liu.seSearch for publications in DiVA
Change search
Link to record
Permanent link

Direct link
BETA
Hollnagel, Erik
Publications (10 of 76) Show all publications
Lundberg, J., Rollenhagen, C. & Hollnagel, E. (2010). What you find is not always what you fix-How other aspects than causes of accidents decide recommendations for remedial actions. Accident Analysis and Prevention, 42(6), 2132-2139
Open this publication in new window or tab >>What you find is not always what you fix-How other aspects than causes of accidents decide recommendations for remedial actions
2010 (English)In: Accident Analysis and Prevention, ISSN 0001-4575, E-ISSN 1879-2057, Vol. 42, no 6, p. 2132-2139Article in journal (Refereed) Published
Abstract [en]

In accident investigation, the ideal is often to follow the principle "what-you-find-is-what-you-fix", an ideal reflecting that the investigation should be a rational process of first identifying causes, and then implement remedial actions to fix them. Previous research has however identified cognitive and political biases leading away from this ideal. Somewhat surprisingly, however, the same factors that often are highlighted in modern accident models are not perceived in a recursive manner to reflect how they influence the process of accident investigation in itself. Those factors are more extensive than the cognitive and political biases that are often highlighted in theory. Our purpose in this study was to reveal constraints affecting accident investigation practices that lead the investigation towards or away from the ideal of "what-you-find-is-what-you-fix". We conducted a qualitative interview study with 22 accident investigators from different domains in Sweden. We found a wide range of factors that led investigations away from the ideal, most which more resembled factors involved in organizational accidents, rather than reflecting flawed thinking. One particular limitation of investigation was that many investigations stop the analysis at the level of "preventable causes", the level where remedies that were currently practical to implement could be found. This could potentially limit the usefulness of using investigations to get a view on the "big picture" of causes of accidents as a basis for further remedial actions.

Keywords
Accident investigation, Bias, Stop-rule, Method, Experience feedback, Remedial actions
National Category
Engineering and Technology
Identifiers
urn:nbn:se:liu:diva-58810 (URN)10.1016/j.aap.2010.07.003 (DOI)
Available from: 2010-08-31 Created: 2010-08-27 Last updated: 2017-12-12
Woltjer, R. & Hollnagel, E. (2009). An analysis of functional resonance of the Alaska Airlines flight 261 accident. Safety Science
Open this publication in new window or tab >>An analysis of functional resonance of the Alaska Airlines flight 261 accident
2009 (English)In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042Article in journal (Refereed) Submitted
National Category
Engineering and Technology
Identifiers
urn:nbn:se:liu:diva-17636 (URN)
Available from: 2009-04-06 Created: 2009-04-06 Last updated: 2017-12-13
Lundberg, J., Rollenhagen, C. & Hollnagel, E. (2009). What-You-Look-For-Is-What-You-Find - The consequences of underlying accident models in eight accident investigation manuals. Safety Science, 47(10), 1297-1311
Open this publication in new window or tab >>What-You-Look-For-Is-What-You-Find - The consequences of underlying accident models in eight accident investigation manuals
2009 (English)In: Safety Science, ISSN 0925-7535, Vol. 47, no 10, p. 1297-1311Article in journal (Refereed) Published
Abstract [en]

Accident investigation manuals are influential documents on various levels in a safety management system, and it is therefore important to appraise them in the light of what we currently know - or assume - about the nature of accidents. Investigation manuals necessarily embody or represent an accident model, i.e., a set of assumptions about how accidents happen and what the important factors are. In this paper we examine three aspects of accident investigation as described in a number of investigation manuals. Firstly, we focus on accident models and in particular the assumptions about how different factors interact to cause - or prevent - accidents, i.e., the accident "mechanisms". Secondly, we focus on the scope in the sense of the factors (or factor domains) that are considered in the models - for instance (hu)man, technology, and organization (MTO). Thirdly, we focus on the system of investigation or the activities that together constitute an accident investigation project/process. We found that the manuals all used complex linear models. The factors considered were in general (hu)man, technology, organization, and information. The causes found during an investigation reflect the assumptions of the accident model, following the What-You-Look-For-Is-What-You-Find or WYLFIWYF principle. The identified causes typically became specific problems to be fixed during an implementation of solutions. This follows what can be called What-You-Find-Is-What-You-Fix or WYFIWYF principle.

