Identification and analysis of hoisting safety risk factors for IBS construction based on the AcciMap and cases study.

Hoisting is an essential aspect of Industrial Building System (IBS) construction. Although research on hoisting safety in China has made strides to focus on "worker," "data," "task," "site," and "accident," there still needs to be more approaches based on multi-dimensional social system thinking. Therefore, the paper aims to fill this gap. We investigated 105 hoisting accidents in China and found that hoisting accidents occurred most frequently in China's southeast coastal region; truck-mounted cranes and tower cranes were the most common types of machinery involved in accidents; hoisting load off, capsizing of crane machinery, and workers falling from height are the three most common accident types; the average impact of a single hoisting accident is approximately RMB 2.43 million direct economic loss, 1.543 deaths and 0.829 injured. This study used three algorithms (Rindge regression, Lasson regression, and partial least squares regression) to explore the impact of deaths and injuries on direct economic losses. By combining Rasmussen's risk framework with the characteristics of hoisting construction, six risk domains and thirty-six safety risk factors were identified. Finally, we used AcciMap technology to construct a qualitative IBS hoisting management model, which exhaustively presents the systematic levels and propagation paths of the influencing factors by the PDCA method. The research helps academics explore strategies to improve the safety of hoisting construction in IBS. Moreover, the study outcomes can inform the policy-making process towards promoting healthy and sustainable construction development.

Applying a systems thinking lens to anti-doping: A systematic review identifying the contributory factors to doping in sport.

The use of performance enhancing substances and methods (known as "doping") in sport is an intractable issue, with current anti-doping strategies predominantly focused on the personal responsibility and strict liability of individual athletes. This is despite an emerging understanding that athletes exist as part of a broader complex sports system that includes governance, policymakers, media, sponsors, clubs, team members, and athlete support staff, to name a few. As such, there is a need to examine the broader systemic factors that influence doping in sport. The aim of this systematic review was to identify and synthesise the factors contributing to doping and doping behaviours, attitudes, and beliefs and the extent to which this knowledge extends beyond the athlete to consider broader sports systems. The review followed PRISMA guidelines with risk of bias and study quality assessed by the Mixed Methods Appraisal Tool, and identified contributory factors synthesised and mapped onto a systems thinking-based framework. Overall, the included studies were determined to be of high quality. Support personnel, the coach, and the coach-athlete relationship represent key influences on the athletes' decisions to dope. From the evidence presented, doping is an emergent property of sport systems and represents a complex systemic problem that will require whole-of-system interventions. The implications for this and the focus of future research are discussed.

Testing the reliability of accident analysis methods: a comparison of AcciMap, STAMP-CAST and AcciNet.

Accident analysis methods are used to model the multifactorial cause of adverse incidents. Methods such as AcciMap, STAMP-CAST and recently AcciNet, are systemic approaches that support the identification of safety interventions across sociotechnical system levels. Despite their growing popularity, little is known about how reliable systems-based methods are when used to describe, model and classify contributory factors and relationships. Here, we conducted an intra-rater and inter-rater reliability assessment of AcciMap, STAMP-CAST and AcciNet using the Signal Detection Theory (SDT) paradigm. A total of 180 hours' worth of analyses across 360 comparisons were performed by 30 expert analysts. Findings revealed that all three methods produced a weak to moderate positive correlation coefficient, however the inter-rater reliability of STAMP-CAST was significantly higher compared to AcciMap and AcciNet. No statistically significant or practically meaningful differences were found between methods in the overall intra-rater reliability analyses. Implications and future research directions are discussed.

Practitioners who undertake accident analysis within their organisations should consider the use of STAMP-CAST due to the significantly higher inter-rater reliability findings obtained in this study compared to AcciMap and AcciNet, particularly if they tend to work alone and/or part of relatively small teams.

Understanding the systemic influences on maritime pilot decision-making.

