Modelling complexity in everyday operations: functional resonance in maritime mooring at quay

Cognition, Technology and Work

Volumn 19, Issue 4, 2017, Pages 711-729

  Patriarca, Riccardo ^a   Bergström, Johan ^b  

^a SAPIENZA UNIVERSITY OF ROME   (Italy)

^b LUND UNIVERSITY   (Sweden)

Author keywords

Complexity; FRAM; Maritime operation; Resilience; Work as done

Indexed keywords

COMPUTER APPLICATIONS; HUMAN COMPUTER INTERACTION;

COMPLEXITY; FRAM; MARITIME OPERATION; RESILIENCE; WORK-AS-DONE;

MOORING;

EID: 85021987564     PISSN: 14355558     EISSN: 14355566     Source Type: Journal    
DOI: 10.1007/s10111-017-0426-2     Document Type: Article

References (72)

1. Akhatar MJ (2014) Fatigue at sea—a manning problem. J Marit Res 11:27–42
2. Akyuz E, Celik M (2014) Utilisation of cognitive map in modelling human error in marine accident analysis and prevention. Saf Sci 70:19–28. doi:10.1016/j.ssci.2014.05.004
3. Akyuz E, Celik M (2015) Application of CREAM human reliability model to cargo loading process of LPG tankers. J Loss Prev Process Ind 34:39–48. doi:10.1016/j.jlp.2015.01.019
4. Akyuz E, Celik E (2016a) A modified human reliability analysis for cargo operation in single point mooring (SPM) off-shore units. Appl Ocean Res 58:11–20. doi:10.1016/j.apor.2016.03.012
5. Akyuz E, Celik M (2016b) A hybrid human error probability determination approach: the case of cargo loading operation in oil/chemical tanker ship. J Loss Prev Process Ind 43:424–431. doi:10.1016/j.jlp.2016.06.020
6. Akyuz E, Akgun I, Celik M (2016) A fuzzy failure mode and effects approach to analyse concentrated inspection campaigns on board ships. Marit Policy Manag 43:887–908. doi:10.1080/03088839.2016.1173737
7. Belmonte F, Schön W, Heurley L, Capel R (2011) Interdisciplinary safety analysis of complex socio-technological systems based on the functional resonance accident model: an application to railway trafficsupervision. Reliab Eng Syst Saf 96:237–249. doi:10.1016/j.ress.2010.09.006
8. Bennett KB (2015) Ecological interface design and system safety: one facet of Rasmussen’s legacy. Appl Ergon. doi:10.1016/j.apergo.2015.08.001
9. Brodje A, Lundh M, Jenvald J, Dahlman J (2013) Exploring non-technical miscommunication in vessel traffic service operation. Cogn Technol Work 15:347–357. doi:10.1007/s10111-012-0236-5
10. Brooker P (2011) Experts, Bayesian Belief Networks, rare events and aviation risk estimates. Saf Sci 49:1142–1155. doi:10.1016/j.ssci.2011.03.006
11. Celik M (2009) Designing of integrated quality and safety management system (IQSMS) for shipping operations. Saf Sci 47:569–577. doi:10.1016/j.ssci.2008.07.002
12. Celik M, Topcu YI (2009) Use of an ANP to prioritize managerial responsibilities of maritime stakeholders in environmental incidents: an oil spill case. Transp Res Part D Transp Environ 14:502–506. doi:10.1016/j.trd.2009.05.008
13. Chen ST, Wall A, Davies P, Yang Z, Wang J, Chou YH (2013) A Human and Organisational Factors (HOFs) analysis method for marine casualties using HFACS-Maritime Accidents (HFACS-MA). Saf Sci 60:105–114. doi:10.1016/j.ssci.2013.06.009
14. Clay-Williams R, Hounsgaard J, Hollnagel E (2015) Where the rubber meets the road: using FRAM to align work-as-imagined with work-as-done when implementing clinical guidelines. Implement Sci 10:125. doi:10.1186/s13012-015-0317-y