Keywords
Accident investigation; Accident models
National Category
Engineering and Technology
Identifiers
urn:nbn:se:liu:diva-21192 (URN)10.1016/j.ssci.2009.01.004 (DOI)
Available from: 2009-09-30 Created: 2009-09-30 Last updated: 2013-09-13
Hollnagel, E., Pruchnicki, S., Woltjer, R. & Etcher, S. (2008). A functional resonance accident analysis of Comair flight 5191. In: International Symposium of the Australian Aviation Psychology Association AAvPA,2008. Sydney: Australian Aviation Psychology Association
Open this publication in new window or tab >>A functional resonance accident analysis of Comair flight 5191
2008 (English)In: International Symposium of the Australian Aviation Psychology Association AAvPA,2008, Sydney: Australian Aviation Psychology Association , 2008Conference paper, Published paper (Other academic)
Abstract [en]

  

Place, publisher, year, edition, pages
Sydney: Australian Aviation Psychology Association, 2008
Keywords
FRAM, functional resonance, accident analysis, safety, accident modeling
National Category
Computer Sciences
Identifiers
urn:nbn:se:liu:diva-43116 (URN)71861 (Local ID)71861 (Archive number)71861 (OAI)
Available from: 2009-10-10 Created: 2009-10-10 Last updated: 2018-01-12
Woltjer, R. & Hollnagel, E. (2008). Functional modeling for risk assessment of automation in a changing air traffic management environment. In: Proceedings of the 4th International Conference Working on Safety, Crete, Greece: .
Open this publication in new window or tab >>Functional modeling for risk assessment of automation in a changing air traffic management environment
2008 (English)In: Proceedings of the 4th International Conference Working on Safety, Crete, Greece, 2008Conference paper, Published paper (Other academic)
National Category
Engineering and Technology
Identifiers
urn:nbn:se:liu:diva-17638 (URN)
Available from: 2009-04-06 Created: 2009-04-06 Last updated: 2009-05-19
Benn, J., Healey, A. & Hollnagel, E. (2008). Improving performance reliability in surgical systems. Cognition, Technology & Work, 10(4), 323-333
Open this publication in new window or tab >>Improving performance reliability in surgical systems
2008 (English)In: Cognition, Technology & Work, ISSN 1435-5558, E-ISSN 1435-5566, Vol. 10, no 4, p. 323-333Article in journal (Refereed) Published
Abstract [en]

Health care has evolved rapidly to meet the medical demands of society, but not to meet the demands of consistent operational safety. In other high risk domains in which the consequences of systems failure are unacceptable, organisational and operational work systems have been developed to deliver consistent, high-quality, failure-free performance. In this paper we review contributions to a special issue of Cognition, Technology and Work on 'Enhancing Surgical Systems'. We consider their implications for improving the reliability of care processes in light of theoretical developments in the area of high-reliability organisations and resilience engineering. Health care must move from reactive safety cultures to be more proactively resilient to the continual threats posed by complexity in clinical care processes and the multi-professional hospital environment. Our analysis emphasises the importance of team working for reliable operational performance. A schematic framework to illustrate how safety interventions in surgery might cohere within an organisational strategy for achieving high-reliability is proposed. The implications for continuous quality improvement and effective regulation of system safety over differing time scales and organisational levels are discussed. © 2007 Springer-Verlag London Limited.

