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The increasing complexity in highly technological systems such as aviation, maritime, air traffic control, telecommunications, nuclear power plants, defence and aerospace, chemical and petroleum industry, and healthcare and patient safety is leading to potentially disastrous failure modes and new kinds of safety issues. Traditional accident modelli...
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... to this theory there are five factors in the accident sequence: 1) social environment (those conditions which make us take or accept risks); 2) fault of the person; 3) unsafe acts or conditions (poor planning, unsafe equipment, hazardous environment); 4) accident; 5) injury. These five factors are arranged in a domino fashion such that the fall of the first domino results in the fall of the entire row (Figure 1). This illustrates that each factor leads to the next with the end result being the injury. ...
Citations
... Moreover, they require all involved parties, especially those in higher layers, to be receptive to absorbing the lessons learned, as management process flaws are often identified, even indirectly. Qureshi (2008) emphasizes AcciMap's foundation on Rasmussen's risk management framework, using functional abstraction models to understand adaptable sociotechnical systems. These models illustrate information flow in hazardous process control systems. ...
This study proposes the use of the Accident Mapping Method (AcciMap) from a fresh perspective, as a management support tool for systemic analyses. The idea put forth is that, during a comparative analysis of various AcciMap graphs collected from accidents/incidents sharing the same organizational links, the recurring and common elements/factors found in those graphs may indicate systemic failures. By observing the mapping of recurring and common elements/factors among the AcciMaps, involvements and responsibilities can be specified. Actions (direct or indirect) that may not have been previously identified or recognized as contributing elements/factors to increased risks in the overall framework become apparent. Illustratively, the study delves into the histories of two sounding rocket launch campaigns for microgravity me. These campaigns, involving VS-30 XV06 and VSB-30 V04 sounding rockets, address intricate sociotechnical systems. Each sounding rocket carries a microgravity platform responsible for housing scientific and technological experiments, supporting functions such as power supply and data communication (downlink/uplink). Additionally, it features a stabilization system (to establish the microgravity environment) and a parachute recovery system. Unfortunately, both launch campaigns were unsuccessful in retrieving their platforms from sea recovery.
... In this way, the achievement of organizational objectives is generally complex and non-linear, and cannot be achieved only by optimizing technical systems, but rather by simultaneously optimizing technical and social aspects. As an immediate consequence, traditional modeling or analysis approaches cannot accurately and completely assess the behaviors and failure modes of such systems (Qureshi, 2008), meaning that a space system belongs to this group decisively. ...
This study reinterprets the Apollo 13 accident as a complex sociotechnical system. It focuses on the critical moment, analyzing the crew's perception of the accident until the ground team's decision to abort the mission. The approach to implementing this proposal followed the perspective of Naturalistic Decision Making (NDM) with the objective of using the Perceptual Cycle Model (PCM) originating from an analysis of the Systems Theoretical Accident and Process Model (STAMP) to highlight the importance from the experience of everyone involved during need-to-action phases when time and resources have become increasingly limited. By applying both models, it was possible to visualize the sequence of occurrences considering the theoretical principles of naturalistic thinking, since the accident did not have a single cause and was not limited to unilateral resolutions by the crew. The study brought a unique perspective that has not yet been explored in depth in the literature regarding the use of decision-making models in a historical space context.
... The field of human factors considers how and why systems meet or fall short of performance expectations, with an emphasis on understanding and prevention of incidents and failures. In this context, systems, such as dam systems, are understood to be dynamic sociotechnical systems consisting of both physical and human elements (Blockley, Pidgeon, and Turner 1987;Qureshi 2008;Rasmussen 1997;Walker 2015). ...
... The field of human factors has advanced and evolved during the past few decades, and the references for this paper include a selected sample of the literature (Catino 2013;Dekker 2005;Dorner 1997;Hollnagel 2004;2014;Hollnagel, Woods, and Leveson 2006;Leveson 2011;Patankar et al. 2001;Perrow 1999;Pidgeon and O'Leary 2000;Qureshi 2008;Rasmussen 1997;Reason 1990;Rosness et al. 2010;Senders and Moray 1991;Strauch 2002;Weick and Sutcliffe 2015;Woods et al. 2010;Woods and Cook 2002). ...
