxiliares de farmácia. Para coleta de dados, utilizaram-se as técnicas de observação não participante direta, entrevista semiestruturada gravada e questionário. Os dados resultantes da observação foram apresentados de forma descritiva e, as entrevistas, foram analisadas por meio de estatística descritiva. Como principais resultados das observações destacaram-se, em ambos os hospitais: ambiente desfavorável para a prescrição, com ruídos e interrupções, prescrições médicas não precedidas pela avaliação clínica do paciente e não revisadas por farmacêuticos, distribuição de medicamentos por dose individualizada e ausência do enfermeiro no processo de preparo e administração de medicamentos. Destaca-se que no hospital psiquiátrico observaram-se prescrições válidas por cerca de 10 dias, ausência de profissional específico para distribuição do medicamento e não utilização de pulseira de identificação. Quanto aos erros de medicação, houve destaque para horário errado de administração (19/14,3%) no hospital geral e erro de preparo, manipulação e/ou acondicionamento no hospital psiquiátrico (52/21,5%). Os tipos de erros mais frequentes foram prescrição errada no hospital geral (30/46,1%) e no hospital psiquiátrico (26/33%) e suas causas deviam-se principalmente às falhas individuais no hospital geral (39/60%) e no hospital psiquiátrico (44/55,7%). Quanto às providências administrativas, sobressaíram-se o relatório no hospital geral (27/41,5%) e a orientação no hospital psiquiátrico (28/35,4%). Interceptar os erros no hospital geral (8/12,3%) e aperfeiçoamento do sistema eletrônico no hospital psiquiátrico (22/28,8%) foram as principais sugestões dos profissionais, direcionadas ao sistema de medicação e atenção nas atividades individuais, tanto no hospital geral (30/46,1%) como no hospital psiquiátrico (47/59,5%), foram direcionadas aos profissionais. Identificou-se, ainda, desconhecimento dos profissionais sobre aspectos de fundamental importância do sistema de medicação para a segurança do paciente. Este estudo revela pontos vulneráveis em relação à segurança do paciente na terapêutica medicamentosa em serviços de internação psiquiátrica e propicia discussão de recomendações que podem promover a segurança no sistema de medicação / This study analyzed and compared the medication system regarding the process of prescription, dispensation, preparation and administration of medication in psychiatric units of a general hospital and a psychiatric hospital, located in the interior of the state of São Paulo, Brazil. Errors in medication were identified and compared in the studied units. The causes, procedures and suggestions for preventing errors were identified and compared, in the perspective of professionals, and their knowledge of the relevant aspects of the medication system was identified. The cross-sectional, quantitative, exploratory survey study was conducted in two psychiatry wards of a general hospital and in four wards of a psychiatry hospital and in the pharmacies of these hospitals. The total sample consisted of 12 physicians, 17 nurses, 68 nursing auxiliaries or technicians, 13 pharmacists and 37 pharmacy assistants. For data collection, non-participant direct observation, recorded semi-structured interview and questionnaires were used as techniques. Data resulting from the observation were presented descriptively and the interviews were analyzed through descriptive statistics. As main results of the observation, in both hospitals it was highlighted the unfavorable environment for prescription, with noise and interruptions, medical prescriptions with previous clinical evaluation of the patient and not revised by pharmacists, distribution of medication by individualized dose and absence of nurses in the process of preparation and administration of medication. It is noteworthy that at the psychiatric hospital prescriptions valid for 10 days were observed, as well as lack of a specific professional to distribute the medication and non-utilization of the identification bracelet. As to the medication errors, it is highlighted the errors in administration timing (19/14.3%) in the general hospital and preparation, manipulation and/or storage error in the psychiatric hospital (52/21.5%). The most frequent types of errors were wrong prescriptions in the general hospital (30/46.1%) and in the psychiatric hospital (26/33%), and its causes were due mostly to individual flaws in the general hospital (39/60%) and in the psychiatric hospital (44/55.7%). Regarding the administrative