15. Dekker S (2006) Resilience engineering: chronicling the emergence of confused consensus. In: Hollnagel E, Woods DD, Leveson N (eds) Resilience engineering: concepts and precepts. Ashgate Publishing, Ltd., Farnham, pp 77–94
16. Dekker S, Pruchnicki S (2014) Drifting into failure: theorising the dynamics of disaster incubation. Theor Issues Ergon Sci. doi:10.1080/1463922X.2013.856495
17. DMA (2006) Mooring accidents on board merchant ships. DMA, Copenhaghen
18. DMAIB (2014a) Safety report April 2014: PACHUCA Mooring accident on 14 December 2012. DMAIB, Valby
19. DMAIB (2014b) Summary report—TORM REPUBLICAN occupational accident on 3 December 2013. DMAIB, Valby
20. Fukuda K, Sawaragi T, Horiguchi Y, Nakanishi H (2016) Applying systemic accident model to learn from near-miss incidents of train maneuvering and operation. IFAC-PapersOnLine 49:543–548. doi:10.1016/j.ifacol.2016.10.619
21. Fukuoka K, Furusho M (2016) Relationship between latent conditions and the characteristics of holes in marine accidents based on the Swiss cheese model. WMU J Marit Aff 15:267–292. doi:10.1007/s13437-015-0099-8
22. Gemelos IC, Ventikos NP (2008) Safety in greek coastal shipping: the role and risk of human factor revisited introduction: the problem. WMU J Marit Aff 7:31–49
23. Harrald JR, Mazzuchi TA, Spahn J, Van Dorp R, Merrick J, Shrestha S, Grabowski M (1998) Using system simulation to model the impact of human error in a maritime system. Saf Sci 30(1):235–247. doi:10.1016/S0925-7535(98)00048-4
24. Hetherington C, Flin R, Mearns K (2006) Safety in shipping: the human element. J Saf Res 37:401–411. doi:10.1016/j.jsr.2006.04.007
25. Hollnagel E (2010) The ETTO principle: efficiency-thoroughness trade-off—why things that go right sometimes go wrong. Risk Anal 30:153–154. doi:10.1111/j.1539-6924.2009.01333.x
26. Hollnagel E (2012) FRAM: the functional resonance analysis method: modelling complex socio-technical systems. Ashgate, Farnham
27. Hollnagel E (2014) Safety-I and safety-II (the past and future of safety management). Ashgate, Farnham
28. Hollnagel E, Pruchnicki S, Woltjer R, Etcher S (2008) Analysis of Comair flight 5191 with the functional resonance accident model. In: 8th International symposium of the Australian aviation psychology association
29. Hsu WK (2015) Assessing the safety factors of ship berthing operations. J Navig 68:576–588. doi:10.1017/S0373463314000861
30. Jia D-J, Li F-C (2016) Study on mooring safety for a ship with constant tension mooring system. J Dalian Marit Univ 42:1–8. doi:10.16411/j.cnki.issn1006-7736.2016.03.001
31. Jia D-J, Li F-C, Zhao T-Y, Meng K (2016) Ship docking safety in severe sea state in harbor. Dalian Haishi Daxue Xuebao/J Dalian Marit Univ 42(1):21–26. doi:10.16411/j.cnki.issn1006-7736.2016.01.005
32. Knapp S, Van De Velden M (2011) Global ship risk profiles: safety and the marine environment. Transp Res Part D Transp Environ 16:595–603. doi:10.1016/j.trd.2011.08.001
33. Lappalainen J, Kunnaala V, Tapaninen U (2014) Present pilotage practices in Finland. WMU J Marit Aff 13:77–99. doi:10.1007/s13437-013-0055-4
34. Li W, Ji R, Huang T (2016) Research on mooring system under typhoon state. In: Ocean. 2016—Shanghai, pp 1–4. doi:10.1109/OCEANSAP.2016.7485693
35. Ljung M, Lutzhoft M (2014) Functions, performances and perceptions of work on ships. WMU J Marit Aff 13:231–250. doi:10.1007/s13437-014-0057-x
