Understanding safe performance in rapidly evolving systems: a risk management analysis of the 2010 US financial market Flash Crash with Rasmussen's risk management framework

Systemic events or widespread disruptions in financial markets like the Flash Crash are a public concern as they jeopardise investors’ confidence in financial markets and result in financial losses for market participants. Federal regulations for financial markets do not keep pace with the evolution and growth of financial technology including advances in algorithmic and high-frequency trading (HFT). We report an analysis of the Flash Crash which occurred on 6 May 2010 using Rasmussen's 1997 risk management framework. While the framework has been validated on a number of well-documented accidents, our work examines the framework in the context of a large-scale adverse event associated with complex technologies and automated systems capable of evolving over time. Our contribution is a set of implications of the Flash Crash associated with Rasmussen's propositions. These implications would inform regulators and risk assessment methods for rapidly evolving complex socio-technical systems.     

Systems thinking applied to safety during manual handling tasks in the transport and storage industry

Injuries resulting from manual handling tasks represent an on-going problem for the transport and storage industry. This article describes an application of a systems theory-based approach, Rasmussen's (1997. Safety Science 27, 183), risk management framework, to the analysis of the factors influencing safety during manual handling activities in a freight handling organisation. Observations of manual handling activities, cognitive decision method interviews with workers (n = 27) and interviews with managers (n = 35) were used to gather information about three manual handling activities. Hierarchical task analysis and thematic analysis were used to identify potential risk factors and performance shaping factors across the levels of Rasmussen's framework. These different data sources were then integrated using Rasmussen's Accimap technique to provide an overall analysis of the factors influencing safety during manual handling activities in this context. The findings demonstrate how a systems theory-based approach can be applied to this domain, and suggest that policy-orientated, rather than worker-orientated, changes are required to prevent future manual handling injuries.     

新形势下我国食品安全标准管理制度的思考

近期的食品安全危机或事故中,违法行为技术化的特征愈加明显,对我国的食品安全标准管理制度提出了更大的挑战,食品安全标准和标准体系本身的缺憾、修改完善过程中对消费者发言权的漠视、执行过程中的具体困难等等问题都需要进一步解决。因此,进一步加强食品安全标准管理制度的基础性研究、加强食品安全标准的编撰和解释工作、充分发挥社会技术力量的独特作用,应当是新形势下食品安全标准管理制度的重要内容。     

The sociotechnical constitution of cognitive work analysis: roles,affordances and malfunctions

Analysis of everyday work practices in sociotechnical systems for eliciting design/intervention requirements involves appropriate work analysis frameworks. The current article provides an extension to one such framework — Cognitive Work Analysis (CWA) — by scrutinising its sociotechnical basis. CWA's forte depends on its ‘design for adaptation’, system related operations, and operators. In contrast, sociotechnical work systems require not only operators and adaptation, but also a significant emphasis on ‘users’ and ‘appropriation’. The current article extends CWA (based on Rasmussen's original concepts) for users; subsequently allowing for system flexibility and possibilities of ‘appropriation’ within acceptable boundaries of the system's correct functioning. To this end, the first phase of Work Domain Analysis is extended by adding a new layer to the abstraction hierarchy (AH), based on Rasmussen's original insights.     

The contribution of human factors to accidents in the offshore oil industry

Accidents such as the Piper Alpha disaster illustrate that the performance of a highly complex socio-technical system, is dependent upon the interaction of technical, human, social, organisational, managerial and environmental factors and that these factors can be important co-contributors that could potentially lead to a catastrophic event. The purpose of this article is to give readers an overview of how human factors contribute to accidents in the offshore oil industry. An introduction to human errors and how they relate to human factors in general terms is given. From here the article discusses some of the human factors which were found to influence safety in other industries and describes the human factors codes used in accident reporting forms in the aviation, nuclear and marine industries. Analysis of 25 accident reporting forms from offshore oil companies in the UK sector of the North Sea was undertaken in relation to the human factors. Suggestions on how these accident reporting forms could be improved are given. Finally, this article describes the methods by which accidents can be reduced by focusing on the human factors, such as feedback from accident reporting in the oil industry, auditing of unsafe acts and auditing of latent failures.     

Use of CCTV to determine road accident factors in urban areas

This paper sets out to assess whether there is a potential use for images collected through the increasingly ubiquitous use of CCTV cameras in urban areas as a means of increasing understanding of the causes of road traffic accidents. Information on causation and contributory factors is essential as a means of understanding why accidents occurred and how the occurrence of similar events may be prevented in the future. CCTV records of accidents could provide an independent perspective on an accident and have the potential to increase both the quality and quantity of information available to the safety researcher.