measures, the report in the general hospital (27/41.5%) and the orientation in the psychiatric hospital (28/35.4%) were underlined. Intercepting the errors in the general hospital (8/12.3%) and improvement of the electronic system in the psychiatric hospital (22/28.8%) were the main suggestions of the professionals directed to the medication system. As to the recommendations for professionals, attention to individual activities were identified both in the general hospital (30/46.1%) as in the psychiatric hospital (47/59.5%). Furthermore, it was identified that professionals did not know about fundamentally important aspects of the medication system for patient safety. This study discloses vulnerabilities in relation to patient safety in drug therapy in psychiatric inpatient services, also stimulating discussion of recommendations that can promote safety in the medication system

The techniques currently used to model risk and manage the safety of the UK railway network are not aligned to the mechanism by which catastrophic accidents occur in this industry. In this thesis, a new risk modelling method is proposed to resolve this problem. Catastrophic accidents can occur as the result of multiple failures occurring to all of the various defences put in place to prevent them. The UK railway industry is prone to this mechanism of accident occurrence, as many different technical, operational and organizational defences are used to prevent accidents. The railway network exists over a wide geographic area, with similar accidents possible at many different locations. The risk from these accidents is extremely variable and depends on the underlying conditions at each particular location, such as the state of assets or the speed of trains. When unfavourable conditions coincide the probability of multiple failures of planned defences increases and a 'risk hotspot' arises. Ideal requirements for modelling risk are proposed, taking account of the need to manage multiple defences of conceptually different type and the existence of risk hotspots. The requirements are not met by current risk modelling techniques although some of the requirements have been addressed experimentally, and in other industries and countries. It is proposed to meet these requirements using Bayesian Networks to supplement and extend fault and event tree analysis, the traditional techniques used for risk modelling in the UK railway industry. Application of the method is demonstrated using a case study: the building of a model of derailment risk on the UK railway network. The proposed method provides a means of better integrating industry wide analysis and risk modelling with the safety management tasks and safety related decisions that are undertaken by safety managers in the industry.

Submitted by Erika Demachki (erikademachki@gmail.com) on 2014-09-18T18:15:47Z No. of bitstreams: 2 Gabriela Camargo Tobias 2013.pdf: 1728892 bytes, checksum: f9a8a88aada23760d9a33309d80eec60 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Jaqueline Silva (jtas29@gmail.com) on 2014-09-18T21:33:57Z (GMT) No. of bitstreams: 2 Gabriela Camargo Tobias 2013.pdf: 1728892 bytes, checksum: f9a8a88aada23760d9a33309d80eec60 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2014-09-18T21:33:57Z (GMT). No. of bitstreams: 2 Gabriela Camargo Tobias 2013.pdf: 1728892 bytes, checksum: f9a8a88aada23760d9a33309d80eec60 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2013-08-28 / In the context of health, the safety culture centered on the quality of care and the systematization of work processes contributes to human error prevention avoidable and, therefore, for the patient safety. The study aims to analyze the perception of a teaching hospital nurses about the dimensions of safety culture’s patient. The methodology is descriptive, exploratory, carried out at a teaching hospital in the Central West region of Brazil, with a population of 117 nurses. The data were collected in October to December of 2011 through autoaplicavel instruments,those belongs to the Hospital Survey on Patient Safety Culture, proposed and used by Agency for Health Research and Quality, specific for the detection of safety culture in hospital, translated and validated for the portuguese language. The data were analysed by the Statistical Package for Social Sciences Program, version 18.0. The project was approved, protocol 064/2008. The percentual of participants were 84.8 % of the nurses of the hospital, 89.7 % were female, predominant age range between 45 to 51 