This page will provide examples of practical applications of the FRAM. Such examples will hopefully answer some - or even many - of the questions that newcomers undoubtedly will have. The examples will also illustrated the broad applicability of the method.

Details of specific examples may be found under publications.

Accident investigations in aviation

  • Sawaragi, T., Horiguchi, Y. & Hina, A. (2006). Safety analysis of systemic accidents triggered by performance deviation. In: IEEE SICE-ICASE, International Joint Conference, pp. 1778–1781.
  • Woltjer, R. (2007). A systemic functional resonance analysis of the Alaska Airlines flight 261 accident. Human Fact. Econ. Aspects Saf., 83
  • Hollnagel, E., Pruchnicki, S., Woltjer, R., et al., 2008. Analysis of Comair flight 5191 with the functional resonance accident model. In: Proceedings of the 8th International Symposium of the Australian Aviation Psychology Association.

(Hollnagel et al., 2008), as well as medical

accidents, for example, ‘‘Dukibuk” (The Sponge in the Abdomen)

(Alm, 2008). Also, it is suitable for application on safety

assessment for systems such as the area navigation (RNAV) operations

(Hollnagel, 2004), a local mail distribution center (Bergqvist

et al., 2007), a nuclear power plant (Lundblad and Speziali, 2007),

the medicine handling at a pharmacy (Mathiesen et al., 2008),

nuclear fuel transportation (Lundblad et al., 2008), railway traffic

supervision (Belmonte et al., 2011), command and control

(Woltjer et al., 2007a, 2007b, 2009; Woltjer, 2009), and, most

remarkably, air traffic management (Macchi et al., 2008, 2010;

Woltjer and Hollnagel, 2008a,b; Sonnerfjord, 2011; De Carvalho,

2011). In recent years, FRAM was applied on the assessment of a

radiopharmaceutical dispatches process (Pereira, 2013), an offshore

platform (Åhman, 2013), the Fukushima Disaster

(Hollnagel and Fujita, 2013), organizational change (Hollnagel,

2013), an oil process unit (Shirali and Ebrahipour, 2014) and an

operations control center (Frost and Mo, 2014).

By the beginning of 2014, the FRAM has been used in domains as varied as aviation, air traffic management, maritime transportation, nuclear power plants, railroads, health care, organisational change, and building and contruction. It is, however, not always possible to provide documentation on this website. One reason may be that the work is propietary; the applications are by their nature practical rather than academic. Another may be language difficulties; there are, for instance several reports available in Danish, but these will hardly be useful for non-Danish readers.

To be continued ...


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