FRAM: The Functional Resonance Analysis Method : Modelling Complex Socio-technical Systems

Resilience engineering has consistently argued that safety is more than the absence of failures. Since the first book was published in 2006, several book chapters and papers have demonstrated the advantage in going behind 'human error' and beyond the failure concept, just as a number of serious accidents have accentuated the need for it. But there has not yet been a comprehensive method for doing so; the Functional Resonance Analysis Method (FRAM) fulfils that need. Whereas commonly used methods explain events by interpreting them in terms of an already existing model, the FRAM is used to model the functions that are needed for everyday performance to succeed. This model can then be used to explain specific events, by showing how functions can be coupled and how the variability of everyday performance sometimes may lead to unexpected and out-of-scale outcomes - either good or bad. The FRAM is based on four principles: equivalence of failures and successes, approximate adjustments, emergence, and functional resonance. As the FRAM is a method rather than a model, it makes no assumptions about how the system under investigation is structured or organised, nor about possible causes and cause-effect relations. Instead of looking for failures and malfunctions, the FRAM explains outcomes in terms of how functions become coupled and how everyday performance variability may resonate. This book presents a detailed and tested method that can be used to model how complex and dynamic socio-technical systems work, to understand why things sometimes go wrong but also why they normally succeed. Since the first book was published in 2006, resilience engineering has consistently argued that safety is more than the absence of failures. Several book chapters and papers have illustrated the advantage in going behind 'human error' and beyond the failure concept, and various complicated accidents have accentuated the need for it. But there has not yet been a comprehensive method for doing so; the Functional Resonance Analysis Method (FRAM) fulfils that need. Whereas commonly used methods explain events by interpreting them in terms of an already existing model, the FRAM is used to produce a model of what is needed for everyday performance to go right. This can then be applied to explain specific events, by showing how functions can be coupled and how the variability of everyday performance sometimes may produce unexpected and out-of-scale outcomes - either good or bad. The FRAM is based on four principles: equivalence of failures and successes, approximate adjustments, emergence, and functional resonance. Since the FRAM is a method rather than a model, it makes no assumptions about how the system under investigation is structured or organised, nor about possible causes and cause-effect relations. Instead of looking for specific failures and malfunctions, the FRAM explains outcomes in terms of functional coupling and resonance. This book presents a detailed and tested method that can be used to model how complex and dynamic socio-technical systems work, and understand both why things sometimes go wrong but also why they normally succeed. About the Author Erik Hollnagel (Ph. D., psychology) is Professor at the University of Southern Denmark, Industrial Safety Chair at MINES Paris-Tech (France), and Professor Emeritus at University of Linköping (Sweden). Since 1971 he has worked within universities, research centres and industries in several countries with problems from domains such as nuclear power generation, aerospace and aviation, air traffic management, software engineering, healthcare, and land-based traffic. His professional interests include industrial safety, resilience engineering, accident investigation, cognitive systems engineering and cognitive ergonomics. He has published more than 250 papers and authored or edited 18 books, some of the most recent titles being The ETTO Principle (Ashgate, 2009) and Resilience Engineering in Practice (Ashgate, 2011). Erik Hollnagel is also Editor-in-Chief of the book series Ashgate Studies in Resilience Engineering Cover -- Contents -- List of Figures -- List of Tables -- Prologue -- 1 The Need -- A State of (Relative) Ignorance -- Ignorance, Complexity and Intractability -- Systems Redefined -- From Probability to Variability -- Conclusions -- Comments on Chapter 1 -- 2 The Intellectual Background -- The Naturalness of Linear Thinking -- Simple Linear Thinking -- Complex Linear Thinking -- Dynamic Systems and Parallel Developments -- The Second Cybernetics -- Conclusions -- Comments on Chapter 2 -- 3 The Principles -- The Equivalence of Failures and Successes -- The Approximate Adjustments -- Emergence -- Resonance -- Conclusions -- Comments on Chapter 3 -- 4 The Method: Preliminaries -- Looking For What Should Go Right -- Step 0: Recognise the Purpose of the FRAM Analysis -- Comments on Chapter 4 -- 5 The Method: Identify and Describe the Functions (Step 1) -- How Can the Functions Be Identified? -- The Six Aspects -- Issues in the Description of Functions -- Comments on Chapter 5 -- 6 The Method: The Identification of Variability (Step 2) -- Variability of Different Types of Functions -- Manifestations (Phenotypes) of Performance Variability -- 7 The Method: The Aggregation of Variability (Step 3) -- Functional Upstream-Downstream Coupling -- Upstream-Downstream Coupling for Preconditions -- Upstream-Downstream Coupling for Resources or Execution Conditions -- Upstream-Downstream Coupling for Control -- Upstream-Downstream Coupling for Time -- Upstream-Downstream Coupling for Input -- Issues in Upstream-Downstream Coupling -- Comments on Chapter 7 -- 8 The Method: Consequences of the Analysis (Step 4) -- Elimination, Prevention, Protection and Facilitation -- Monitoring (Performance Indicators) -- Dampening -- What About Quantification? -- Comments on Chapter 8 -- 9 Three Cases -- 'Duk i buk' (The Sponge in the Abdomen) There has not yet been a comprehensive method that goes behind 'human error' and beyond the failure concept, and various complicated accidents have accentuated the need for it. The Functional Resonance Analysis Method (FRAM) fulfils that need. This book presents a detailed and tested method that can be used to model how complex and dynamic socio-technical systems work, and understand both why things sometimes go wrong but also why they normally succeed.