years, 51% with 16 to 21 years of profession, 36% with the same time in the institution and 13.7 % worked in the Emergency Room. The weekly workload of 87% was about 20 to 39 hours and 96% had directly contact with the patient. The reply “Not punitive to mistakes” had the lowest rate, 28%. The weaknesses for the institution were: the team considers that their mistakes could be used against them; the team was afraid that the mistakes were recorded in their functional files; insufficient staff; they work more than necessary; occurrence of problems in the exchange of information between the units; the security has to be sacrificed instaed of doing more things; patient safety problem in the unit, procedures and inadequate systems for the mistakes prevention. The strength points were: the supervisor/manager takes the suggestions to improve the patient safety, considers security problems; work actively doing things to improve the servisse quality; support each other; work in a team; treating with respect and having a good relationship with professionals from other units. However, 59% considered safety patient acceptablevin the unit, and 52% said they never reported adverse events. The conclusion was that the research gave the nurses perception and envolved them with the patient security, the same as how to prove that the aplication of a analysed instrument for actions can be used for estimulating the adoption of politics those bring changes and attitudes for the development of institution security culture. / No contexto da saúde, a cultura de segurança centrada na qualidade da assistência e na sistematização dos processos de trabalho contribui para prevenção de erros humanos evitáveis e, consequentemente, para a segurança do paciente. O estudo tem como objetivo analisar a percepção de enfermeiros de um hospital de ensino quanto às dimensões da cultura de segurança do paciente. A metodologia é descritiva, exploratória; foi realizado em um hospital de ensino da região Centro- Oeste do Brasil, tendo, como população, 117 enfermeiros. Os dados foram coletados no período de outubro a dezembro de 2011, por meio de um instrumento autoaplicável, o Hospital Survey on Patient Safety Culture, proposto e utilizado pela Agency for Health Research and Quality, específico para pesquisa de cultura de segurança em hospital, traduzido e validado para a língua portuguesa. Os dados foram analisados pelo Programa Statistical Package for Social Sciences, versão 18.0. O projeto foi aprovado pelo protocolo 064/2008. O total de participantes equivaleu a 84,8% dos enfermeiros do hospital, sendo 89,7% do sexo feminino, faixa etária predominante entre 45 a 51 anos, 51% com 16 a 21 anos de trabalho na profissão, 36% tinham o mesmo tempo na instituição e 13,7% atuavam no Pronto- Socorro. A carga semanal de trabalho de 87% foi de 20 a 39 horas e 96% tinham contato direto com o paciente. A maior taxa de respostas positivas foi 71%, relacionadas tanto ao Trabalho em Equipe no âmbito das unidades do hospital e às Expectativas e Ações do Supervisor/Gerente para a Promoção da Segurança do Paciente. A menor taxa foi 28% para a Resposta Não Punitiva aos Erros. Foram consideradas fraquezas para a instituição: os membros da equipe considerarem que seus erros poderiam ser usados contra si mesmos; medo que os erros fossem anotados nas suas fichas funcionais; quadro de pessoal insuficiente; trabalhar mais do que o desejável; ocorrência de problemas no intercâmbio de informações entre as unidades; a segurança ser preterida para que possam realizar maior número de tarefas; problemas de segurança do paciente na unidade e procedimentos e sistemas inadequados para prevenção de erros. Os pontos fortes foram: o supervisor/gerente considerar as sugestões para melhorar a segurança do paciente, levar em conta problemas de segurança; trabalharem ativamente no sentido de melhorar a qualidade do serviço; apoiarem-se mutuamente; atuarem em equipe; tratarem-se com respeito e acreditarem ser agradável trabalhar com profissionais de outras unidades. Entretanto, 59% consideraram aceitável o grau de segurança do paciente na unidade e 52% afirmaram nunca terem relatado eventos adversos. Concluiu-se que o estudo possibilitou aos enfermeiros a percepção e envolvimento com a segurança do paciente, assim como comprovar que a aplicação de um instrumento de análise de ações pode ser utilizado para estimular a adoção de políticas de gestão que promovam mudanças e atitudes direcionadas para o desenvolvimento da cultura de segurança institucional.