... Instead, they may be complex and involve nonlinear relationships, feedback loops, causes having multiple effects, effects having multiple causes, cascading effects, emergent properties, unforeseen interdependencies, unforeseen failure modes, and a lack of distinct root causes or dominant contributing factors (Dekker 2006;Dorner 1997;Qureshi 2008;Strauch 2002). . Interactions among physical and human factors usually generate warning signs which are not recognised, or not sufficiently acted upon, prior to the failure (Weick and Sutcliffe 2015). . ...
... Turner (1994) analyzed serious technical accidents and concluded that approximately 20 to 30% of the factors of accidents were technical, with 80% involving social, administrative, or managerial factors. A series of studies the search on air and maritime accidents in Qureshi (2008) highlighted human and organizational factors as the main contributors to accidents and incidents. ...
This article presents Training Assessment: Prevention of Major Accidents through the Approach of Proactive Safety, Risks, and Emergencies (APSRE), for senior, full, junior, and undergraduate professionals and university graduate and postgraduate students, with the aim of improving the way thinking about a Proactive Safety Environment. With the development of research on Risk Management and the conception of the Proactive Safety Approach, with the aim of preventing major accidents and the damage arising from these events, the need to train people in organizations was verified, to support the survey and research of information, warning signs, analysis of proactive safety demands, planning, and development of actions, for the prevention of these major accidents, which are historically recurrent. The training for this course is made up of four free online consultation modules and is hosted on the Internet. The course presents in Module 1, an introductory basis, in Module 2, the theory of accidents, in Module 3, case studies of major accidents in the world, and in Module 4, activities and exercises to prevent and mitigate these major accidents. After the creation of this course, training was developed individually and in classes. In total, 12 classes of the Risk Management and Major Accident Prevention Course were trained, around 250 people in the class format, and around 50 people individually, totaling 300 people. The qualification of the Course Management of Risks and Prevention of Major Accidents, according to the validation presented in this article, can be used to meet different profiles, for senior professionals with knowledge in this subject, the qualification can be propitious for debates and reflections, for the full levels, training can be conducive to deepening the concepts and proposals, for junior levels and students, training can provide an initial base of learning for development in Risk Management and Major Accident Prevention. Conventional risk assessments can be reassessed, due to the contents presented in this article, and the Approach of Proactive Safety, Risks, and Emergencies (APSRE) through the presented framework, can be used to supplement conventional risk assessments.
... Uma série de estudos sobre acidentes aéreos e marítimos, em Qureshi (2008), mostraram que os fatores humanos e organizacionais como os principais contribuintes para acidentes e incidentes. Uma análise dos principais acidentes aéreos e marítimos na América do Norte durante 1996-2006 e concluíram que a proporção de fatores causais e contribuintes relacionados a questões organizacionais excede aqueles devidos a erro humano. ...
A proposta deste livro, apresenta a contribuição da Engenharia de Segurança, da Ergonomia e de outras áreas do conhecimento, para fundamentar a capacitação em gestão da segurança em organizações, utilizando a Abordagem da Segurança Proativa, para prevenir e mitigar Acidentes Maiores, tais como os casos da explosão do ônibus espacial Challenger, do acidente nuclear em Fukushima, da Refinaria Texas City e da explosão no Porto de Beirute, dentre outros. Esta capacitação pode ser utilizada por profissionais seniores, titulares, juniores e estudantes, com o objetivo de aprimorar a maneira de pensar sobre um ambiente de segurança proativo.
Para se propor esta capacitação, foram desenvolvidos estudos de casos em organizações, setores e atividades, uma revisão bibliográfica em trabalhos, dissertações, relatórios de órgãos reguladores, livros, artigos científicos e matérias da mídia, sobre acidentes maiores no Brasil e no exterior, e sobre engenharia de segurança, ergonomia e abordagem sociotécnica.
A capacitação deste curso é composta por quatro módulos de consulta online gratuitos e está hospedada na internet. O curso apresenta no Módulo 1, uma base introdutória, no Módulo 2, a teoria dos acidentes, no Módulo 3, estudos de caso de acidentes maiores no mundo, e no Módulo 4, atividades e exercícios para prevenir e mitigar esses acidentes maiores.
Esta capacitação redireciona o foco do erro humano para o foco no Sistema Sociotécnico Estruturado; na Gestão Dinâmica da Segurança e na Visão Sistêmica da Segurança com as outras Áreas da Organização.
Se propõem que, com a capacitação preconizada neste trabalho, e com a aplicação destes três princípios e a utilização do Framework da Abordagem da Segurança Proativa, possam fornecer bases para análises e planejamento de ações, com o intuito de prevenir e minimizar Eventos Negativos Maiores e Fatais, e podem ser um complemento para avaliações de risco tradicionais.
