Towards understanding work-as-done in air traffic management safety assessment and design

Reliability Engineering and System Safety

Volumn 141, Issue , 2015, Pages 115-130

  Woltjer, Rogier ^a   Pinska Chauvin, Ella ^b   Laursen, Tom ^c   Josefsson, Billy ^d  

^a SWEDISH DEFENCE RESEARCH AGENCY   (Sweden)

^b EUROCONTROL EXPERIMENTAL CENTRE   (France)

^c IFATCA and Naviair ^*  (Denmark)

^d Project Management and Support   (Sweden)

Author keywords

Air traffic management; Design; Resilience engineering; Safety assessment; System safety; Work as done

Indexed keywords

ADVANCED TRAFFIC MANAGEMENT SYSTEMS; AIR NAVIGATION; AIR TRANSPORTATION; AVIATION; DESIGN; SAFETY ENGINEERING;

AIR TRAFFIC MANAGEMENT; RESILIENCE ENGINEERINGS; SAFETY ASSESSMENTS; SYSTEM SAFETY; WORK-AS-DONE;

AIR TRAFFIC CONTROL;

EID: 84937937253     PISSN: 09518320     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.ress.2015.03.010     Document Type: Article

References (75)

1. H. Alm, and R. Woltjer Patient safety investigation through the lens of FRAM D. De Waard, A. Axelsson, M. Berglund, B. Peters, C. Weikert, Human factors: a system view of human, technology and organisation 2010 Shaker Publishing Maastricht, The Netherlands 153 165
2. R. Amalberti The paradoxes of almost totally safe transportation systems Saf Sci 37 2001 109 126
3. J.M. Carroll, and M.B. Rosson Getting around the task-artifact cycle: how to make claims and design by scenario ACM Trans Inf Syst 10 2 1992 181 212
4. P. Checkland Systems thinking, systems practice 1981 John Wiley & Sons Chichester
5. S.W.A. Dekker Ten questions about human error: a new view of human factors and system safety 2004 Lawrence Erlbaum Associates, Inc. Mahwah, NJ
6. S.W.A. Dekker, P. Cilliers, and J. Hofmeyr The complexity of failure: implications of complexity theory for safety investigations Saf Sci 49 6 2011 939 945
7. DSB. Defense science board task force report: the role of autonomy in DoD systems, Washington, DC, USA; US DoD, 2012.
8. EASA Annual safety review 2013 2014 European Aviation Safety Agency Cologne, Germany
9. W.C. Elm, J.W. Gualtieri, B.P. Mckenna, J.S. Tittle, J.E. Peffer, S.S. Szymczak, and et al. Integrating cognitive systems engineering throughout the systems engineering process J Cogn Eng Decis Mak 2 3 2008 249 273
10. EU. Commission Implementing Regulation (EU) No 1035/2011 of 17 October 2011 laying down common requirements for the provision of air navigation services and amending Regulations (EC) No 482/2008 and (EU) No 691/2010. Official Journal of the European Union, L271, 23-41; 2011.
11. EU, EUROCONTROL. E-OCVM version 3.0 volume I - European operational concept validation methodology, Brussels; 2010.
12. EUROCONTROL. Safety regulatory requirement - ESARR 4, risk assessment and mitigation in ATM. Brussels: EUROCONTROL, 2001.
13. EUROCONTROL. Air navigation system safety assessment methodology (SAM), SAF.ET1.ST03.1000-MAN-01 (2.1 ed.). Brussels: EUROCONTROL, 2006.
14. EUROCONTROL A white paper on resilience engineering for ATM 2009 EUROCONTROL Brussels
15. EUROCONTROL From Safety-I to Safety-II: a white paper 2013 EUROCONTROL Brussels
16. P.J. Feltovich, R.R. Hoffman, D. Woods, and A. Roesler Keeping it too simple: how the reductive tendency affects cognitive engineering IEEE Intell Syst 2004 90 94 May/June
17. Fowler D, Perrin E, Pierce R. Success is not merely absence of failure - a systems-engineering approach to safety assessment. In: Proceedings of IET system safety 2009; 2009.
18. D. Fowler, E. Perrin, and R. Pierce 2020 Foresight - a systems-engineering approach to assessing the safety of the SESAR operational concept Air Traffic Control Q 19 4 2011 239 267
19. H.W. Heinrich Industrial accident prevention: a scientific approach 1st ed. 1931 McGraw-Hill Book Company, Inc. New York and London
20. I.A. Herrera, and R. Woltjer Comparing a multi-linear (STEP) and systemic (FRAM) method for accident analysis Reliab Eng Syst Saf 95 12 2010 1269 1275
21. R.R. Hoffman Human factors contributions to knowledge elicitation Hum Factors 50 3 2008 481 488
22. R.R. Hoffman, and D.D. Woods Beyond Simon's slice: five fundamental trade-offs that bound the performance of macrocognitive work systems IEEE Intell Syst 26 6 2011 67 71
23. E. Hollnagel Cognitive systems performance analysis E. Hollnagel, G. Mancini, D.D. Woods, Intelligent decision support in process environments 1986 Springer-Verlag Berlin 211 226