Maritime incidents occurring during pilotage are of international concern. Maritime pilots control most pilotage operations worldwide, yet despite the safety criticality of their role, research examining pilot decision-making processes during these complex and dynamic operations is scarce. This article describes the findings from two studies that utilised an integrated systems thinking framework to understand how pilots make decisions and what factors are perceived to influence their decisions. Interviews were held with 22 pilots (Study 1) and 17 maritime safety stakeholders (Study 2) in the New Zealand maritime context. The findings illustrate the challenges pilots face during pilotage and provide insights into their decision-making processes and the systemic factors that can be addressed to improve maritime safety. Given the multiple causal pathways to incidents occurring during pilotage identified by this research, it is suggested that multiple systems-wide interventions are needed, which is likely to require a long-term, strategic approach.

Incident reporting in the outdoors: a systems-based analysis of injury, illness, and psychosocial incidents in led outdoor activities in Australia.

Incident reporting systems are a fundamental component of safety management, however, most systems used in practice are not aligned with contemporary accident causation models. This article presents an analysis of a National Incident Dataset (NID) for adverse incidents occurring in the Australian Led Outdoor Activity (LOA) sector. The aim was to investigate the adverse Injury, Illness, and Psychosocial incidents reported to the NID. In total, 1657 injuries, 532 illnesses, and 146 psychosocial incidents were analysed from 357,691 program participation days. The findings show that the rate of incidents per 1000 program participant days in LOAs was 4.6 for injury, 1.5 for illness, and 0.04 for psychosocial incidents, and incident severity was predominately minor. The analysis of systemic contributory factors demonstrates that incidents in LOA are systemic in nature, with multiple levels of the LOA system identified as contributing to adverse incidents. For example, contributory factors were identified across local government (facilities), schools (communication), parents (communication), LOA management (policies and procedures), people involved in the incidents (mental and physical condition), and the environment (terrain) and equipment (clothing). This study presents an assessment of the current state of safety in the Australian LOA sector and demonstrates the utility of applying systems ergonomics methods in practice. Practitioner summary: This article presents an analysis of 1657 injury, 532 illness, and 146 psychosocial incidents occurring in the Australian Led Outdoor Activity (LOA) sector, using a systems ergonomics method. The findings demonstrate the incident charactersitics and how decisions and actions from across the system contribute to adverse incidents in LOAs.

Development of Rasmussen's risk management framework for analysing multi-level sociotechnical influences in the design of envisioned work systems.

Besides radically altering work, advances in automation and intelligent technologies have the potential to bring significant societal transformation. These transitional periods require an approach to analysis and design that goes beyond human-machine interaction in the workplace to consider the wider sociotechnical needs of envisioned work systems. The Sociotechnical Influences Space, an analytical tool motivated by Rasmussen's risk management model, promotes a holistic approach to the design of future systems, attending to societal needs and challenges, while still recognising the bottom-up push from emerging technologies. A study explores the concept and practical potential of the tool when applied to the analysis of a large-scale, 'real-world' problem, specifically the societal, governmental, regulatory, organisational, human, and technological factors of significance in mixed human-artificial agent workforces. Further research is needed to establish the feasibility of the tool in a range of application domains, the details of the method, and the value of the tool in design. Practitioner summary: Emerging automation and intelligent technologies are not only transforming workplaces, but may be harbingers of major societal change. A new analytical tool, the Sociotechnical Influences Space, is proposed to support organisations in taking a holistic approach to the incorporation of advanced technologies into workplaces and function allocation in mixed human-artificial agent teams.

Evaluation of a systems ergonomics-based incident reporting system.