This study focuses on an area of central Leeds in the UK and shows that an existing CCTV camera system used for urban traffic management reasons has the potential to record around a quarter of the accidents which occur in the area, based on patterns of past occurrence. Most city centres in the UK will have similar camera systems set-up. By the introduction of additional strategically placed cameras and replacement of existing cameras with ones dedicated to accident recording, this figure could be increased substantially.

The paper also considers how effective cameras and video records will be as a means of identifying contributory factor information once an accident is recorded. The contributory factor classification used by a recently introduced system in Britain is assessed in terms of how visible each of the factors is likely to be on video and their relative frequency of occurrence. It is concluded that CCTV has a high potential to provide corroborative evidence about many of the most commonly occurring factors, and to throw further light on accident causation.     

Incorporating organizational factors into Probabilistic Risk Assessment (PRA) of complex socio-technical systems: A hybrid technique formalization

This paper is a result of a research with the primary purpose of extending Probabilistic Risk Assessment (PRA) modeling frameworks to include the effects of organizational factors as the deeper, more fundamental causes of accidents and incidents. There have been significant improvements in the sophistication of quantitative methods of safety and risk assessment, but the progress on techniques most suitable for organizational safety risk frameworks has been limited. The focus of this paper is on the choice of “representational schemes” and “techniques.” A methodology for selecting appropriate candidate techniques and their integration in the form of a “hybrid” approach is proposed. Then an example is given through an integration of System Dynamics (SD), Bayesian Belief Network (BBN), Event Sequence Diagram (ESD), and Fault Tree (FT) in order to demonstrate the feasibility and value of hybrid techniques. The proposed hybrid approach integrates deterministic and probabilistic modeling perspectives, and provides a flexible risk management tool for complex socio-technical systems. An application of the hybrid technique is provided in the aviation safety domain, focusing on airline maintenance systems. The example demonstrates how the hybrid method can be used to analyze the dynamic effects of organizational factors on system risk.     

Understanding the views of the UK food packaging supply chain in order to support a move to circular economy systems

This study set out to better understand the feelings of stakeholders from the UK food packaging supply chain towards a move to circular economy (CE) systems. The research areas studied included current and future challenges facing supply chain stakeholders, the consideration of transformative technologies (TT) to enable packaging solutions in the move to CE systems and what CE systems using TT would look like for the UK's chilled food packaging sector. A questionnaire was selected to obtain data from across the UK food packaging supply chain. Participants were selected from six industry stakeholder groups, with 24 completing the questionnaire. This study has clearly shown there is a large spectrum of solutions in a move to CE, each with their own benefits and limitations. TT has an ability to enable these, but in selecting the best one for a specific packaging solution, a decision maker must take into consideration business constraints of the supply chain and the consumer's behaviour towards new solutions.     

露天爆破事故分析与安全管理研究

露天爆破具有应用范围广、炸药用量多、安全风险高和受环境影响大的特点.为避免爆破作业发生安全事故或引发民事纠纷,在进行露天爆破作业安全事故统计并具体分析典型案例的基础上,基于《爆破安全规程》规定,对露天爆破有害效应给出了计算方法,同时提出了预防露天爆破事故的安全技术措施和安全管理措施,以期提高爆破作业人员的技术水平和安全...     

Accident investigation reporting deficiencies related to organizational factors in machinery space fires and explosions

Careful accident investigation provides opportunities to review safety arrangements in socio-technical systems. There is consensus that human intervention is involved in the majority of accidents. Ever cautious of the consequences attributed to such a claim vis-à-vis the apportionment of blame, several authors have highlighted the importance of investigating organizational factors in this respect. Specific regulations to limit what were perceived as unsuitable organizational influences in shipping operations were adopted by the International Maritime Organization (IMO). Guidance is provided for the investigation of human and organizational factors involved in maritime accidents. This paper presents a review of 41 accident investigation reports related to machinery space fires and explosions. The objective was to find out if organizational factors are identified during maritime accident investigations. An adapted version of the Human Factor Analysis and Classification System (HFACS) with minor modifications related to machinery space features was used for this review. The results of the review show that organizational factors were not identified by maritime accident investigators to the extent expected had the IMO guidelines been observed. Instead, contributing factors at the lower end of organizational echelons are over-represented.     

Individual latent error detection: is there a time and a place for the recall of past errors?

A task carried out in error creates a latent condition that can result in a future undesirable outcome if the error is not detected later. The paper presents a study of the relatively under-researched phenomenon of post-task latent error detection. Focusing on UK naval aircraft maintenance, it was hypothesised that time, location and systems cues influence individual latent error detection amongst naval air engineers who experience the phenomenon. The systems view of human error is combined with a multi-process approach to post-task latent error research, for which findings suggest that distributed cognition across the entire socio-technical system may be influential in post-task latent error detection. Directions for future research will be of benefit to those interested in furthering safety resilience using a systems approach to minimise the consequences arising from latent error.

