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).

Esta tese tem como problema de pesquisa “como analisar atividades e eventos na perspectiva da teoria dos sistemas cognitivos correlacionados com foco no trabalho e nos fenômenos emergentes das interações entre humanos e seus sistemas tecnológicos?” A partir disso, busca como objetivo, propor um protocolo para realização dessa análise. A pesquisa é realizada por meio de um estudo etnográfico no contexto da análise da atividade de cálculo das velocidades de decolagem em aeronaves de transporte comercial, sendo apresentada em cinco artigos. O primeiro descreve de que modos o campo da Engenharia de Sistemas Cognitivos (CSE) vem sendo constituído. Adicionalmente, é proposta uma agenda de pesquisa em sistemas socio‐técnicos complexos enfatizando a necessidade de trabalhos com o foco de análise nos fenômenos emergentes das interações, tomando o sistema cognitivo como unidade de análise. O segundo artigo visa à identificação e caracterização da atividade de cálculo das velocidades de decolagem e dos protótipos de falhas nessa atividade. Os resultados indicam a existência de fragilidades caracterizadas por 12 protótipos de falhas. O terceiro artigo tem por objetivo analisar o cálculo das velocidades de decolagem como um processo de cognição situada e distribuída, a fim de identificar possíveis vulnerabilidades nessa atividade. O estudo constatou quatro vulnerabilidades, vistas aqui muito mais como características nos processos da atividade: as representações ao nível do cockpit são sempre parciais e incompletas; algumas interações requerem, além da corporificação, interpretações; as interações entre os agentes não seguem um processo canônico de coordenação; e o controle da prevenção de falhas é preciso, porém, não é adequado. O quarto artigo descreve como a coordenação pode ser interpretada como um fenômeno cognitivo distribuído e situado em cockpit de aeronaves. Nesse sentido, o estudo parte da integração da perspectiva da teoria dos sistemas cognitivos correlacionados com quatro requisitos de coordenação descritos na literatura: representação compartilhada (common ground), interprevisibilidade, diretividade e sincronia. A automação, além dos pilotos, é concebida como um terceiro agente da cabine. Como resultados dessa integração, são propostos quatro modos de coordenação no cockpit, os quais ocorrem em diferentes etapas de um voo. O quinto artigo apresenta o protocolo para análise dos fenômenos emergentes resultantes de interações em sistemas cognitivos correlacionados A aplicação do protocolo é ilustrada por meio da análise do cálculo das velocidades de decolagem. Os resultados do estudo são usados para a avaliação do protocolo, segundo critérios de validade, confiabilidade, usabilidade e potencial para alavancagem de melhorias. / This thesis seeks to answer the research question “how to analyze activities and events in the perspective of joint cognitive systems as focused on the work and the phenomena emerging from interactions between humans and their technical system?” Hence, the study aims at proposing a protocol to carry out this analysis. The research is conducted by means of an ethnographic research in the context of the activity of takeoff speeds calculation in commercial transport aircraft, and is presented in five articles. The first one describes how the conceptual field of Cognitive Systems Engineering (CSE) has been made up. In addition, a research agenda in complex socio‐technical systems is proposed, emphasizing the need for the analysis of work with focus on phenomena emerging from interactions. The second article aims at identifying and characterizing the activity of take‐off speeds calculation and its prototypes of failure. The results indicate the existence of fragilities, that were organized in 12 prototypes of failure. The third article aims at analyzing take‐off speeds calculation as a situated and distributed process in order to identify possible vulnerabilities in this activity. The study has found four vulnerabilities, which are seen as characteristics of the process: the representations at the cockpit level are always partial and incomplete; some interactions require interpretations instead of corporifications; the interactions between agents do not follow a canonical coordination process; and the failure prevention control is accurate, although, not adequate. The fourth article describes how coordination may be interpreted as a situated and distributed phenomenon in the cockpit of an aircraft. In this respect, the study draws on the integration of the perspectives of joint cognitive systems theory with four coordination requirements described in the literature: shared representation (common ground), interpredictability, directability and synchrony. Automation, rather than only pilots, is conceived of as a third agent in the cabin. As a result of this integration, four modes of coordination in the cockpit are proposed, which occur at different stages of the flight. The fifth article presents a protocol for the analysis of emerging phenomena in joint cognitive systems. The application of the protocol is illustrated by means of the analysis of take‐off speeds calculation. The results of the study are used for the evaluation of the protocol, according to criteria of validity, reliability, usability and potential for the leverage of improvements.