Que esta contribuição possa ajudar profissionais e organizações a aprimorar a Gestão da Segurança.
... Single-factor models attribute incidents to one distinct event (e.g., an attack, a technical or human error), while linear models assume failures at multiple (but interconnected) levels. As socio-technical systems became more complex, more holistic causation models were developed to replace previous post hoc descriptions of incidents by cause-effect modelling (Qureshi, 2008). Cultural and Management Models focused on how organizational culture and management contribute to incidents or prevent them, while systemic models viewed incidents as sometimes inevitable and attributed their occurrence and severity to inadequate control systems or insufficient organizational resilience. ...
... However, it is important to recognize that they are not infallible and may not always include all contributing factors to an incident. For example, their capacity to explain incident causation in more complex systems is limited (Qureshi, 2008). Historically, these models often label what cannot be attributed to technical failures as "human error." ...
... In more complex linear models, also known as "epidemiological models," causes may not always be manifest but instead may be latent, and "defenses" or "barriers" may prevent incidents from happening, like a functioning immune system. Some researchers have argued that organizational incidents do not arise solely due to a single human error but instead result from the interconnectedness of several latent factors originating at many levels within an organization (Qureshi, 2008). In the "Swiss Cheese Model," an incident may also have latent organizational factors that are difficult to observe, such as time pressure, understaffing, or inadequate equipment, that only become visible when combined with active failures (James Reason 1990). ...
In the aftermath of cybersecurity incidents within organizations, explanations of their causes often revolve
around isolated technical or human events such as an Advanced Persistent Threat or a “bad click by an
employee.” These explanations serve to identify the responsible parties and inform efforts to improve security
measures. However, safety science researchers have long been aware that explaining incidents in socio-technical
systems and determining the role of humans and technology in incidents is not an objective procedure but rather
an act of social constructivism: what you look for is what you find, and what you find is what you fix. For
example, the search for a technical “root cause” of an incident might likely result in a technical fix, while from a
sociological perspective, cultural issues might be blamed for the same incident and subsequently lead to the
improvement of the security culture. Starting from the insights of safety science, this paper aims to extract
lessons on what general explanations for cybersecurity incidents can be identified and what methods can be used
to study causes of cybersecurity incidents in organizations. We provide a framework that allows researchers and
practitioners to proactively select models and methods for the investigation of cybersecurity incidents.
... Traditional safety systems are effective but often rely on reactive approaches (Hollnagel, 2018) (Qureshi, 2008). The introduction of AI and data-driven methods can revolutionize reactor safety by enabling predictive measures (Jiang et al., 2018). ...
Nuclear power plays a vital role in meeting global energy demands, but ensuring the safety of nuclear reactors remains a paramount challenge. In recent years, the emergence of artificial intelligence (AI) technologies has opened new avenues to significantly enhance nuclear reactor safety through predictive anomaly detection and risk assessment. This research proposes an innovative AI-driven approach that integrates machine learning techniques and data analytics to monitor, detect, and assess potential anomalies in nuclear reactors. The research begins with a comprehensive literature review on nuclear reactor safety and the application of AI in various industrial domains, emphasizing predictive maintenance and anomaly detection. It highlights the need for an AI-driven approach to enhance nuclear reactor safety proactively. In conclusion, this research establishes the transformative potential of AI in enhancing nuclear reactor safety. The proposed AI-driven approach empowers operators with powerful tools to ensure the safe and efficient operation of nuclear power plants. As AI technologies continue to advance, the research opens doors for further exploration and development, paving the way for a more sustainable and secure future in nuclear energy production.
... As reported by industry practitioners, most hazard analyses are performed using traditional methods, such as FMEA, FTA, and ETA. These techniques are based upon linear accident causality models, which are not well suited for incorporating complex and non-linear relationships between different elements of a system (Qureshi, 2008). Various authors have highlighted that these techniques have serious limitations in the analysis of modern complex systems (Dallat et al., 2019;Leveson, 2017;Qureshi, 2008). ...
... These techniques are based upon linear accident causality models, which are not well suited for incorporating complex and non-linear relationships between different elements of a system (Qureshi, 2008). Various authors have highlighted that these techniques have serious limitations in the analysis of modern complex systems (Dallat et al., 2019;Leveson, 2017;Qureshi, 2008). Leveson (2017) explained that since these traditional methods have been developed, the systems have witnessed dramatic changes, such as increased complexity; therefore, new methods are needed. ...
