FRAM for systemic accident analysis: a matrix representation of functional resonance

Due to the inherent complexity of nowadays Air Traffic Management (ATM) system, standard methods looking at an event as a linear sequence of failures might become inappropriate. For this purpose, adopting a systemic perspective, the Functional Resonance Analysis Method (FRAM) originally developed by Hollnagel, helps identifying non-linear combinations of events and interrelationships. This paper aims to enhance the strength of FRAM-based accident analyses, discussing the Resilience Analysis Matrix (RAM), a user-friendly tool that supports the analyst during the analysis, in order to reduce the complexity of representation of FRAM. The RAM offers a two dimensional representation which highlights systematically connections among couplings, and thus even highly connected group of couplings. As an illustrative case study, this paper develops a systemic accident analysis for the runway incursion happened in February 1991 at LAX airport, involving SkyWest Flight 5569 and USAir Flight 1493. FRAM confirms itself a powerful method to characterize the variability of the operational scenario, identifying the dynamic couplings with a critical role during the event and helping discussing the systemic effects of variability at different level of analysis

A monte carlo evolution of the functional resonance analysis method (FRAM) to assess performance variability in complex systems

Modern trends of socio-technical systems analysis suggest the development of an integrated view on technological, human and organizational system components. The Air Traffic Management (ATM) system can be taken as an example of one of the most critical socio-technical system, deserving particular attention in managing operational risks and safety. In the ATM system environment, the traditional techniques of risk and safety assessment may become ineffective as they miss in identifying the interactions and couplings between the various functional aspects of the system itself: going over the technical analysis, it is necessary to consider the influences between human factors and organizational structure both in everyday work and in abnormal situations. One of the newly introduced methods for understanding these relations is the Functional Resonance Analysis Method (FRAM) which aims to define the couplings among functions in a dynamic way. This paper evolves the traditional FRAM, proposing an innovative semi-quantitative framework based on Monte Carlo simulation. Highlighting critical functions and critical links between functions, this contribution aims to facilitate the safety analysis, taking account of the system response to different operating conditions and different risk state. The paper presents a walk-through section with a general application to an ATM process

Framing the FRAM: A literature review on the functional resonance analysis method

The development of the Functional Resonance Analysis Method (FRAM) has been motivated by the perceived limitations of fundamentally deterministic and probabilistic approaches to understand complex systems’ behaviour. Congruent with the principles of Resilience Engineering, over recent years the FRAM has been progressively developed in scientific terms, and increasingly adopted in industrial environments with reportedly successful results. Nevertheless, a wide literature review focused on the method is currently lacking. On these premises, this paper aims to summarise all available published research in English about FRAM. More than 1700 documents from multiple scientific repositories were reviewed through a protocol based on the PRISMA review technique. The paper aims to uncover a number of characteristics of the FRAM research, both in terms of the method's application and of the authors contributing to its development. The systematic analysis explores the method in terms of its methodological aspects, application domains, and enhancements in qualitative and quantitative terms, as well as proposing potential future research directions

Environmental Audit improvements in industrial systems through FRAM

Environmental risk management requires specific methodologies to focus audit activities on the most critical elements of production systems. Limited resources require a clear motivation to put attention on specific technological, human, organizational components, and often should address the monitor of interactions among these elements. Recent research in environmental risk looks at methods to deal with complexity as interesting tools to reduce real impacts on pollution and consumption. In this paper, we provide evidence of the advantage in using the Functional Resonance Analysis Method (FRAM), not only to identify the criticalities of a complex production system but to provide a methodology to continuously improve the audit activities in parallel with the introduction of technique to reduce environmental risk. The case study presents the evolution of environmental audit in a sinter plant, proving the need for a review of the criticality list and the successful application of FRAM to refocus the control activities

System Safety Assessment of the Warehouse Operation Using Functional Resonance Analysis Method and Resilience Analysis Grid

This study applied the perspective of Safety-II using the Functional Resonance Analysis Method (FRAM) and the Resilience Analysis Grid (RAG) to analyze safety in warehouse operations from a system perspective. FRAM was used to emphasize what caused things to go right, with the findings highlighting higher performance and safety variability occurring in activities that require multiple individual or group efforts. RAG was used to assess the organization’s potential to handle unexpected occurrences, identify the potential resilience of the warehouse in its daily activities, and evaluate the ability to maintain flow and worker safety based on four pillars of resilience. The assessment resulted in a value of 3.50 in the ability to respond, 2.84 in the ability to monitor, 3.88 in the ability to learn, and 3.21 in the ability to anticipate. Combining FRAM and RAG enhances the depth of a new perspective of safety analysis and addresses resilience factors in daily operations

Risk Assessment of Launching Airbags Using Functional Resonance Accident Model

‘Ship Launching Airbags’ can greatly increase the economic benefits of a new gravitational launching operation. Gravitational launching of a new ship with marine airbags takes into account the resistance force of rolling friction. However, a launching operation is a high-risk process, as it involves many risk factors. In this paper, Functional Resonance Accident Model (FRAM) was used systematically to identify potential risks and carry out the risk analysis of the ship launching operation. The human factor, technical factors, and organisational factors were identified based on the common performance conditions of FRAM. Functional performance changes, prevention, and hazard control barriers were evaluated to identify key operations. The results show that the ship launching operation is characterized by high collision, decreasing stability, and the need for the use of airbags

