The Sandbox Facility
Extending the capabilities of the FMV
There is an increasing interest in utilising the FRAM approach for the analysis of what exactly is going on in complex sociotechnical systems in practical high hazard environments. There are, for example, a number of ongoing projects at the moment in aviation, self-driving vehicles and, of course, on the challenges of the COVID 19 pandemic for healthcare responses. But as well as these practical applications there is an increasing interest from the academic community, in extending and developing further, the underpinning concepts, as shown below.
Accou, B., & Reniers, G. (2019). Developing a method to improve safety management systems based on accident investigations: The Safety FRactal ANalysis. Safety Science, 115, 285–293.
Adriaensen, A., Patriarca, R., Smoker, A., & Bergström, J. (2019). A sociotechnical analysis of functional properties in a joint cognitive system: A case study in an aircraft cockpit. Ergonomics, 62, 1–48.
Aguilera, M. V. C., da Fonseca, B. B., Ferris, T. K., Vidal, M. C. R., &de Carvalho, P. V. R. (2016). Modelling performance variabilities in oil spill response to improve system resilience. Journal of Loss Prevention in the Process Industries, 41, 18–30.
Albery, S., Borys, D., & Tepe, S. (2016). Advantages for risk assessment: Evaluating learnings from question sets inspired by the FRAM and the risk matrix in a manufacturing environment. Safety Science, 89,180–189.
Alvarenga, M. A. B., e Melo, P. F. F., & Fonseca, R. A. (2014). A critical review of methods and models for evaluating organizational factors in Human Reliability Analysis. Progress in Nuclear Energy,75, 25–41.
Anderson, N, Carson- Stevens, A, Krishnan, R, Ayres, T, Kumar, M, Slater, D. “"Applying the Functional Resonance Analysis Method (FRAM) to Minimize Hospital-acquired COVID-19 Infection in the Emergency Department.," submitted to Annals of Emergency Medicine.
Anvarifar, F., Voorendt, M. Z., Zevenbergen, C., & Thissen, W. (2017). An application of the Functional Resonance Analysis Method (FRAM) to risk analysis of multifunctional flood defences in the Netherlands. Reliability Engineering & System Safety, 158, 130–141.
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 traffic supervision. Reliability Engineering & System Safety, 96(2), 237–249.
Bergström, J., Van Winsen, R., & Henriqson, E. (2015). On the rationale of resilience in the domain of safety: A literature review. Reliability Engineering & System Safety, 141, 131–141.
Bjerga, T., Aven, T., & Zio, E. (2016). Uncertainty treatment in risk analysis of complex systems: The cases of STAMP and FRAM. Reliability Engineering & System Safety, 156, 203–209.
Bridges, K. E., Corballis, P. M., & Hollnagel, E. (2018). “Failure‐to‐Identify “hunting incidents: A resilience engineering approach. Human Factors,60(2), 141–159.
Buikstra, E., Strivens, E., & Clay‐Williams, R. (2020). Understanding variability in discharge planning processes for the older person. Safety Science, 121, 137–146.
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. Implementation Science, 10(1), 125.
Costantino, F., Di Gravio, G., & Tronci, M. (2018). Environmental audit improvements in industrial systems through FRAM. IFACPapersOnLine,51(11), 1155–1161.
Dallat, C., Salmon, P. M., & Goode, N. (2017). Risky systems versus risky people: To what extent do risk assessment methods consider the systems approach to accident causation? A review of the literature. Safety Science.
Damen, N. L., de Vos, M. S., Moesker, M. J., Braithwaite, J.,de Lind van Wijngaarden, R. A. F., Kaplan, J., Hamming, J. F., & Clay‐Williams, R. (2018). Preoperative anticoagulation management in everyday clinical practice: An International comparative analysis of
work-as-done using the functional resonance analysis method. Journal of Patient Safety, 14(2), DOI: 10.1097/PTS.0000000000000515
De Carvalho, P. V. R. (2011). The use of Functional Resonance Analysis Method (FRAM) in a mid‐air collision to understand some characteristics of the air traffic management system resilience. Reliability Engineering & System Safety, 96(11), 1482–1498.
de Vries, L. (2017). Work as done? Understanding the practice of sociotechnical work in the maritime domain. Journal of Cognitive Engineering and Decision Making, 11(3), 270–295.