INTRODUCTION: Incident reporting and learning systems are a fundamental component of safety management. The purpose of this study was to evaluate a novel incident reporting system specific to the Australian Led Outdoor Activity (LOA) sector. The Understanding and Preventing Led Outdoor Accidents Data System (UPLOADS), is a recently introduced systems thinking-based incident reporting and learning system that utilises contemporary safety theory and methods. METHOD: The implementation of UPLOADS was evaluated using the RE-AIM framework based on the following dimensions: Reach, Efficacy, Adoption, Implementation, and Maintenance. A pragmatic evaluation approach was used in which evaluation data were collected through the triangulation of multiple sources including different LOA stakeholders from both the individual organisational level (LOA providers) and LOA sector governance level (LOA industry representatives), incident data collected through the UPLOADS National Incident Dataset, and the online and physical presence of UPLOADS. RESULTS: The findings show that a key strength of UPLOADS is its effectiveness as incident reporting tool for improving safety in the LOA sector. However, a weakness of UPLOADS is that it is not being implemented appropriately by the LOA providers. CONCLUSION: Overall, the current findings suggest that UPLOADS incident reporting tool is perceived by SMEs as an effective tool for improving safety in LOA. However, further work is required for UPLOADS to have a greater impact on the LOA sector. Specifically, Implementation of the UPLOADS system requires improvement, as well as additional training and education may be required to upskill and empower LOA providers to improve reporting and enhance the value placed on safety by LOA stakeholders. The RE-AIM framework was an appropriate evaluation framework for understanding the effectiveness of UPLOADS as a LOA sector specific incident reporting and learning system. PRACTICAL APPLICATIONS: The current findings have practical implications for ergonomics researchers applying evaluation frameworks in the real world, and LOA providers for implementing safety interventions. Lastly, contemporary systems-based incident reporting and learning systems have the capability to enhance the safety practices of the LOA sector.

Taking a mixed-methods approach to collision investigation: AcciMap, STAMP-CAST and PCM.

Recently, ergonomics and safety researchers have turned their attention towards applying combinations of sociotechnical methods rather than using single methods in isolation. In the current research, a mixed-method approach combining two systems-based methods, Accimaps and the Systems Theoretic Accident Model and Process - Causal Analysis using Systems Theory (STAMP-CAST), and one cognitive approach, the Perceptual Cycle Model (PCM), were employed in analysing a rail-level crossing incident in Bangladesh. Each method was applied individually to investigate the collision, and interventions were proposed corresponding to incident events at different risk management framework levels. The three methods provided different perspectives of the whole picture, together identifying an array of contributory factors. The complementary nature of these methods aided in proposing a comprehensive set of safety recommendations, thereby demonstrating the benefit of a mixed-method approach for collision investigation in low-income settings.

Adopting systems models for multiple incident analysis: utility and usability.

BACKGROUND: This study aims to present two system models widely used in Human Factors and Ergonomics (HF/E) and evaluate whether the models are adoptable to England's national patient safety team in improving the exploration and understanding of multiple incident reports of an active patient safety issue and the development of the remedial actions for a potential National Patient Safety Alert. The existing process of examining multiple incidents is based on inductive thematic analysis and forming the remedial actions is based on barrier analysis of intelligence on potential solutions. However, no formal systems models evaluated in this study have been used. METHODS: AcciMap and Systems Engineering Initiative for Patient Safety (SEIPS) were selected, applied and evaluated to the analysis of two different sets of patient safety incidents: (i) incidents concerning ingestion of superabsorbent polymer granules and (ii) incidents concerning the interruption in use of High Nasal Flow Oxygen. The first set was analysed by the first author and the utility and usability were reflected. The second set was analysed collectively by a purposeful sample of patient safety team members, who create the National Patient Safety Alerts from incident-level data and information. All of them attended a 30-min video-based training and a 1.5 h case-based online workshop. Post-workshop individual interviews were conducted to evaluate their perceived utility and usability of each model. RESULTS: The patient safety team showed overwhelming support for the utility of the system models as a 'framework' that provides a systematic, structured way of looking at an issue and examining the causes, whilst also sharing concerns regarding their usability. AcciMap was viewed useful particularly in providing a visual comprehensive overview of the issue but considered chaotic by some participants due to many arrows between factors. SEIPS was perceived easier to understand due to the familiarity of the structure (Donbedian's model), but the non-hierarchical format of SEIPS was considered less useful. CONCLUSIONS: The participants of the study agreed with the high level of utility of both models for their unique strengths, but shared some concern for the usability of them in terms of complexity and further training/coaching time would be required to adopt these models in their daily practices. It is recommended that the gap between HF/E practitioners and patient safety practitioners can be narrowed by strengthening education, and coaching and mentoring relationships between the two groups, led by the increasing number of healthcare practitioners who embrace their membership to HF/E practice.