Keywords
Continuous quality improvement, Health care systems, High-reliability organisations, Reliability, Resilience engineering, Safety management, Surgery, Teams
National Category
Engineering and Technology
Identifiers
urn:nbn:se:liu:diva-50098 (URN)10.1007/s10111-007-0092-x (DOI)
Available from: 2009-10-11 Created: 2009-10-11 Last updated: 2017-12-12
Woltjer, R. & Hollnagel, E. (2008). Modelling and evaluation of air traffic management automation using the functional resonance analysis method. In: International Symposium of the Australian Aviation Psychology Association AAvPA,2008. Sydney: Australian Aviation Psychology Association
Open this publication in new window or tab >>Modelling and evaluation of air traffic management automation using the functional resonance analysis method
2008 (English)In: International Symposium of the Australian Aviation Psychology Association AAvPA,2008, Sydney: Australian Aviation Psychology Association , 2008Conference paper, Published paper (Other academic)
Place, publisher, year, edition, pages
Sydney: Australian Aviation Psychology Association, 2008
Keywords
air traffic management, atc, safety, risk assessment, automation, cognitive systems engineering, functional resonance, FRAM
National Category
Computer Sciences
Identifiers
urn:nbn:se:liu:diva-43117 (URN)71862 (Local ID)71862 (Archive number)71862 (OAI)
Available from: 2009-10-10 Created: 2009-10-10 Last updated: 2018-01-12
Woltjer, R., Smith, K. & Hollnagel, E. (2008). Representation of spatio-temporal resource constraints in network-based command and control. In: Naturalistic decision making and macrocognition: Ed.: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (pp. 351-371). Aldershot, United Kingdom: Ashgate Publishing Limited
Open this publication in new window or tab >>Representation of spatio-temporal resource constraints in network-based command and control
2008 (English)In: Naturalistic decision making and macrocognition: Ed.: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R., Aldershot, United Kingdom: Ashgate Publishing Limited , 2008, p. 351-371Chapter in book (Other (popular science, discussion, etc.))
Place, publisher, year, edition, pages
Aldershot, United Kingdom: Ashgate Publishing Limited, 2008
National Category
Engineering and Technology
Identifiers
urn:nbn:se:liu:diva-17587 (URN)987-0-7546-7020 (ISBN)
Available from: 2009-04-03 Created: 2009-04-03 Last updated: 2009-05-19
Woltjer, R., Smith, K. & Hollnagel, E. (2007). Constraint recognition and state space representation in collaborative distributed command and control. In: Swedish Human Factors Network HFN Conference,2006 (pp. 72-82). Linköping: HFN
Open this publication in new window or tab >>Constraint recognition and state space representation in collaborative distributed command and control
2007 (English)In: Swedish Human Factors Network HFN Conference,2006, Linköping: HFN , 2007, p. 72-82Conference paper, Published paper (Other academic)
Place, publisher, year, edition, pages
Linköping: HFN, 2007
National Category
Computer Sciences
Identifiers
urn:nbn:se:liu:diva-40017 (URN)52060 (Local ID)52060 (Archive number)52060 (OAI)
Note
HFN report 2007-1Available from: 2009-10-10 Created: 2009-10-10 Last updated: 2018-01-13
Hollnagel, E. & Woltjer, R. (2007). Finding the hidden connections in aviation systems: A workshop on the functional resonance accident model. In: International Symposium on Aviation Psychology ISAP,2007.
Open this publication in new window or tab >>Finding the hidden connections in aviation systems: A workshop on the functional resonance accident model
2007 (English)In: International Symposium on Aviation Psychology ISAP,2007, 2007Conference paper, Published paper (Other academic)
National Category
Computer Sciences
Identifiers
urn:nbn:se:liu:diva-40019 (URN)52063 (Local ID)52063 (Archive number)52063 (OAI)
Note
WorkshopAvailable from: 2009-10-10 Created: 2009-10-10 Last updated: 2018-01-13
Organisations

Search in DiVA

Show all publications