Dekker, S., Cilliers, P., & Hofmeyr, J.‐H. (2011). The complexity of failure: Implications of complexity theory for safety investigations. Safety Science, 49(6), 939–945.
Duan, G., Tian, J., & Wu, J. (2015). Extended FRAM by integrating with model checking to effectively explore hazard evolution. Mathematical Problems in Engineering, 2015, 1–11.
Falegnami, A., Costantino, F., Di Gravio, G., & Patriarca, R. (2019). Unveil key functions in socio‐technical systems: Mapping FRAM into a multilayer network. Cognition, Technology & Work, 22, 877–899.
Ferreira, P. N. P., & Cañas, J. J. (2019). Assessing operational impacts of automation using functional resonance analysis method. Cognition, Technology & Work, 21, 1–18.
França, J. E. M., Hollnagel, E., dos Santos, I. J. L., & Haddad, A. N. (2019). FRAM AHP approach to analyse offshore oil well drilling and construction focused on human factors. Cognition, Technology &Work, 22, 653–665.
Fukuda, K., Sawaragi, T., Horiguchi, Y., & Nakanishi, H. (2016). Applying systemic accident model to learn from near‐miss incidents of train manoeuvring and operation. IFAC‐Papers Online, 49(19), 543–548.
Furniss, D., Curzon, P., & Blandford, A. (2016). Using FRAM beyond safety: A case study to explore how sociotechnical systems can flourish or stall. Theoretical Issues in Ergonomics Science, 17(5–6),507–532.
Gao, Y., Fan, Y., Wang, J., & Duan, Z. (2019). Evaluation of governmental safety regulatory functions in preventing major accidents in China. Safety Science, 120, 299–311.
Gattola, V., Patriarca, R., Tomasi, G., & Tronci, M. (2018). Functional resonance in industrial operations: A case study in a manufacturing plant. IFAC‐Papers Online, 51(11), 927–932.
Grant, E., Salmon, P. M., Stevens, N. J., Goode, N., & Read, G. J. (2018).Back to the future: What do accident causation models tell us about accident prediction? Safety Science, 104, 99–109.
Herrera, I. A., & Woltjer, R. (2010). Comparing a multi‐linear (STEP) and systemic (FRAM) method for accident analysis. Reliability Engineering& System Safety, 95(12), 1269–1275.
Hill, R., & Hollnagel, E. (2016). Instructions for use of the FRAM Model Visualiser (FMV).
Hill, R., Hollnagel, E. & Slater, D. “The FRAM Model Visualiser-the Pro version” https://www.researchgate.net/publication/353086492_The_FRAM_Model_Visualiser_-The_Pro_Version
Hirose, T., & Sawaragi, T. (2020). Extended FRAM model based on cellular automaton to clarify complexity of socio‐technical systems and improve their safety. Safety Science, 123, 104556.
Hirose, T., Sawaragi, T., & Horiguchi, Y. (2016). Safety analysis of aviation flight‐deck procedures using systemic accident model. IFACPapersOnLine,49(19), 19–24.
Hirose, T., Nomoto, H., Hollnagel, E., Hill, R., Sawaragi, T. & Salter, D. Treating variability formally in FRAM, https://www.researchgate.net/publication/342639227_TREATING_VARIABILITY_FORMALLY_IN_FRAM
Hollnagel, E. (2012a). Coping with complexity: Past, present and future. Cognition, Technology & Work, 14(3), 199–205.
Hollnagel, E. (2012b). FRAM, the functional resonance analysis method: Modelling complex socio‐technical systems. Ashgate Publishing, Ltd.
Hollnagel, E. (2016). Barriers and accident prevention. Routledge.
Hollnagel, E. (2018). Safety‐I and safety‐II: The past and future of safety management. CRC press.