36. Lundblad K, Speziali J (2008) FRAM as a risk assessment method for nuclear fuel transportation. In: International conference working on safety
37. Maritime and Coastguard Agency (2010) Code of safe working practices for merchant Seamen. In: Consolidat. ed. The Stationery Office (TSO), Norwich (UK)
38. Mazaheri A, Montewka J, Nisula J, Kujala P (2015) Usability of accident and incident reports for evidence-based risk modeling—a case study on ship grounding reports. Saf Sci 76:202–214. doi:10.1016/j.ssci.2015.02.019
39. Mikkers M, Henriqson E, Dekker S (2013) Managing multiple and conflicting goals in dynamic and complex situations: exploring the practical field of maritime pilots. J Marit Res 9:13–18
40. Mukherjee PK, Brownrigg M (2013) Farthing on international shipping. 4th edn. Springer, Heidelberg, London. ISBN: 978-3-642-34598-2
41. Naikar N, Sanderson PM (2001) Evaluating design proposals for complex systems with work domain analysis. Hum Factors 43:529–542
42. OCIMF (2015) The hazards of Snap-back: initial learnings from a serious incident of mooring line failure. OCIMF, London
43. Patriarca R, Bergström J, Di Gravio G (2017a) Defining the functional resonance analysis space: combining Abstraction Hierarchy and FRAM. Reliab Eng Syst Saf 165:34–46. doi:10.1016/j.ress.2017.03.032
44. Patriarca R, Di Gravio G, Costantino F (2017b) A Monte Carlo evolution of the Functional Resonance Analysis Method (FRAM) to assess performance variability in complex systems. Saf Sci 91:49–60. doi:10.1016/j.ssci.2016.07.016
45. Patriarca R, Di Gravio G, Costantino F, Tronci M (2017c) The Functional Resonance Analysis Method for a systemic risk based environmental auditing in a sinter plant: a semi-quantitative approach. Environ Impact Assess Rev 63:72–86. doi:10.1016/j.eiar.2016.12.002
46. Pickup L, Atkinson S, Hollnagel E, Bowie P, Gray S, Rawlinson S, Forrester K (2017) Blood sampling—two sides to the story. Appl Ergon. doi:10.1016/j.apergo.2016.08.027
47. Praetorius G (2014) Vessel Traffic Service (VTS): a maritime information service or traffic control system? Understanding everyday performance and resilience in a socio-technical system under change. Chalmers University of Technology, Gothenburg
48. Praetorius G, Hollnagel E (2014) Control and resilience within the maritime traffic management domain. J Cogn Eng Decis Mak. doi:10.1177/1555343414560022
49. Praetorius G, Lützhöft M (2012) Decision support for vessel traffic service (VTS): user needs for dynamic risk management in the VTS. Work 41:4866–4872. doi:10.3233/WOR-2012-0779-4866
50. Praetorius G, Hollnagel E, Dahlman J (2015) Modelling vessel traffic service to understand resilience in everyday operations. Reliab Eng Syst Saf 141:10–21. doi:10.1016/j.ress.2015.03.020
51. Praetorius G, Graziano A, Schröder-Hinrichs J-U, Baldauf M (2016) Fram in FSA—introducing a function-based approach to the formal safety assessment framework. Adv Intell Syst Comput. doi:10.1007/978-3-319-41682-3_34
52. Rasmussen J (1985) The role of hierarchical knowledge representation in decision making and system management. IEEE Trans Syst Man Cybern SMC 15:234–243. doi:10.1109/TSMC.1985.6313353
53. Reason J (1990) The contribution of latent human failures to the breakdown of complex systems. Philos Trans R Soc Lond B Biol Sci 327:475–484. doi:10.1098/rstb.1990.0090
54. Reason J (2000) Human error: models and management. BMJ Br Med J 320:768–770