In 2009 there were 3.28 million non-fatal occupational injuries and illnesses (Bureau of Labor Statistics, 2010). Of these injuries and illnesses, 965,000 resulted in lost days from work. In addition there were 4,340 workplace fatalities. Given the number of occupational injuries, illnesses, and fatalities, and the associated direct and indirect costs, organizations have sought to improve safety at work. Safety climate and safety motivation are two variables hypothesized to affect safety behaviors and safety outcomes. Safety climate refers to the shared perceptions of workgroup members, of the organizations' commitment to safety as evidenced by heir immediate supervisors' pattern of implementing safety policies and procedures (Zohar, 2003). Therefore, the workgroup supervisor plays an major role in the development of safety climate. Social exchange theory and previous studies of leadership styles and safety suggest that supervisors who convey concern for subordinates' well-being increase workers' motivation to reciprocate by increasing their safe behaviors at work. However, no research to date has examined the relationship between supervisors' personality and workers perceptions of safety climate, or the effect of Big Five trait-level variables on workers safety motivation. In this study I hypothesize that supervisors' proactive personality and three Big Five traits will be positively related to workers' safety climate perceptions. In addition, I hypothesize that four Big Five traits in workers will be positively related to workers safety motivation. Finally, I hypothesize that group-level safety climate will be significantly related to individual-level safety motivation after controlling for workers' personality. Participants in this study were maintenance and construction workers from a municipal city bureau, in 28 workgroups, totaling 146 workers and 28 supervisors. Workgroup sizes vary but averaged 6.21 members, including the supervisor. The data were collected in small groups (paper-and-pencil) and electronically (on-line); workers and supervisors answered questionnaire items on personality variables, safety climate, safety motivation, safety behaviors, and safety outcomes. In addition, archival data on safety outcomes were collected. The data were analyzed using a combination of multiple regression, multi-level modeling, and path analysis to test hypotheses and answer research questions. Both proactive personality and Big Five traits in supervisors accounted for incremental variance in aggregated workgroup safety climate over controls. In addition, workgroup safety climate and individual workers' cautiousness were significant predictors of workgroup safety motivation in a hierarchical linear model. At the individual level of the model, only the traits of cautiousness and morality were significant predictors of individual safety motivation. Tests of the Neal and Griffin (2004) model showed that safety motivation partially mediated the relationship between individual safety climate and safety participation behaviors. In addition, safety motivation fully mediated the relationships between morality and both safety compliance and safety participation behaviors. Finally, safety motivation partially mediated the relationship between cautiousness and both safety compliance and safety participation behaviors. The results suggest that supervisor personality can have an effect on the on workgroup safety climate perceptions. In addition, this study provided evidence that Big Five traits are useful predictors of the antecedents of accidents and injuries. Suggestions for training managers and future research are also discussed.

China Steel Corporation (CSC) has introduced OHSAS 18001 system since 2000, and has acquired good performance and credits, but it seems hard to get further progress in performance. One of the major reasons is that industrial safety awareness does not take root in every employer¡¦s mind. So it is important to make an all-purpose safety concept environment. In 2011, Safety-Caring program was put into action plant widely to build safety culture. This study focuses on the effect of safety management by promoting safety caring activities in steel-making plant. It hopefully improves the safety performance through verification of practical experiment according to theoretical analysis. The study processes and conclusion are as followings: 1. Two rounds of questionnaires were issued; the first one was done about one year later of safety caring project started, this questionnaire was to understand the effect of safety caring program in steel plant. The second one was to evaluate the key factors of success to run safety caring program, and the later questionnaire was issued about five months later following the first one. 2. The culture of CSC is based on the kindheartedness and humanity priority. So safety caring program is suitable to build an all-purpose safety culture in CSC. 3. The results from the two rounds of questionnaires show the highly approval of safety caring program. The successive safety education, the promise of the authority, the proclamation of the labor union and steel plant, and the safety knowledge sharing consistently promoted, therefore, the safety performance is getting higher. 4. The major factors of running safety program are: active safety caring, the promise of the authority, personal safety knowledge, the proclamation and the support of the labor union, and the notification performance of steel-making plant. The factor of the promise of the authority is the most outstanding. On the other hand, the following factors are not so obvious, such as: safety management system, safety feeling, service leading, commanding leading, rewards and punishments, working pressure, and income satisfaction. 5. The more the safety caring is done, the more approval of safety program, and the more willingness to obey the safety rules. It is evident that keeping the promotion of safety activities can lower the industrial accidents.

The aim of this thesis is to propose a safety management framework for construction companies. A literature review was performed to identify significant factors that would improve safety performance. Two management tools are used within the scope of this study: the balanced scorecard and quality function deployment (QFD). Strategic goals are established for each perspective of the balanced scorecard: financial and cultural, employee, process and learning and growth. Afterwards, a questionnaire was prepared using the QFD approach. The goals in the financial and cultural perspective were defined as the needs of the organization related to safety (&ldquo / customer requirements&rdquo / in the original QFD approach). The goals in the remaining perspectives formed the actions that the organization could do to achieve its needs (&ldquo / product how&rsquo / s&rdquo / in the original QFD). Results of the questionnaire were used to form the final strategic goals in balanced scorecard. Safety performance measures and initiatives were defined for the accomplishment of the goals in the balanced scorecard.