Hollnagel, E. & Slater, D. THE " FUNCTIONAL RESONANCE ANALYSIS METHOD AND MANUAL (VERSION 2), https://www.researchgate.net/publication/325825191_THE_FUNCTIONAL_RESONANCE_ANALYSIS_METHOD_AND_MANUAL_VERSION_2
Hounsgaard, J. (2016). Patient safety in everyday work: Learning from things that go right. Syddansk Universitet.
Huang, W., Shuai, B., Zuo, B., Xu, Y., & Antwi, E. (2019). A systematic railway dangerous goods transportation system risk analysis approach: The 24 model. Journal of Loss Prevention in the Process Industries, 61, 94–103.
Hulme, A., Stanton, N. A., Walker, G. H., Waterson, P., & Salmon, P. M. (2019). What do applications of systems thinking accident analysis methods tell us about accident causation? A systematic review of applications between 1990 and 2018. Safety Science, 117, 164–183.
Jensen, A., & Aven, T. (2017). Hazard/threat identification: Using functional resonance analysis method in conjunction with the Anticipatory Failure Determination method. Proceedings of the Institution of Mechanical Engineers, Part O: Journal of Risk and
Reliability, 231(4), 383–389.
Jensen, A., & Aven, T. (2018). A new definition of complexity in a risk analysis setting. Reliability Engineering & System Safety, 171,169–173.
Kaya, G. K., Ovali, H. F., & Ozturk, F. (2019). Using the functional resonance analysis method on the drug administration process to assess performance variability. Safety Science, 118, 835–840.
Laugaland, K., Aase, K., & Waring, J. (2014). Hospital discharge of the elderly‐an observational case study of functions, variability and performance‐shaping factors. BMC Health Services Research, 14(1),365.
Lee, J., & Chung, H. (2018). A new methodology for accident analysis with human and system interaction based on FRAM: Case studies in maritime domain. Safety Science, 109, 57–66.
Lee, J., Yoon, W. C., & Chung, H. (2019). Formal or informal human collaboration approach to maritime safety using FRAM. Cognition, Technology & Work, 22, 861–875.
Leveson, N. (2011). Engineering a safer world: Systems thinking applied to safety. MIT Press.
Li, W., He, M., Sun, Y., & Cao, Q. (2019). A proactive operational risk identification and analysis framework based on the integration of ACAT and FRAM. Reliability Engineering & System Safety, 186,101–109.
Mackinnon, R, Slater, D, Härenstam, P, Von Thiele Schwarz, U, Stenfors, (2021), “Adaptations to practice and resilience in a paediatric major trauma centre during a mass casualty incident”, September 2021, BJA British Journal of Anaesthesia,
Mackinnon, R, Härenstam, P, Kennedy, C, Hollnagel, E, Slater, D, (2021), “A novel approach to explore Safety-I and Safety-II perspectives in in situ simulations—the structured what if functional resonance analysis methodology, December 2021, Advances in Simulation 6(1)
MacKinnon, R, Slater, D, (2021), “Safety -A Genetic Paradigm” FRAMily Webinar conference paper 2021, https://www.researchgate.net/publication/354787339_Safety_-A_Genetic_Paradigm
MacKinnon, R. & Slater, D. (2019), Examination of the standard Out of Hospital Cardiac Arrest (OHCA) CPR procedures using FRAM, https://www.researchgate.net/publication/334139096_Examination_of_the_standard_Out_of_Hospital_Cardiac_Arrest_OHCA_CPR_procedures_using_FRAM
McNab, D., Freestone, J., Black, C., Carson‐Stevens, A., & Bowie, P. (2018). Participatory design of an improvement intervention for the primary care management of possible sepsis using the Functional Resonance Analysis Method. BMC Medicine, 16(1), 174.
O'Hara, J. K., Baxter, R., & Hardicre, N. (2020). 'Handing over to the patient': A FRAM analysis of transitional care combining multiple stakeholder perspectives. Applied Ergonomics, 85, 103060.
Pardo‐Ferreira, M. C., Martínez‐Rojas, M., Salguero‐Caparrós, F., & Rubio‐Romero, J. C. (2019). Evolution of the Functional Resonance Analysis Method (FRAM) through the combination with other methods. Dirección y Organización, 1, 41–50.
