The systems approach is arguably the dominant concept within accident analysis research. Viewing accidents as a result of uncontrolled system interactions, it forms the theoretical basis of various ...systemic accident analysis (SAA) models and methods. Despite the proposed benefits of SAA, such as an improved description of accident causation, evidence within the scientific literature suggests that these techniques are not being used in practice and that a research-practice gap exists. The aim of this study was to explore the issues stemming from research and practice which could hinder the awareness, adoption and usage of SAA. To achieve this, semi-structured interviews were conducted with 42 safety experts from ten countries and a variety of industries, including rail, aviation and maritime. This study suggests that the research-practice gap should be closed and efforts to bridge the gap should focus on ensuring that systemic methods meet the needs of practitioners and improving the communication of SAA research.
Researchers, healthcare managers and human factors practitioners who need to know the latest developments within the theory and application of Patient Safety Culture within healthcare should read ...this book.
Over the last few decades the food production, distribution and consumption chains have become complex as a result of globalisation and food travelling over large distances. The food supply chain is ...a multi-layered structure with multiple interactions across and within the hierarchical levels across the entire food system. As unwanted factors and food safety behaviours could lead to global food poisoning catastrophes, it is important to adopt a systems approach to gain a whole-system perspective of the global food system.
In this review the importance of adopting a complex systems approach towards the global food system and a possible systems analysis method that would help capture this perspective are described. This study emphasizes the importance of adopting a proactive approach, starting with identifying the similarities between the characteristics of complex systems and the food system and the importance and benefits of adopting a whole system approach in the global food system.
Adopting a complex systems approach to the global food system is of paramount relevance as this would help further understand the interconnectivity of food systems and how multifaceted factors across systemic levels play a major role in achieving food safety. Using a systems analysis model such as the Systems-Theoretic Accident Models and Processes (STAMP) model provides the ability to tackle the limitations of event chain models and analyse the complex interactions among various components in the complex food system. It is the need of the hour to study food systems at micro and macro-levels and develop a model that would have the ability to identify food safety related issues across the global food system.
•The global food system has the characteristics of a complex system.•It is important to adopt a proactive approach to understand the global food system.•The use of a systems-of-systems approach to understand the global food system is proposed.•The approach suggests the use of Human Factors models to understand the working of food systems and the controls therein.
•A STAMP-CAST analysis of ten fatal road traffic collisions in Cambridgeshire, UK.•Actors involved in the collisions were identified across all levels of the system.•The controls in place in the UK ...are insufficient to prevent serious harm.•A total of 60 recommendations are made across policy and practice.•STAMP is a valuable system-based tool for road safety management.
There have been strong calls in the research literature for the adoption of system-based approaches to further reduce road casualties. However, person-based approaches remain at the forefront of both national and local-level decision-making around road safety in the UK. Focusing on person-based approaches inhibits learning across the system. Practical examples are needed to support adoption of system-based approaches and ensure safety learning is maximised within the industry.
This study builds on previous work (Staton et al., 2022) mapping the control structure for the municipal area of Cambridgeshire, UK. It utilizes a system-based accident investigation method: Causal Analysis based on System Theory (CAST) (Leveson, 2019). The method is based on Rasmussen’s Risk Management Framework and is used to identify weaknesses in the control structure across the entire sociotechnical system. This supports understanding why the collision occurred and prevention of similar future events, rather than apportioning blame. In the study, CAST is used to investigate a random sample of ten fatal collisions that occurred in Cambridgeshire between 2018 and 2020. The investigations were conducted retrospectively using police forensic collision investigation files that had already concluded crown or coroner’s court proceedings.
Across all ten collisions investigated, 21 different types of actor were identified across all levels of the system, each of whom played some role in at least one of the collisions. As a result, 49 specific recommendations are made concerning these actor’s roles in preventing future road deaths and serious injuries. In addition, 11 system-wide recommendations are made relating to communication and coordination; the safety information system; safety culture; design of the safety management system; changes and dynamics over time; and economic factors in the system environment.
This study demonstrates that the CAST method is a viable tool for learning in the road safety industry and provides a taxonomy of system hazards, alongside the system control structure from Staton et al. (2022), to support any future analysis using this method. The use of CAST identifies the importance of controls within the road transport system and that currently, despite having one of the best road safety records in the world, the existing controls in place in the UK are insufficient to prevent serious injury and death occurring daily and are in danger of being eroded further through a political agenda of deregulation.
This study reinforces that road safety requires system-based approaches and the strength of the CAST method in identifying system-wide recommendations which can be used in support of a Safe System approach to provide recommendations across the Safe System pillars.
This paper extends an earlier examination of the concept of ‘mesoergonomics’ (Karsh et al., 2014) and its application to Human Factors/Ergonomics (HFE). Karsh et al. (2014) developed a framework for ...mesoergonomic inquiry based on a set of steps and questions, the purpose of which was to encourage researchers to cross system levels in the studies (e.g., organisation-group-individual levels of analysis) and to explore alternative causal mechanisms and relationships within their data. The present paper further develops the framework and draws on previous work across a diverse range of sources (safety science, systems theory, the sociology of disaster and ethology) which has examined the subject of accident causation, levels of analysis and explanatory factors contributing to system failure. The outcomes from this exercise are a revised framework which seeks to explore what we term ‘isomorphisms’ and includes questions covering: (a) how internal isomorphisms develop or evolve within the system; and, (b) how these isomorphisms are shaped by cultural, professional and other forms of external influence. The workings of the revised framework are illustrated through using the example of the UK NHS Morecambe Bay Investigation (Kirkup, 2015). The paper concludes with a summary of ways forward for the framework, as well as new directions for theory within systems ergonomics/human factors.
•This paper extends an earlier examination of the concept of ‘mesoergonomics’ (Karsh et al., 2014).•Karsh et al. (2014) developed a framework for mesoergonomic inquiry based on a set of steps and questions, the purpose of which was to encourage researchers to cross system level in their studies.•The present paper further develops the framework and focuses on accident causation, levels of analysis and other forms of explanation contributing to system failure.•The workings of the revised framework are illustrated using the example of the UK NHS Morecambe Bay Investigation (Kirkup, 2015).
This paper summarises some of the research that Ken Eason and colleagues at Loughborough University have carried out in the last few years on the introduction of Health Information Technologies (HIT) ...within the UK National Health Service (NHS). In particular, the paper focuses on three examples which illustrate aspects of the introduction of HIT within the NHS and the role played by the UK National Programme for Information Technology (NPfIT). The studies focus on stages of planning and preparation, implementation and use, adaptation and evolution of HIT (e.g., electronic patient records, virtual wards) within primary, secondary and community care settings. Our findings point to a number of common themes which characterise the use of these systems. These include tensions between national and local strategies for implementing HIT and poor fit between healthcare work systems and the design of HIT. The findings are discussed in the light of other large-scale, national attempts to introduce similar technologies, as well as drawing out a set of wider lessons learnt from the NPfIT programme based on Ken Eason's earlier work and other research on the implementation of large-scale HIT.
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