Elektricitet är mycket centralt i dagens samhälle och många av samhällets funktioner är beroende av en fungerande eldrift. I och med detta är det mycket viktigt att driftcentralen hos ett elnätsföretag har förmågan att behålla kontrollen vid en storstörning. En storstörning som fenomen är någonting som inte inträffar speciellt ofta, men när det väl händer drabbas driftcentralen hårt. Syftet med studien var att beskriva det sammansatta kognitiva system som driftcentralen på Utsikt Nät, Tekniska Verken AB, utgör vid en störningssituation och identifiera kritiska punkter som påverkar det sammansatta kognitiva systemets beslutsfattande och förmåga att bibehålla kontroll över processen vid störningsdrift. Studien genomfördes som en etnografisk studie och bestod av observationer och intervjuer. Observationerna syftade till att skapa en förståelse för hur detta sammansatta kognitiva system fungerar vid normaldrift. Intervjuerna användes för att identifiera vad som skiljer störningsdriften från normaldriften och låg främst till grund för analysen av det sammansatta kognitiva systemet vid störningsdrift. De kategorier som framkom under analysen och ligger till grund för resultatet var Organisation, Arbetssätt, Beslutsfattande och Kommunikation. Driftcentralen med kringliggande grupper utgör en komplex organisation som ska klara av att hantera oförutsägbara händelser. Denna studie visar att detta sammansatta kognitiva system klarar av denna uppgift till en acceptabel nivå med hjälp av erfarenheten och kunskapsnivån hos driftledarna och fältarbetarna, men vissa förbättringar kan göras för att öka kontrollförmågan vid störningsdrift.

I Sverige genomförs varje år offentliga upphandlingar till ett värde av ca 500 miljarder kronor. Alla offentligt finansierade verksamheter måste följa lagen om offentlig upphandling och den formella upphandlingsprocess som lagen specificerar. Lagen är allmänt formulerad och anvisar en process där fokus ligger på förarbete och matematisk utvärdering. Cognitive Systems Engineering har vuxit fram utifrån insikten att effektiva processer kontinuerligt behöver använda såväl feedback och feedforward för att uppnå sina mål. Typiska tillämpningar är dynamiska, tätt kopplade processer där dessa behov är tydliga, men CSE som ramverk är generellt definierat och bör gälla även för en beslutsprocess på organisationsnivå. En CSE-analys har potential att förtydliga funktionella faktorer som tillåter upphandlare att genomföra effektiva och ändamålsenliga upphandlingar. I syftet att testa ovanstående hypotes genomfördes en fallstudie av Linköpings Universitets upphandling av företagshälsovård 2008. Studien är explorativ då kombinationen av teori och analysobjekt är otestad. För att relatera värdet av CSE mot andra teoribildningar har studien även analyserat upphandlingen utifrån STS och ekonomisk teori. Studien visar att CSE kan tillämpas vid analys av upphandlingsprocess inom offentlig upphandling. Ekonomisk teori har starka normativa drag medan STS är utpräglat deskriptiv. Kontrollperspektivet ser till både normativa och deskriptiva aspekter och bidrar med ökad förklaringskraft. I LiU:s upphandling var formella protokoll viktiga för arbetets legitimitet men det var i det praktiska arbetet man fann utrymme att utöva kontroll.

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The Vessel Traffic Service (VTS) is a complex system tasked with ensuring the safety of navigation within specified areas known as VTS areas. Earlier research in the domain has often focused on the decision support systems and other tools employed by the VTS operators to provide the vessels in the area with VTS services. Consequently, less effort has gone into looking at the system itself and the human factors aspects of the system. This study uses the Functional Resonance Analysis Method (FRAM) to create a functional model of the VTS. It looks at how a VTS works, what the different components are and how these components are related. The main purpose of the FRAM model is to serve as a basis for future application by identifying the functions that constitute the system, and to illuminate the potential variability therein. To demonstrate how it might be used, an instantiation of an observed scenario will be presented. A structural description of the VTS is also presented, which aims to serve as an introduction to the domain for readers who are previously unfamiliar with it. The functional model shows that a lot of the potential variability seems to lie in the functions that rely heavily on human interaction, which is to be expected, as human performance is highly variable. It also shows that the availability and reliability of relevant information is crucial in order to be able to provide the VTS services, and if the information for some reason is unavailable or insufficient it seems likely to cause variability.

Many modern-day industries share features of tight coupling and high complexity, making it difficult to describe incidents in terms of direct attribution. This situation has been answered by novel theories on the bonds between people and their environment. Cognitive Systems Engineering (CSE) offers a new way of analysing human activities, acknowledging the impact of complex interaction and unpredictability. Doing so allows for innovative ways of pursuing work safety. In this study, the concept of safety culture has been interpreted from a CSE perspective and applied in a qualitative assessment of current safety work of at SSAB EMEA. A total number of 26 SSAB employees were interviewed, probing attitudes, perceptions and safety system structures at the Oxelösund steel mill, rolling mill and upper organizational layers. Additional data was collected using informers, SSAB documentation and participatory observation. Data was processed using a combination of top-down and bottom-up analytical approaches, creating a qualitative assessment of safety culture from salient themes. Results reveal an advanced state of safety management. However, management’s intentions are inhibited by issues in management presence and communication, management training, worker influence, forms and content of operator training, reporting, feedback, flow of communication and safety-related core assumptions. Revisiting lessons learned within the field of CSE, suggestions are made to possible areas of improvement and future research. These suggestions concern employee involvement in safety work, work identities, forms of training, manager roles and communication.

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