In the presence of operational uncertainty, one of the greatest challenges in systems engineering is to ensure system effectiveness, mission capability and survivability. Safety management is shifting from passive, reactive and diagnosis-based approaches to autonomous architectures that will manage safety and survivability through active, proactive and prognosis-based solutions. Resilience engineering is an emerging discipline, with alternative recommendations on safer and more survivable system architectures. A resilient system can "absorb" the impact of change due to unexpected disturbances, while it "adapts" to change, in order to maintain its physical integrity and mission capability. A framework of proposed resilience estimations is the basis for a scenario-based assessment technique, driven by modeling and simulation-based (M&S) analysis, for obtaining system performance, health monitoring, damage propagation and overall mission capability responses. For the technique development and testing, a small-scale canonical problem has been formulated, involving a reconfigurable spring-mass-damper system, in a multi-spring configuration. Operational uncertainty is introduced through disturbance factors, such as external forces with varying magnitude, input frequency, event duration and occurrence time. Case studies with varying levels of damping and alternative reconfiguration strategies return the effects of operational uncertainty on system performance, mission capability, and survivability, as well as on the "restore", "absorb", and "adapt" resilience capacities. The Topological Investigation for Resilient and Effective Systems, through Increased Architecture Survivability (TIRESIAS) technique is demonstrated for a reduced scale, reconfigurable naval cooling network application. With uncertainty effects modeled through network leak combinations, TIRESIAS provides insight on leak effects to survival times, mission capability degradations, and on resilience function capacities, for the baseline configuration. Comparative case studies were conducted for different architecture configurations, which have been generated for different total number of control valves and valve locations on the topology.

The Normal Operations Safety Survey (NOSS) is an observational methodology to collect safety data during normal Air Traffic Control (ATC) operations. It aims to inform organizations about safety matters by using trained ATC staff to take a structured look at everyday operations. By monitoring normal operations through the use of direct over-the-shoulder observations, it is believed that safety deficiencies can be identified in a proactive manner prior to the occurrence of accidents or incidents. NOSS was developed as a collaborative effort between the International Civil Aviation Organization, ATC providers, controller representatives, government regulators, and academics to fill a gap in available ATC safety information. System designers consider three basic assumptions: the technology needed to achieve the system production goals, the training necessary for people to operate the technology, and the regulations that dictate system behavior. These assumptions represent the expected performance. When systems are deployed, however, particularly in realms as complex as ATC, they do not perform quite as designed. NOSS aims to capture the operational drift that invariably occurs upon system deployment. NOSS captures how the ATC system operates in reality, as opposed to how it was intended to operate. NOSS is premised on the Threat and Error Management (TEM) framework. TEM frames human performance in complex and dynamic settings from an operational perspective by simultaneously focusing on the environment and how operators respond to that environment. TEM posits that threats and errors are a part of everyday operations in ATC and must be managed in order to maintain safety margins. This dissertation describes NOSS and its contributions to ATC safety management systems. It addresses the validity and reliability of NOSS data and presents case studies from field trials conducted by a number of ATC providers. / text

This research examines the structure of safety climate in the manufacturing sector. It does so by examining and comparing attitudes to, and perceptions of, safety issues in two manufacturing organisations and one organisation involved in the supply of construction materials. The concept of safety climate, and the associated concept of safety culture, have been the subject of much research and theory building in recent years and this thesis builds on previous work. The research framework used here employed a mainly quantitative methodology in order to investigate the architecture of safety climate using structural modelling. Statistical modelling has been applied in other safety studies, often involving safety climate as one variable in a global description of safety systems. However it has rarely been used to model and describe the structure of safety climate as an indicator of safety culture, as in this research. The structure of safety climate described in this research is characterised by the interaction of organisational, group interaction, work environment and individual variables, which provide indicators of influences on individual levels of safety activity. Structural models of the data from all three participating organisations fitted the broad pattern of organisational variables influencing group and work environment variables, which, in turn influence individual variables. A more detailed comparison of organisational structures, however, highlighted slight differences between the two manufacturing organisations and more pronounced differences between these and the construction material supply organisation, suggesting that most elements in the structure of attitudes to safety described here are industry specific. These results are explained in terms of working environments. Differences in structure, consistent with job roles, were also apparent between occupational levels. The research, in line with previous work in the field, has highlighted the importance of management commitment to, and actions for, safety, as well as the role of individual responsibility in the promotion of safety activity. The work reported here has emphasised their importance in developing and maintaining an organisational culture for safety.