Relevance to human factors/ergonomics theoryThe nature and extent of post-task latent error detection is explored using a systems approach, for which distributed cognition across the entire socio-technical system appears influential. The aim of current research is to develop interventions to further mitigate for latent errors and thus advance the systems application of ergonomics theory.     

A critical view of severity classification in risk assessment methods

The knowledge of operational experts plays a fundamental role in performing safety assessments in safety critical organizations. The complexity and socio-technical nature of such systems produce hazardous situations which require a thorough understanding of concrete operational scenarios and cannot be anticipated by simply analysing single failures of specific functions. This paper addresses some limitations regarding state-of-the-art safety assessment techniques, with special reference to the adoption of “chain of event” models in accident causation (widely criticised by many authors), to the use of severity classes and to the adoption of the worst credible effect criterion. Such methods tend to assume a linear link between single hazards considered in isolation and corresponding consequences for safety, thus neglecting the intrinsic complexity of the systems under analysis and reducing the opportunities for an effective involvement of operational experts. An alternative approach is proposed to overcome these limitations, by distinguishing different typologies of hazards and integrating the analysis of single functions with the study of concrete operational scenarios.     

RiskSOAP: Introducing and applying a methodology of risk self-awareness in road tunnel safety

Complex socio-technical systems, such as road tunnels, can be designed and developed with more or less elements that can either positively or negatively affect the capability of their agents to recognise imminent threats or vulnerabilities that possibly lead to accidents. This capability is called risk Situation Awareness (SA) provision. Having as a motive the introduction of better tools for designing and developing systems that are self-aware of their vulnerabilities and react to prevent accidents and losses, this paper introduces the Risk Situation Awareness Provision (RiskSOAP) methodology to the field of road tunnel safety, as a means to measure this capability in this kind of systems. The main objective is to test the soundness and the applicability of RiskSOAP to infrastructure, which is advanced in terms of technology, human integration, and minimum number of safety requirements imposed by international bodies. RiskSOAP is applied to a specific road tunnel in Greece and the accompanying indicator is calculated twice, once for the tunnel design as defined by updated European safety standards and once for the ‘as-is’ tunnel composition, which complies with the necessary safety requirements, but calls for enhancing safety according to what EU and PIARC further suggest. The derived values indicate the extent to which each tunnel version is capable of comprehending its threats and vulnerabilities based on its elements. The former tunnel version seems to be more enhanced both in terms of it risk awareness capability and safety as well. Another interesting finding is that despite the advanced tunnel safety specifications, there is still room for enriching the safe design and maintenance of the road tunnel.     

Book review

The goal of this study is to extend Rasmussen's framework for risk management to research organisations having to deal with reduced income from government funding and increased market orientation. One human factors research organisation was studied in detail. Using archival records, changes were studied over the period 1989–2010. The results showed an increase in income from market funding relative to government funding, and a decrease in written output. Predictions by stress–strain theory were confirmed in that during the first 5 years of the period under consideration, a linear relationship between the increase in market funding and written output was observed, whereas a nonlinear relationship was observed in the next 5–10 years, indicating a larger decrease in written output than would be expected. Generally, the results show that research organisations are adaptive systems that trade off resource allocation to either commercial activities or scientific activities, depending on incentive schemes.     

Emergence,consolidation and dominance of meta-regimes: Exploring the historical evolution of mass production (1765–1972) from the Deep Transitions perspective

Grand environmental and societal challenges have drawn increasing attention to system innovation and socio-technical transitions. A recent Deep Transitions framework has provided a comprehensive theory of the co-evolutionary patterns of multiple socio-technical systems over the last 250 years. However, so far the framework has not been subjected to systematic empirical exploration. In this paper we address this gap by exploring the co-evolutionary model linking niche-level dynamics, transitions in single systems and ‘great surges of development’, as conceptualized by Schot and Kanger (2018) [1]. For this purpose, we conduct a case study on the historical evolution of mass production in the Transatlantic region from 1765 to 1972. Instead of focusing on dominant technologies or common practices the development of mass production is understood as the emergence of a meta-regime, i.e. a set of mutually aligned rules guiding production activities in multiple socio-technical systems. The results broadly confirm the overall model but also enable to extend the Deep Transitions framework by uncovering new mechanisms and patterns in the variation, diffusion and contestation of meta-regimes.     

