•We conducted a systematic literature review of contemporary systems thinking accident analysis methods.•Qualitative and quantitative syntheses of study results were performed for Accimap, HFACS, ...STAMP-CAST, and FRAM.•Across the methods, a majority of the contributory factors underpinning accident causation were identified at lower system levels.•The development of novel accident analysis approaches in the safety science research context is encouraged based on the findings discussed.
This systematic review examines and reports on peer reviewed studies that have applied systems thinking accident analysis methods to better understand the cause of accidents in a diverse range of sociotechnical systems contexts.
Four databases (PubMed, ScienceDirect, Scopus, Web of Science) were searched for published articles during the dates 01 January 1990 to 31 July 2018, inclusive, for original peer reviewed journal articles. Eligible studies applied AcciMap, the Human Factors Analysis and Classification System (HFACS), the Systems Theoretic Accident Model and Processes (STAMP) method, including Causal Analysis based on STAMP (CAST), and the Functional Resonance Analysis Method (FRAM). Outcomes included accidents ranging from major events to minor incidents.
A total of 73 articles were included. There were 20, 43, six, and four studies in the AcciMap, HFACS, STAMP-CAST, and FRAM methods categories, respectively. The most common accident contexts were aviation, maritime, rail, public health, and mining. A greater number of contributory factors were found at the lower end of the sociotechnical systems analysed, including the equipment/technology, human/staff, and operating processes levels. A majority of studies used supplementary approaches to enhance the analytical capacity of base applications.
Systems thinking accident analysis methods have been popular for close to two decades and have been applied in a diverse range of sociotechnical systems contexts. A number of research-based recommendations are proposed, including the need to upgrade incident reporting systems and further explore opportunities around the development of novel accident analysis approaches.
•Historical review of models and methods for collision analysis.•Analysis of the Uber collision with a pedestrian using eight methods.•Comparison of eight methods for collision analysis against ...systemic, theoretical, methodological and practical criteria.•Detailed analysis of the Uber collision with a pedestrian with Actor Map and AcciMap.•Proposed list of potential recommendations for testing automated vehicles.
Unlike aviation, maritime and rail, road traffic collision investigation currently does not have a national investigatory body in the UK. Yet the numbers of people killed and seriously injured on the roads is far in excess of those other domains. The research presented in this paper is part of a larger project investigating the development of a road collision investigation branch in the UK. An important part of the process involves identifying a suitable accident analysis method to support investigations with the development of suitable interventions. This paper describes a study that was undertaken to identify a systemic method for investigating road collisions. Eight potential methods were identified and compared using a common incident, that of the recent Uber collision with a pedestrian. The methods were analysed against four sets of criteria: systemic, theoretical, methodological and practical. The AcciMap method, together with the accompanying Actor Map, was recommended as an appropriate approach to support road traffic collision investigations.
Cognitive work analysis Jenkins, Daniel P
c2009., 2009, 2008-12-01, 2017-09-18, 2017-06-12
eBook
'Complex sociotechnical systems' are systems made up of numerous interacting parts, both human and non-human, operating in dynamic, ambiguous and safety critical domains. Cognitive Work Analysis ...(CWA) is a structured framework specifically developed for considering the development and analysis of these complex socio-technical systems. Unlike many human factors approaches, CWA does not focus on how human-system interaction should proceed (normative modelling) or how human-system interaction currently works (descriptive modelling). Instead, through a focus on constraints, it develops a model of how work can be conducted within a given work domain, without explicitly identifying specific sequences of actions (formative modelling).
This paper reviews the key perspectives on human error and analyses the core theories and methods developed and applied over the last 60 years. These theories and methods have sought to improve our ...understanding of what human error is, and how and why it occurs, to facilitate the prediction of errors and use these insights to support safer work and societal systems. Yet, while this area of Ergonomics and Human Factors (EHF) has been influential and long-standing, the benefits of the 'human error approach' to understanding accidents and optimising system performance have been questioned. This state of science review analyses the construct of human error within EHF. It then discusses the key conceptual difficulties the construct faces in an era of systems EHF. Finally, a way forward is proposed to prompt further discussion within the EHF community.
Practitioner statement This state-of-science review discusses the evolution of perspectives on human error as well as trends in the theories and methods applied to understand, prevent and mitigate error. It concludes that, although a useful contribution has been made, we must move beyond a focus on an individual error to systems failure to understand and optimise whole systems.