Poenotenje medaspektnih povezav v metodi FRAM

With a growing complexity of socio-technical systems and event outcomes that cannot be understood in terms of causality, traditional accident modelling approaches are no longer adequate to analyse accidents in such systems. Thus, in recent years novel systemic approaches have been developed. Functional Resonance Analysis Method (FRAM) is a means to understand how seemingly small performance variations of functions in a complex socio-technical system coincide and mutually affect each other in unexpected ways resulting in the functional resonance. A FRAM model consists of essential system functions, each characterised by six aspects. The functional resonance is defined based on couplings among aspects. Currently, the method provides only a general classification of couplings: Matter, Energy or Information (MEI). Such classification prevents an analytical view on the complex structure of relations in observed socio-technical systems and permits the construction of non-uniform models. This thesis, thus, seeks to unify FRAM models by developing a classification scheme of inter-functional couplings. The proposed MEDI classification helps to maximise compatibility, safety and quality of FRAM models in general. It represents one of the necessary steps towards the method automatisation.Ob vse večji zapletenosti socio-tehničnih sistemov in izidov dogodkov, ki jih ni mogoče razumeti z vidika vzročnosti, tradicionalne metode za modeliranje nesreč v takšnih sistemih ne ustrezajo več. V zadnjih letih so bili zato razviti novi analitični pristopi. Metoda FRAM ali metoda analize funkcijske resonance je metodologija, ki omogoča razumevanje, kako na videz majhne variacije delovanja funkcij v zapletenem socio-tehničnem sistemu sovpadajo in medsebojno vplivajo na nepričakovane načine, ki povzročijo funkcijsko resonanco. Model FRAM sestavljajo ključne sistemske funkcije, opisane s šestimi aspekti. Funkcijska resonanca je opredeljena na podlagi povezav med funkcijami. Trenutno metoda ponuja le splošno klasifikacijo povezav: Materija, Energija ali Informacija (MEI). Takšna klasifikacija onemogoča analitični pogled na zapleteno strukturo relacij v opazovanem sistemu in dopušča gradnjo nepoenotenih modelov. Cilj pričujočega dela je poenotiti modele FRAM z razvojem klasifikacijske sheme medaspektnih povezav. Predlagana nova klasifikacija medaspektnih povezav MEDI pripomore k večji združljivosti, varnosti in kakovosti modelov FRAM na splošno, ter predstavlja enega od potrebnih korakov k avtomatizaciji metode

Study on Developments in Accident Investigation Methods: A Survey of the "State-of-the-Art

Available on: http://www.stralsakerhetsmyndigheten.se/Global/Publikationer/Rapport/Sakerhet-vid-karnkraftverken/2008/SKI-Rapport-2008-50.pdfSKI Report 2008:50 (Swedish Nuclear Power Inspectorate) - ISSN 1104-1374The objective of this project was to survey the main accident investigation methods that have been developed since the early or mid-1990s. The motivation was the increasing frequency of accidents that defy explanations in simple terms, for instance cause-effect chains or “human error”. Whereas the complexity of socio-technical systems is steadily growing across all industrial domains, including nuclear power production, accident investigation methods are only updated when their inability to account for novel types of accidents and incidents becomes inescapable. Accident investigation methods therefore typically lag behind the socio-technological developments by 20 years or more

Using FRAM beyond safety: A case study to explore how sociotechnical systems can flourish or stall

FRAM (Functional Resonance Analysis Method) is a relatively new method that has been proposed to explore how functional variability can escalate into unexpected, and often unwanted, events. It has been used for accident analyses and risk assessments in safety. We apply (and slightly modify) FRAM, to analyse how functions are configured to create systems that excel. Our case study focuses on how functions in human factors project work positively resonate to improve the delivery of value. From interviews with 22 practitioners we derived 29 functions and 6 subsystems showing how functions are coupled. Practitioners validated this model through respondent validation. Our case study evaluates the applicability and usability of FRAM. It shows how we adapted the method to make it more usable. It shows that FRAM can be used to examine positive and negative resonance in systems, to investigate how complex sociotechnical systems can flourish or stall.This work was supported by the UK Engineering and Physical Sciences Research Council under Grant [GR/S67494/01], [GR/S67500/01] and [EP/G059063/1

Introduction to the use of fram on the effectiveness assessment of a radiopharmaceutical dispatches process

This article aims to make an introduction to the use of Functional Resonance Analysis Method (FRAM) on the effectiveness assessment of a specific radiopharmaceutical dispatching process. The main purpose was to provide a didactic view of the method application to further in-depth analysis. The investigation also provided a relevant body of knowledge of radiopharmaceuticals dispatches processes. This work uses the term ‘effectiveness assessment’ instead of ‘risk assessment’ due to the broader meaning the former provide. The radiopharmaceutical dispatching process is the final task of a dynamic system designed to attend several medical facilities. It is comprised by functions involving mostly human activities, such as checking and packaging the product and measuring the radiopharmaceutical nuclear activity. Although the dispatch process has well-known steps for its completion, the human factor is the fundamental mechanism of work and control, being susceptible of irregular and instable performance. As a socio-technical system, the risk assessment provided by FRAM may be of importance for safety and quality improvements, even more if considered the nuclear nature of the product, which makes risk assessment critical and mandatory. A system is safe if it is resistant and resilient to perturbations. Identification and assessment of possible risks is, therefore, an essential prerequisite for system safety. Although this seems obvious, most risk assessments are conducted under relative ignorance of the full behavior of the system. Such condition has lead to an approach to assess the risks of intractable systems (i.e., systems that are incompletely described or underspecified), namely Resilience Engineering. Into this area, the Functional Resonance Analysis Method has been developed in order to provide concepts, terminology and a set of methods capable of dealing with such systems. The study was conducted following the Functional Resonance Analysis Method. At first, the functions of the radiopharmaceutical dispatches process were identified and described as required for everyday performance to succeed, than for every function the essentials aspects for the function to be carried out were described. After that, some scenarios or instantiations of the model were analyzed in order to propose ways to monitor and dampen performance variability