A COVID-19 outbreak on board ship: Analysis of the sociotechnical system of epidemiological management in the French Navy.

In late 2019, an epidemic of SARS-CoV-2 broke out in central China. Within a few months, this new virus had spread right across the globe, officially being classified as a pandemic on 11 March 2020. In France, which was also being affected by the virus, the government applied specific epidemiological management strategies and introduced unprecedented public health measures. This article describes the outbreak management system that was applied within the French military and, more specifically, analyzes an outbreak of COVID-19 that occurred on board a nuclear aircraft carrier. We applied the AcciMap systemic analysis approach to understand the course of events that led to the outbreak and identify the relevant human and organizational failures. Results highlight causal factors at several levels of the outbreak management system. They reveal problems with the benchmarks used for diagnosis and decision-making, and underscore the importance of good communication between different levels. We discuss ways of improving epidemiological management in military context.

Applying a systems thinking lens to injury causation in the outdoors: Evidence collected during 3 years of the Understanding and Preventing Led Outdoor Accidents Data System.

INTRODUCTION: This article presents a detailed systems analysis of injury incidents from 35 Australian led outdoor activity organisations between 2014 to 2017. METHOD: Injury incident reports were collected using a specific led outdoor activity incident reporting system known as UPLOADS (Understanding and Preventing Led Outdoor Accidents Data System). RESULTS: In total, 1367 people sustained injuries from across 20 different activities, with an injury rate of 1.9 injured people per 1000 participants over the three-year period. A total of 2234 contributory factors from multiple levels of the led outdoor activity system were identified from the incident reports, and 361 relationships were identified between contributory factors. DISCUSSION: This systems analysis of injury incidents demonstrates that it is not only factors within the immediate context of the incident (Participants, Environment, Equipment) but factors from across multiple systemic levels that contributes to injury incidents (Schools, Parents, Activity centre management). Prevention efforts should focus on addressing the whole network of contributing factors and not only the prominent factors at the lower system levels within the immediate context of the injury incident occurrences.

Complexity theory in accident causation: using AcciMap to identify the systems thinking tenets in 11 catastrophes.

The quest to explain and understand the cause of accidents is both ever-present and ongoing amongst the safety science community. In an attempt to advance the theory and science of accident causation, researchers have recently formalised a set of '15 systems thinking tenets' that cover the conditions and characteristics of work systems that are believed to contribute to the cause of accidents. The purpose of this study was to attempt to identify the systems thinking tenets across a range of different systems and accidents using the Accident Mapping (AcciMap) method. The findings suggest that the tenets can be attributed to play a role in accident causation, however as a result of this process, the capability of AcciMap has been brought into question. Implications and directions for future research are described. Practitioner Summary: This study is an extension of previous work that suggested there was a need to test for the 'systems thinking tenets of accident causation' in a multi-incident dataset. We used AcciMap to evaluate whether it has the capability to support ongoing accident analysis activities in ergonomics research.

Representing two road traffic collisions in one Accimap: highlighting the importance of emergency response and enforcement in a low-income country.

Seemingly erratic pedestrian crossing has become a major source of vehicle-pedestrian collisions on highways in Bangladesh, and across other low- and middle-income countries (LMICs). In this article, we approach the challenge from a sociotechnical systems perspective by using the Accimap method to analyse a pair of time-separated yet interconnected road traffic collisions. The first event involved a truck colliding with a road divider; in the second, fatal incident, a bus hit a university student. The traditional-style investigation conducted immediately after the collision apportioned blame to end users, that is, drivers and pedestrian; however, application of sociotechnical systems thinking revealed the contribution from lack of emergency response and enforcement among many other important factors. Results and recommendations are discussed in terms of reducing the chance and severity of such collisions across LMICs, and in terms of the need to look beyond the end-user, a focus that remains dominant in such settings. Practitioner summary: This paper applies sociotechnical systems thinking to pedestrian safety in Bangladesh by analysing two inter-connected road traffic collisions using a single Accimap. The findings emphasise the importance of implementing road safety interventions that target all system levels, and draw attention to the importance of post-collision response in low-income settings. Abbreviation: BUET: Bangladesh University of Engineering and Technology.