Accident analysis methods are used to model the multifactorial cause of adverse incidents. Methods such as AcciMap, STAMP-CAST and recently AcciNet, are systemic approaches that support the ...identification of safety interventions across sociotechnical system levels. Despite their growing popularity, little is known about how reliable systems-based methods are when used to describe, model and classify contributory factors and relationships. Here, we conducted an intra-rater and inter-rater reliability assessment of AcciMap, STAMP-CAST and AcciNet using the Signal Detection Theory (SDT) paradigm. A total of 180 hours' worth of analyses across 360 comparisons were performed by 30 expert analysts. Findings revealed that all three methods produced a weak to moderate positive correlation coefficient, however the inter-rater reliability of STAMP-CAST was significantly higher compared to AcciMap and AcciNet. No statistically significant or practically meaningful differences were found between methods in the overall intra-rater reliability analyses. Implications and future research directions are discussed.
Practitioners who undertake accident analysis within their organisations should consider the use of STAMP-CAST due to the significantly higher inter-rater reliability findings obtained in this study compared to AcciMap and AcciNet, particularly if they tend to work alone and/or part of relatively small teams
•AcciMap is arguably the most popular accident analysis method.•We reviewed and synthesised 23 published AcciMap studies.•We identified 5587 contributory factors spanning 79 contributory factor ...types.•We found a set of contributory factors that often play a role in major accidents.•Further applications of our contributory factor classification scheme are encouraged.
As AcciMap is now arguably the most popular accident analysis method in the peer-reviewed literature, there are key learnings to be taken from reviewing and synthesising published AcciMap analyses. In particular, the extent to which the network of contributory factors underpinning accidents is consistent across safety critical domains. This study reviewed and synthesised 23 AcciMap analyses published in the peer-reviewed literature. Contributory factors and relationships were extracted and thematically coded to form a single multi-domain, multi-incident AcciMap. The resulting AcciMap contains 5587 contributory factors spanning seventy-nine distinct contributory factor types. The findings reveal a set of generic contributory factors that consistently play a role in major accidents regardless of domain. Additionally, contributory factors previously only associated with sharp-end human operators are, in fact, prevalent across multiple levels of accident systems. The implications of these findings for accident theory and accident analysis and prevention activities are discussed. For future AcciMap analyses it is recommended that the contributory factor classification scheme developed in the present study is used to support the identification and classification of contributory factors. In addition, further education for analysts on the systems thinking perspective on accident causation is recommended.
Critical essay: sociotechnical construction Walker, Guy H.; Foscarin-Kosmetatou, Simona; Marr, Simon ...
Construction management and economics,
03/2024, Letnik:
42, Številka:
3
Journal Article
Recenzirano
Odprti dostop
The Houses of Parliament Restoration and Renewal Programme is the UK's largest ever. The cultural value, funding model, risk profile, and fragility of the building exposes an uncomfortable truth. ...Construction business-as-usual has become an enterprise risk. Current levels of productivity, health, and wellbeing are not acceptable on a project of such high national importance. The Programme joins calls made in the Farmer Review, Project 13, the Construction Play Book , and now the Building Safety Bill for transformative change. It is in the unique position of being able to proactively drive this change. It is an exemplar project intended to deliver a learning legacy for the sector at large. It is also the first project to show an interest in a new approach called Sociotechnical Construction. The focus of this new approach is the joint optimization of socio/human and technical/organizational factors. The evidence points to these being instrumental in resolving the construction sector's long-standing productivity and wellbeing paradox. This critical essay describes and defines Sociotechnical Construction, sets out the call to action, and presents the case for why it is needed now.
Human Factors Methods and Accident Analysis is the first book to offer a practical guide for investigators, practitioners and researchers wishing to apply accident analysis methods. It is also unique ...in presenting a series of novel applications of accident analysis methods, including HF methods not previously used for these purposes (e.g. EAST, critical path analysis), as well as applications of methods in new domains.
There is growing interest in the use of systems-based risk assessment methods in Human Factors and Ergonomics (HFE). The purpose of this study was to test the intra-rater reliability and ...criterion-referenced concurrent validity of three systems-based risk assessment approaches: (i) the Systems-Theoretic Process Analysis (STPA) method; (ii) the Event Analysis of Systemic Teamwork Broken Links (EAST-BL) method; and, (iii) the Network Hazard Analysis and Risk Management System (Net-HARMS) method. Reliability and validity measures were obtained using the Signal Detection Theory (SDT) paradigm. Whilst STPA identified the highest number of risks, the findings indicate a weak to moderate level of reliability and validity for STPA, EAST-BL and Net-HARMS. There were no statistically significant differences between the methods across analyses. The results suggest that there is merit to the continued use of systems-based risk assessment methods following a series of methodological extensions that aim to enhance the reliability and validity of future applications.
Practitioner summary The three risk assessment methods produced weak to moderate levels of stability and accuracy regarding their capability to predict risks. There is a pressing need to further test the reliability and validity of safety methods in Human Factors and Ergonomics.
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