Patriarca, R., & Bergström, J. (2017). Modelling complexity in everyday operations: Functional resonance in maritime mooring at quay. Cognition, Technology & Work, 19(4), 711–729.
Patriarca, R., Bergström, J., & Di Gravio, G. (2017). Defining the functional resonance analysis space: Combining Abstraction Hierarchy and FRAM. Reliability Engineering & System Safety, 165, 34–46.
Patriarca, R., Falegnami, A., Costantino, F., & Bilotta, F. (2018). Resilience engineering for socio‐technical risk analysis: Application in neurosurgery. Reliability Engineering & System Safety, 180, 321–335.
Patriarca, R., Gianluca, D. P., Giulio, D. G., & Francesco, C. (2018). FRAM for systemic accident analysis: A matrix representation of functional resonance. International Journal of Reliability, Quality and Safety Engineering, 25(01), 1850001.
Patriarca, R., Di Gravio, G., & Costantino, F. (2017). A Monte Carlo evolution of the Functional Resonance Analysis Method (FRAM) to assess performance variability in complex systems. Safety Science,91, 49–60.
Patriarca, R., Di Gravio, G., Costantino, F., & Tronci, M. (2017). The Functional Resonance Analysis Method for a systemic risk based environmental auditing in a sinter plant: A semi‐quantitative approach. Environmental Impact Assessment Review, 63, 72–86.
Pereira, A. G. A. A. (2013). Introduction to the Use of FRAM on the effectiveness assessment of a radiopharmaceutical Dispatches process. International Nuclear Atlantic Conference.
Pickup, L., Atkinson, S., Hollnagel, E., Bowie, P., Gray, S., Rawlinson, S., & Forrester, K. (2017). Blood sampling‐two sides to the story. Applied Ergonomics, 59, 234–242.
Praetorius, G., Graziano, A., Schröder‐Hinrichs, J.‐U., & Baldauf, M. (2017). FRAM in FSA—Introducing a function‐based approach to the formal safety assessment framework. In N. A. Stanton, S. Landry, G. Di
Bucchianico, & A. Vallicelli (Eds.), Advances in Human Aspects of Transportation (pp. 399–411). Springer.
Praetorius, G., Hollnagel, E., & Dahlman, J. (2015). Modelling vessel traffic service to understand resilience in everyday operations. Reliability Engineering & System Safety, 141, 10–21.
Raben, D. C., Bogh, S. B., Viskum, B., Mikkelsen, K. L., & Hollnagel, E.(2018). Learn from what goes right: A demonstration of a new systematic method for identification of leading indicators in health care. Reliability Engineering & System Safety, 169, 187–198.
Raben, D. C., Viskum, B., Mikkelsen, K. L., Hounsgaard, J., Bogh, S. B., &Hollnagel, E. (2018). Application of a non‐linear model to understand healthcare processes: Using the functional resonance analysis method on a case study of the early detection of sepsis.Reliability Engineering & System Safety, 177, 1–11.
Ragosta, M., Martinie, C., Palanque, P., Navarre, D., & Sujan, M. A. (2015). Concept maps for integrating modelling techniques for the analysis and re‐design of partly autonomous interactive systems. Proceedings of the 5th International Conference on Application and Theory of Automation in Command and Control Systems, pp. 41–52.
Righi, A. W., & Saurin, T. A. (2015). Complex socio‐technical systems: Characterization and management guidelines. Applied Ergonomics,50, 19–30.
Roland, D. (2018). Guideline developers are not the only experts: Utilising the FRAM method in sepsis pathways. BMC Medicine,16(1), 213.
Rosa, L. V., Haddad, A. N., & de Carvalho, P. V. R. (2015). Assessing risk in sustainable construction using the Functional Resonance Analysis Method (FRAM). Cognition, Technology & Work, 17(4), 559–573.
Ross, A., Sherriff, A., Kidd, J., Gnich, W., Anderson, J., Deas, L., &Macpherson, L. (2018). A systems approach using the functional resonance analysis method to support fluoride varnish application for children attending general dental practice. Applied Ergonomics,68, 294–303.