Fatigue risk management: Organizational factors at the regulatory and industry/company level

This paper focuses on the development of fatigue risk management systems (FRMS) in the transport sector. The evolution of regulatory frameworks is traced, from uni-dimensional hours of service regulations through to frameworks that enable multi-dimensional FRMS. These regulatory changes reflect advances in understanding of human error in the aetiology of accidents, and in fatigue and safety science. Implementation of FRMS shifts the locus of responsibility for safety away from the regulator towards companies and individuals, and requires changes in traditional roles. Organizational, ethnic, and national culture need to be considered. Recent trends in the work environment have potential to adversely affect FRMS, including precarious employment and shortages of skilled labour. Essential components of an FRMS, and examples of FRMS in different transport modes, are described. It is vital that regulators, employer, and employees have an understanding of the causes and consequences of fatigue that is sufficient for them to meet their responsibilities in relation to FRMS. While there is a strong evidence base supporting the principles of FRMS, experience with implementation is more limited. The evidence base for effective implementation will expand, since FRMS is data-driven, and ongoing evaluation is integral. We strongly advocate that experience be shared wherever possible.     

Effective Safety Management: a Case Study in the Chemical Industry

A major non‐trivial problem within the area of industrial safety management today is to analyse, next to the safety impact of the technical equipment, the safety impact of a ‘business process’ as currently required by regulation and safety standards. This paper describes a case study of a pesticide company struggling with the question of how to improve the safety of their operational process further and at the same time also improve the reliability of their operational process. According to the literature ‘control of the business process’ is the keyword to improve the safety and reliability ‘performance’ of a company. A formal control model is proposed together with a classification system (using maturity levels) to analyse and qualify business processes with respect to their impact on process safety. This method has been applied in a case study where it resulted in a model of a business process. Using the model it was possible to classify the business process control system used and to identify related improvement opportunities. The proposed method showed that, in contrast to the company's perception, it was not the production department that was responsible for most of the problems but the peripheral processes relating to the production department. The interaction between departments caused not only potential safety problems, but also caused system reliability problems. For the company it was demonstrated that the interdependency of the (different activities in the‐) operational process is an essential element preventing further improvement if not addressed properly. Copyright © 2004 John Wiley & Sons, Ltd.     

Identifying risks and emergent risks across sociotechnical systems: the NETworked hazard analysis and risk management system (NET-HARMS)

Accidents are a systems phenomenon and multiple methods are available to enable retrospective analysis of accidents through this lens. However, the same cannot be said for the methods available for forecasting risk and accidents. This paper describes a new systems-based risk assessment method, the NETworked hazard analysis and risk management system (NET-HARMS), that was designed to support practitioners in identifying (1) risks across overall work systems, and (2) emergent risks that are created when risks across the system interact with one another. An overview of NET-HARMS is provided and demonstrated through a case study application. An initial test of the method is provided by comparing case study outcomes (i.e. predicted risks) with accident data (i.e. actual risks) from the domain in question. Findings show that NET-HARMS is capable of forecasting systemic and emergent risks and that it could identify almost all risks that featured in the accidents in the comparison data-set.     

Using cognitive work analysis to explore system flexibility

The presented work describes a structured approach for identifying flexible working practices in complex socio-technical systems; further, it presents a framework for the elicitation of design changes capable of increasing system adaptability. The proposed approach uses the first three phases of the cognitive work analysis framework: work domain analysis; control task analysis; and strategies analysis. Functions are extracted from an abstraction hierarchy; these are then explored in a number of different situations using a contextual activity template. These functions are then explored in greater detail with the strategies analysis phase. The contextual activity template is used to identify situations where functions are unable to perform; in order to increase the flexibility of the system, new strategies are then proposed and represented in strategies analyses flow diagrams. To communicate the approach, it is introduced using the familiar, domestic domain of an ‘Apple iPod’. The paper presents a structured approach based upon cognitive work analysis for exploring system flexibility. The case study presented, an Apple iPod, shows how design changes to the system can be informed by this approach. This paper takes an existing approach and clarifies the link between analysis and design.     

Lifted Brownian Kriging Models

Gaussian processes have become a standard framework for modeling deterministic computer simulations and producing predictions of the response surface. This article investigates a new covariance function that is shown to offer superior prediction compared to the more common covariances for computer simulations of real physical systems. This is demonstrated via a gamut of realistic examples. A simple, closed-form expression for the covariance is derived as a limiting form of a Brownian-like covariance model as it is extended to some hypothetical higher-dimensional input domain, and so we term it a lifted Brownian covariance. This covariance has connections with the multiquadric kernel. Through analysis of the kriging model, this article offers some theoretical comparisons between the proposed covariance model and existing covariance models. The major emphasis of the theory is explaining why the proposed covariance is superior to its traditional counterparts for many computer simulations of real physical systems. Supplementary materials for this article are available online.