Applying AcciMap to test the common cause hypothesis using aviation near misses.

The common cause hypothesis, as applied here, proposes that similar networks of influencing factors may contribute to both adverse outcomes and near misses. This hypothesis has not been evaluated using a systems-thinking perspective. The aims of this study are to evaluate whether networks of contributory and protective factors exist within aviation serious near miss reports and to determine if the common cause hypothesis is applicable in this context. Sixteen incident reports from French civil aviation crash investigation bureau were analysed using the AcciMap method. Contributory and protective factors, and relationships between both were identified via coding of the reports. The results indicate that considering protective factors support a richer picture of incidents and provide support for the common cause hypothesis as measured by similar mean factor volume and sociotechnical levels for both contributory and protective factors. However, the findings also show the direction of relationships among protective and contributory factors may be indicative of a difference among adverse outcomes, near misses, and normal work. Future research should consider how a network of relationships may impact on the common contributory and protective factors found in near misses.

A systems thinking perspective on the barriers to treatment access for people with eating disorders.

Treatment access remains low for people with eating disorders. In addressing the complexity inherent in this challenge, this article introduces systems thinking and argues that it could provide new insights. Systems thinking views behavior as an emergent property of a system and considers the relationships between technical, organizational, and social components. Several methods used in safety science incorporate this thinking. For example, AcciMap draws focus to the influence of decisions and actions made across hierarchical levels of a system, including those by government, regulatory bodies, management, services, and individuals. By examining the findings of the existing literature on barriers to eating disorder treatment access according to these levels, it is evident that most identified barriers relate to individuals and that further research is needed to consider the influence of high-level stakeholders. Research using systems thinking should consider the causal networks of influence from government, regulatory, and organizational decisions and actions through to outcomes for clinicians and individuals. The understanding of how barriers operate within specific healthcare systems also warrants investigation. Systems thinking is yet to be formally applied in the area of eating disorders and thus represents an opportunity to inform the development and implementation of more effective, system wide interventions.

Who is responsible for global road safety? A cross-cultural comparison of Actor Maps.

The traditional three 'E's approach to road safety (engineering, education, enforcement) has had, and will continue to have, a significant impact on road traffic casualty rates worldwide. Nevertheless, with rising motorisation in many countries, global fatality numbers have changed little over the past decade. Following calls for the application of sociotechnical systems thinking to the problem, we widen the road safety discussion with an additional four 'E's; economics, emergency response, enablement, and, the umbrella term for the approach taken, ergonomics. The research presents an application of Rasmussen's Risk Management Framework to the road safety systems of five distinct nations; Bangladesh, China, Kenya, the UK, and Vietnam. Following site visits, reviews of literature, and interviews with subject matter experts in each of the countries, a series of Actor Map models of the countries' road safety systems were developed. These are compared and discussed in terms of the wide variety of interconnecting organisations involved, their influences on road safety outcomes, the differences between nations, and the need to look beyond road users when designing road safety interventions.

Distributed improvisation: a systems perspective of improvisation 'epics' by led outdoor activity leaders.

Improvisation represents the spontaneous and real-time conception and execution of a novel response to an unanticipated situation. In order to benefit from the positive safety potential of this phenomenon, it is necessary to understand what influences its appropriateness and effectiveness. This study has applied the system-based methodology Impromaps to analysing accounts of improvisation aimed at mitigating adverse safety outcomes. These accounts were obtained from led outdoor activity (LOA) leaders through critical decision method interviews. Influencing factors and interactions have been identified across all system levels. The factors most influential to leaders' ability to improvise are 'Policy, procedures and rules', 'Organisation culture', 'Training', 'Role responsibilities', 'Communication/instruction/demonstration', 'Situation awareness', 'Leader experience', 'Mental simulation', 'Equipment, clothing & PPE' and 'Terrain/physical environment'. To enhance the likelihood of effective, appropriate improvisation, LOA providers are recommended to focus on higher level factors over which they are able to exert greater control. Practitioner Summary: To enhance resilience in safety-critical situations, organisations need to understand what influences appropriate, effective improvisation. To elucidate this, the Impromaps methodology is applied to in-depth interview data. The Impromap affords a graphical depiction of the influencing factors and interactions across the system, providing a basis for the development of interventions.