Rosso, C. B., & Saurin, T. A. (2018). The joint use of resilience engineering and lean production for work system design: A study in healthcare. Applied Ergonomics, 71, 45–56.
Salehi V, Veitch B, Smith D. Modeling complex socio‐technical systems using the FRAM: A literature review. Hum. Factors Man. 2021;31:118–142. https://doi.org/10.1002/hfm.20874
Saurin, T. A., & Werle, N. J. B. (2017). A framework for the analysis of slack in socio‐technical systems. Reliability Engineering & SystemSafety, 167, 439–451.
Schutijser, B. C. F. M., Jongerden, I. P., Klopotowska, J. E., Portegijs, S.,de Bruijne, M. C., & Wagner, C. (2019). Double checking injectable medication administration: Does the protocol fit clinical practice? Safety Science, 118, 853–860.
Settanni, E., Thenent, N. E., Newnes, L. B., Parry, G., & Goh, Y. M. (2017). Mapping a product‐service‐system delivering defence avionics availability. International Journal of Production Economics, 186, 21–32.
Shire, M. I., Jun, G. T., & Robinson, S. (2018). The application of system dynamics modelling to system safety improvement: Present use and future potential. Safety Science, 106, 104–120.
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Slater, D, Hollnagel, E, MacKinnon, R, Carson-Stevens, A, Sujan, M, Ross, A, Bowie, P (2022). “A Systems Analysis of the COVID-19 Pandemic Response in the United Kingdom–Part 1-The overall Context. Safety Science (2022) 146, 1055525
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Smith, D., Veitch, B., Khan, F., & Taylor, R. (2017). Understanding industrial safety: Comparing fault tree, Bayesian network, and FRAM approaches. Journal of Loss Prevention in the Process Industries,45, 88–101.
Smith, D., Veitch, B., Khan, F., & Taylor, R. (2018a). Using FRAM to evaluate ship designs and regulations. In P. Kujala, & L. Lu (Eds.), Marine design XIII (Vol. 2, pp. 677–683). CRC Press.
Smith, D., Veitch, B., Khan, F., & Taylor, R. (2018b). Using the FRAM to understand arctic ship navigation: Assessing work processes during the Exxon Valdez Grounding. Trans Nav: International Journal on Marine Navigation and Safety of Sea Transportation, 12, 447–457.
Smith, D., Veitch, B., Khan, F., & Taylor, R. (2020). Integration of resilience and FRAM for safety management. ASCE‐ASME Journal of Risk and Uncertainty in Engineering Systems, Part A: Civil Engineering, 6(2),4020008.
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Sujan, M. A., Embrey, D., & Huang, H. (2020). On the application of human reliability analysis in healthcare: Opportunities and challenges. Reliability Engineering & System Safety, 194, 106189.
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Tian, J., Wu, J., Yang, Q., & Zhao, T. (2016). FRAMA: A safety assessment approach based on Functional Resonance Analysis Method. Safety Science, 85, 41–52.
Toroody, A. B., Abaei, M. M., & Gholamnia, R. (2016). Conceptual compression discussion on a multi‐linear (FTA) and systematic (FRAM) method in an offshore operation's accident modelling. International Journal of Occupational Safety and Ergonomics, 22(4), 532–540.
Wachs, P., Righi, A. W., & Saurin, T. A. (2018). The functional resonance analysis method as a debriefing tool in scenario‐based‐training. Congress of the International Ergonomics Association, pp. 132–138.
Wachs, P., & Saurin, T. A. (2018). Modelling interactions between procedures and resilience skills. Applied Ergonomics, 68, 328–337.
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Yang, Q., Tian, J., & Zhao, T. (2017). Safety is an emergent property: Illustrating functional resonance in Air Traffic Management with formal verification. Safety Science, 93, 162–177.
Yu, M., Quddus, N., Kravaris, C., & Mannan, M. S. (2020). Development of a FRAM‐based framework to identify hazards in a complex system. Journal of Loss Prevention in the Process Industries, 63,103994.
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. Cognition, Technology &Work, 18(4), 777–791.
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