24. E. Hollnagel Cognitive reliability and error analysis method: CREAM 1998 Elsevier Oxford, New York
25. E. Hollnagel Barriers and accident prevention 2004 Ashgate Aldershot, UK
26. E. Hollnagel The ETTO principle: efficiency-thoroughness trade-off: why things that go right sometimes go wrong 2009 Ashgate Farnham, UK
27. E. Hollnagel Epilogue: RAG - the resilience analysis grid E. Hollnagel, J. Pariès, D.D. Woods, J. Wreathall, Resilience engineering in practice: a guidebook 2011 Ashgate Aldershot, UK 275 296
28. E. Hollnagel Prologue: the scope of resilience engineering E. Hollnagel, J. Pariès, D.D. Woods, J. Wreathall, Resilience engineering in practice: a guidebook 2011 Ashgate Aldershot, UK p. xxix-xxxix
29. E. Hollnagel FRAM: the functional resonance analysis method - modelling complex socio-technical systems 2012 Ashgate Aldershot, UK 154
30. E. Hollnagel A tale of two safeties Nucl Saf Simul 4 1 2013 1 9
31. E. Hollnagel Is safety a subject for science? Saf Sci 67 2014 21 24
32. Hollnagel E, Hounsgaard J, Colligan L. FRAM - the functional resonance analysis method - a handbook for the practical use of the method. Centre for quality, in the Southern Region of Denmark; 2014.
33. Resilience engineering in practice: a guidebook E. Hollnagel, J. Pariès, D.D. Woods, and J. Wreathall 2011 Ashgate Aldershot, UK
34. Hollnagel E, Pruchnicki S, Woltjer R, Etcher S. Analysis of Comair flight 5191 with the functional resonance accident model. In: Proceedings of the eighth international symposium of the Australian Aviation Psychology Association, Sydney, Australia; 2008.
35. E. Hollnagel, and D.D. Woods Joint cognitive systems: foundations of cognitive systems engineering 2005 CRC Press/Taylor & Francis Boca Raton, FL
36. Resilience engineering: concepts and precepts E. Hollnagel, D.D. Woods, and N. Leveson 2006 Ashgate Aldershot, UK
37. ICAO. (n.d.). Draft NOSS manual. Retrieved from (http://www.skybrary.aero/bookshelf/books/517.pdf).
38. ICAO. ICAO Doc 9859 - safety management manual, 3rd ed.; 2013.
39. C.W. Johnson, B. Kirwan, and A. Licu The interaction between safety culture and degraded modes: a survey of national infrastructures for air traffic management Risk Manage 11 2009 241 284
40. G.A. Klein, and R. Calderwood Decision models: some lessons from the field IEEE Trans Syst Man Cybern 21 5 1991 1018 1026
41. G.A. Klein, R. Calderwood, and D. MacGregor Critical decision method for eliciting knowledge IEEE Trans Syst Man Cybern 19 3 1989 462 472
42. G.A. Klein, R. Pliske, B. Crandall, and D.D. Woods Problem detection Cogn Technol Work 7 2005 14 28
43. G.A. Klein, D. Snowden, and C.L. Pin Anticipatory thinking K.L. Mosier, U.M. Fischer, Informed by knowledge: expert performance in complex situations 2011 Taylor & Francis Group New York, NY 235 246
44. N.G. Leveson Engineering a safer world: systems thinking applied to safety 2011 MIT Press Cambridge, MA
45. Pariès J, Bieder C, Reason J, Isaac A. The development of a safety management tool within ATM (HERA-SMART) (EUROCONTROL HRS/HSP-002-REP-08), Brussels; 2003.
46. C. Perrow Normal accidents: living with high-risk technologies 1984 Basic Books, Inc., Publishers New York, NJ
47. A. Rankin, J. Lundberg, R. Woltjer, C. Rollenhagen, and E. Hollnagel Resilience in everyday operations: a framework for analyzing adaptations in high-risk work J Cogn Eng Decis Mak 8 1 2014 78 97
48. A. Rankin, J. Lundberg, and R. Woltjer A Framework for Learning from Adaptive Performance C.P. Nemeth, E. Hollnagel, Resilience Engineering in Practice 2 2014 Ashgate Farnham, UK 79 95 Becoming Resilient
49. J.T. Reason Managing the risks of organisational accidents 1997 Ashgate Aldershot, UK
50. Reason JT, Hollnagel E, Pariès J. Revisiting the "Swiss Cheese" model of accidents (EUROCONTROL experimental centre EEC note no. 13/06). Bretigny-sur-Orge, France; 2006.
51. GI Rochlin Safe operation as a social construct Ergonomics 42 11 1999 1549 1560
52. P.V Rodrigues De Carvalho The use of functional resonance analysis method (FRAM) in a mid-air collision to understand some characteristics of the air traffic management system resilience Reliab Eng Syst Saf 96 11 2011 1482 1498
53. SESAR, EU, EUROCONTROL. The roadmap for sustainable air traffic management: European ATM Master Plan, 2nd ed. Brussels; 2012.