55. Sanderson P, Burns C (2017) Rasmussen and the boundaries of empirical evaluation. Appl Ergon. doi:10.1016/j.apergo.2016.10.003
56. Sandhåland H, Oltedal H, Eid J (2015) Situation awareness in bridge operations—a study of collisions between attendant vessels and offshore facilities in the North Sea. Saf Sci 79:277–285. doi:10.1016/j.ssci.2015.06.021
57. Sawaragi T, Horiguchi Y, Hina A (2006) Safety analysis of systemic accidents triggered by performance deviation. In: 2006 SICE-ICASE international joint conference. IEEE, pp 1778–1781. doi:10.1109/SICE.2006.315635
58. Schröder-Hinrichs JU (2010) Human and organizational factors in the maritime world—are we keeping up to speed? WMU. J Marit Aff 9:1–3. doi:10.1007/BF03195162
59. Shorrock S (2016) The varieties of human work [WWW Document]. Humanist. Syst. blog. https://humanisticsystems.com/2016/12/05/the-varieties-of-human-work/. Accessed 25 Apr 2017
60. Soares CG, Teixeira AP (2001) Risk assessment in maritime transportation. Reliab Eng Syst Saf 74:299–309. doi:10.1016/S0951-8320(01)00104-1
61. Standards Board (1994) BS 6349-4:1994 Maritime structures (part 4: Code of practice for design of fendering and mooring system). Standards Board
62. Sujan M-A, Felici M (2012) Combining failure mode and functional resonance analyses in healthcare settings. Lecture notes in computer science (including subseries lecture notes in artificial intelligence. Lecture notes in bioinformatics) 7612 LNCS, pp 364–375. doi:10.1007/978-3-642-33678-2_31
63. Toffoli A, Lefèvre JM, Bitner-Gregersen E, Monbaliu J (2005) Towards the identification of warning criteria: analysis of a ship accident database. Appl Ocean Res 27:281–291. doi:10.1016/j.apor.2006.03.003
64. Turan O, Kurt RE, Arslan V, Silvagni S, Ducci M, Liston P, Schraagen JM, Fang I, Papadakis G (2016) Can we learn from aviation: safety enhancements in transport by achieving human orientated resilient shipping environment. Transp Res. doi:10.1016/j.trpro.2016.05.132
65. UK P&I Club (2009) Risk focus: mooring. UK P&I Club, London
66. Valdez Banda OA, Goerlandt F, Montewka J, Kujala P (2015) A risk analysis of winter navigation in Finnish sea areas. Accid Anal Prev 79:100–116. doi:10.1016/j.aap.2015.03.024
67. van Westrenen F (2014) Modelling arrival control in a vessel traffic management system. Cogn Technol Work 16:501–508. doi:10.1007/s10111-014-0279-x
68. van Westrenen F, Praetorius G (2014) Maritime traffic management: a need for central coordination? Cogn Technol Work 16:59–70. doi:10.1007/s10111-012-0244-5
69. Woltjer R, Haraldsson J, Pinska-Chauvin E, Josefsson B (2013) Resilience in ATM operations: incorporating robustness and resilience in safety assessment. In: Proceedings of the 5th resilience engineering association symposium. Soesterberg, pp 25–27
70. Woods DD (1988) Coping with complexity: the psychology of human behaviour in complex systems. In: Goodstein LP, Andersen HB, Olsen SE (eds) Task, errors and mental models. Taylor & Francis, Bristol, pp 128–148
71. Yip TL (2008) Port traffic risks—a study of accidents in Hong Kong waters. Transp Res Part E Logist Transp Rev 44:921–931. doi:10.1016/j.tre.2006.09.002
72. Zheng Z, Tian J, Zhao T (2016) Refining operation guidelines with model-checking-aided FRAM to improve manufacturing processes: a case study for aeroengine blade forging. Cogn Technol Work. doi:10.1007/s10111-016-0391-1