A systemic analysis of South Korea Sewol ferry accident - Striking a balance between learning and accountability.

The South Korea Sewol ferry accident in April 2014 claimed the lives of over 300 passengers and led to criminal charges of 399 personnel concerned including imprisonment of 154 of them as of Oct 2014. Blame and punishment culture can be prevalent in a more hierarchical society like South Korea as shown in the aftermath of this disaster. This study aims to analyse the South Korea ferry accident using Rasmussen's risk management framework and the associated AcciMap technique and to propose recommendations drawn from an AcciMap-based focus group with systems safety experts. The data for the accident analysis were collected mainly from an interim investigation report by the Board of Audit and Inspection of Korea and major South Korean and foreign newspapers. The analysis showed that the accident was attributed to many contributing factors arising from front-line operators, management, regulators and government. It also showed how the multiple factors including economic, social and political pressures and individual workload contributed to the accident and how they affected each other. This AcciMap was presented to 27 safety researchers and experts at 'the legacy of Jens Rasmussen' symposium adjunct to ODAM2014. Their recommendations were captured through a focus group. The four main recommendations include forgive (no blame and punishment on individuals), analyse (socio-technical system-based), learn (from why things do not go wrong) and change (bottom-up safety culture and safety system management). The findings offer important insights into how this type of accident should be understood, analysed and the subsequent response.

Rasmussen's legacy in the great outdoors: A new incident reporting and learning system for led outdoor activities.

Jens Rasmussen's seminal risk management framework and accompanying Accimap method have become highly popular in safety science circles. Despite this, widespread adoption of the model and method in practice has not yet been achieved. This paper describes a project involving the development and implementation of an incident reporting and learning system underpinned by Rasmussen's risk management framework and Accimap method. The system was developed for the led outdoor activity sector in Australia to enable reporting and analysis of injuries and near miss incidents, with the aim of supporting the development of more effective countermeasures. An analysis of the data derived from the first 3 months use of the system by 43 organisations is presented. The outputs provide an in-depth Accimap-based analysis of all incidents reported by participating organisations over the 3 month period. In closing, the importance of developing usable domain specific tools to support translation of Ergonomics theory and methods in practice is discussed.

Applying the AcciMap methodology to investigate the tragic Sewol Ferry accident in South Korea.

This study applies the AcciMap methodology, which was originally proposed by Professor Jens Rasmussen (1997), to the analysis of the tragic Sewol Ferry accident in South Korea on April 16, 2014, which killed 304 mostly young people and is considered as a national disaster in that country. This graphical representation, by incorporating associated socio-technical factors into an integrated framework, provides a big-picture to illustrate the context in which an accident occurred as well as the interactions between different levels of the studied system that resulted in that event. In general, analysis of past accidents within the stated framework can define the patterns of hazards within an industrial sector. Such analysis can lead to the definition of preconditions for safe operations, which is a main focus of proactive risk management systems. In the case of the Sewol Ferry accident, a lot of the blame has been placed on the Sewol's captain and its crewmembers. However, according to this study, which relied on analyzing all available sources published in English and Korean, the disaster is the result of a series of lapses and disregards for safety across different levels of government and regulatory bodies, Chonghaejin Company, and the Sewol's crewmembers. The primary layers of the AcciMap framework, which include the political environment and non-proactive governmental body; inadequate regulations and their lax oversight and enforcement; poor safety culture; inconsideration of human factors issues; and lack of and/or outdated standard operating and emergency procedures were not only limited to the maritime industry in South Korea, and the Sewol Ferry accident, but they could also subject any safety-sensitive industry anywhere in the world.