54. SESARJU. ATC global 2012: technical workshop/4D/business trajectory. Technical workshop documentation. Brussels. Retrieved September 23, 2013, from (http://www.sesarju.eu/news-press/documents/atc-global-2012-technical-workshop-4dbusiness-trajectory-1026); 2012.
55. H.A. Simon A behavioral model of rational choice Q J Econ 69 1 1955 99 118
56. Skybrary. 4D Trajectory concept. Retrieved January 07, 2014, from (http://www.skybrary.aero/index.php/4D-Trajectory-Concept); 2014.
57. L.A. Suchman Plans and situated actions: the problem of human machine communication 1987 Cambridge University Press New York
58. Tavanti M, Marti P, Bourgois M. Tacit knowledge and frugal artifacts: a challenge for technology mediated collaboration. In: G. Grote, H. Günter, and A. Totter editors. Trust and control in complex socio-technical systems. Proceedings of the 13th European conference on cognitive ergonomics (ECCE13), Zurich, CH: EACE and ACM; 2006. p. 105-108.
59. Walker KE, Deary DS, Woods DD. Reducing the potential for cascade: recognizing and mitigating situations that threaten business viability. In: Proceedings of the fifth resilience engineering association symposium, Soesterberg, NL: REA; 2013.
60. K.E. Weick, K.M. Sutcliffe, and D. Obstfeld Organizing and the process of sensemaking Organiz Sci 16 4 2005 409 421
61. R. Woltjer Functional modeling of constraint management in aviation safety and command and control 2009 Linköping University PhD Thesis. Linköping Studies in Science and Technology Dissertation no. 1249
62. Woltjer R, Haraldsson J, Pinska-Chauvin E, Laursen T, Josefsson B. Resilience in ATM operations: incorporating robustness and resilience in safety assessment. In: I. Herrera, J.M. Schraagen, J. Van der Vorm, D. Woods editors. Proceedings of the fifth resilience engineering association symposium, Soesterberg, NL: Resilience Engineering Association; 2013. p. 203-208.
63. Woltjer R, Pinska-Chauvin E, Laursen T, Josefsson B. Resilience engineering in air traffic management: increasing resilience through safety assessment in SESAR. In: D. Schaefer editor. Proceedings of the third SESAR innovation days, EUROCONTROL; 2013.
64. D.D. Woods Designs are hypotheses about how artifacts shape cognition and collaboration Ergonomics 41 2 1998 168 173
65. D.D. Woods Essential characteristics of resilience E. Hollnagel, D.D. Woods, N. Leveson, Resilience engineering: concepts and precepts 2006 Ashgate Aldershot, UK 21 34
66. Woods DD, Branlat M. Basic patterns in how adaptive systems fail. In: Hollnagel E, Pariès J, Woods DD, Wreathall J, editors. Resilience engineering in practice: a guidebook; 2011. p. 127-143.
67. Woods DD, Chan YJ, Wreathall J. The stress-strain model of resilience operationalizes the four cornerstones of resilience engineering. In: Proceedings of the fifth resilience engineering association symposium, Soesterberg, NL: REA; 2013.
68. D.D. Woods, and S. Dekker Anticipating the effects of technological change: a new era of dynamics for human factors Theor Issues Ergon Sci 1 3 2000 272 282
69. D.D. Woods, S. Dekker, R. Cook, L. Johannesen, and N. Sarter Behind human error 2nd ed. 2010 Ashgate Aldershot, UK
70. Woods DD, Branlat M, Herrera I, Woltjer R. Where is the organization looking in order to be proactive about safety? A framework for revealing whether it is mostly looking back, also looking forward or simply looking away. Journal of Contingencies and Crisis Management. http://dx.doi.org/10.1111/1468-5973.12079
71. D.D Woods, and E. Hollnagel Joint cognitive systems: patterns in cognitive systems engineering 2006 CRC Press/Taylor & Francis Boca Raton, FL
72. D.D. Woods, and N.B. Sarter Capturing the dynamics of attention control from individual to distributed systems: the shape of models to come Theor Issues Ergon Sci 11 1-2 2010 7 28
73. D.D. Woods, and R.I. Cook Nine steps to move forward from error Cognition Technology & Work 4 2002 137 144
74. D.D. Woods, and R.I. Cook Incidents - Markers of Resilience or Brittleness? E. Hollnagel, D.D. Woods, N. Leveson, Resilience engineering: concepts and precepts 2006 Ashgate Aldershot, UK 69 76
75. J. Wreathall Properties of resilient organizations: an initial view E. Hollnagel, D.D. Woods, N. Leveson, Resilience engineering: concepts and precepts 2006 Ashgate Aldershot, UK 275 285