While many hazard analysis techniques exist, little empirical research has been dedicated to their use in industrial contexts, in particular concerning how practitioners validate hazard analyses. This raises questions about the accuracy, comprehensiveness, and credibility of safety analyses, and how practitioners consider this issue in relation to the overall system safety work. Acquiring qualitative evidence regarding the validation of hazard analysis among practitioners is important to support evidence-based safety practices. This paper qualitatively investigates the state of practice in hazard analysis and its validation for system safety among practitioners. Twenty semi-structured interviews were conducted with practitioners in safety–critical industries in North America. Feedback from practitioners indicates that only a limited number of hazard analysis methods are applied in industry, which are mainly based upon linear accident theory. It is also found that almost all practitioners perform some form of validation as they believe this type of safety work improves safety. Experts Reviews and benchmark exercises are the only methods reported for validating hazard analysis. In addition, practitioners highlighted several weaknesses of the current hazard analysis and hazard analysis validation practices, of which subjectivity is seen as the most important one. The authors discuss this in context of the emerging academic consensus that hazard analysis is inherently subjective, but that it can nevertheless be very useful especially when it relies on strong evidence. Also, several opportunities for organizations, regulatory bodies, and academic institutions are identified to improve the current state of the practice in both hazard analysis and hazard analysis validation.
https://www.sciencedirect.com/science/article/abs/pii/S092575352300022X?dgcid=author#t0005
... A series of studies on air and maritime accidents in Qureshi (2008) showed human and organizational factors as the main contributors to accidents and incidents. An analysis of major air and maritime accidents in North America during 1996-2006 concluded that the proportion of causal and contributing factors related to organizational issues exceeds those due to human error. ...
This proposal presents the Sociotechnical Construction of Risks, Ergonomics, and the two 14 principles of the Proactive Approach to Safety, Risks, and Emergencies, the Structured 15 Sociotechnical Approach and Dynamics of Proactive Safety intending to complement traditional 16 risk assessments, and prevent and Mitigating Major and Fatal Negative Events, the in organizations 17 such as cases of the explosion of the space shuttle Challenger, the nuclear accident in Fukushima, 18 the Texas City Refinery and the explosion in the Port of Beirut, among others. To propose these two 19 principles, case studies were developed at Fiocruz, and in organizations, sectors, and activities, a 20 bibliographic review on theses, dissertations, reports from regulatory bodies, books, scientific 21 articles, and media articles, on major and fatal negative events, and ergonomics, socio-technical 22 approach, and resilience engineering. A tragedy prevention course was created, with four free 23 online consultation modules, based on cases of major negative events. These principles redirect the 24 focus from human error to Focus on the Structured Sociotechnical System and Focus on the 25 Dynamics of Proactive Safety. It is proposed that these two principles can provide us with bases for 26 analysis, to prevent and minimize Major and Fatal Negative Events, and are a complement to 27 traditional risk assessments. 28
... (Zheng, Jiang, Zhou, & Xue, 2022) proposed a novel spatiotemporal ship domain to improve risk assessment. Complex nature of maritime accidents (Qureshi, 2008) have been studied in the scope of globally scalable methodologies' ...
... According to (Qureshi, 2008) each study in the literature can be classified under three major accident theory subtypes, namely complex linear theory, relational theory and systemic theory based on. In complex linear theory, accidents are explained as a sequence of individual events where cause and effect are present. ...
As the maritime traffic is getting denser, the number of encounters is increasing. The aim of this study is to develop a prediction model to classify encounters as risky or non-risky when two ships encounter in a certain buffer zone. A novel methodology is proposed to integrate three-dimensional clustering in the algorithm training process. K-means clustering, and ensemble machine learning algorithms-based prediction framework is developed to overcome class imbalance. The methodology is tested in the Strait of Istanbul (SOI) and parameters are generated from a long-term AIS dataset. Framework is validated via cross validation techniques. Precision, Recall, Accuracy and ROC-AUC Score are used as measures to evaluate models. Benchmark models are generated, and the most advanced model successfully predicts each 4 out of 5 risky encounters without the knowledge of distance between two ships. Eliminating distance from decision factors provides an action period before risky encounters. Therefore, proposed framework can be a guide for autonomous vessels for safe navigation and maritime authorities to improve maritime safety.
