Riccardo Patriarca

Defining the functional resonance analysis space: Combining Abstraction Hierarchy and FRAM

System-thinking and related systemic methods enhance traditional risk and hazard assessments and accident analysis, as well as system design. The Functional Resonance Analysis Method (FRAM) is a recently developed method for systemic analysis. FRAM facilitates descriptions of the functional relations among system elements. In case of large systems (e.g. several agents, multiple procedures, many technical equipment), building a FRAM model may become a difficult task, moreover resulting in a complex model, with limited benefits for the purpose of the analysis.

Modelling complexity in everyday operations: functional resonance in maritime mooring at quay

Maritime operations are complex socio-technical activities, with many interacting agents. Such agents are acting based on different, sometimes conflicting, goals. The traditional approach for safety, based on decomposition and bimodality, might lead to ineffective analyses, ignoring the transient and hidden links among activities as they are performed in everyday work. In this sense, the Functional Resonance Analysis Method (FRAM) offers a representation of work-as-done, acknowledging variability as unavoidable and desirable in order to avoid failures and maintain production. This paper adopts FRAM in combination with an Abstraction/Agency framework to understand and contribute with new perspectives to the complexity of processes. This approach, in line with the principles of Resilience Engineering, is adopted in the traditionally underspecified operation of mooring at quay. The detailed model confirms the benefits of FRAM in representing complex highly coupled tasks, especially in combination with an analysis at different levels of abstractions. The outcomes of the study show how a FRAM model offers systemic and punctual insights for understanding emergent criticalities, analysing complex incident scenarios, identifying potential mitigating actions, exploring different varieties of work and gaining systemic knowledge.

Inventory model for a multi-echelon system with unidirectional lateral transshipment

Literature analysis for lateral transshipment models in complex networks.Multi-site multi-item multi-echelon model with unidirectional lateral transshipment.Model based on the system-approach with availability target and cost minimization.Genetic algorithm for the optimization of non-linear constrained function.A case study of a European airline shows the benefits of the model. Inventory management constitutes a fundamental decision-making problem, especially in systems which must guarantee high availability levels. In complex multi-echelon networks, in case of shortage at a location, resupplying from a near location on the same echelon rather than from the original supplier at the upper echelon, would be a potential faster and then more profitable policy. A wide interest in literature shows the importance of this policy, i.e. the lateral transhipment (LTR), as a means to reduce the inventory costs. This paper deals with unidirectional LTR, which often represent a reasonable policy in scenarios where backorders have different effects on the system. Based on METRIC, this paper defines a system-approach model for determining the stock levels of repairable items in a complex network, by a genetic algorithm optimization process. The model considers non-zero maintenance time for each item and different skills of maintenance centres, in a multi-echelon single-indenture system, with unidirectional LTR allowed. The expert system developed in the paper assists the decision maker to define the inventory levels for the maintenance sites across the system, taking advantage of the LTR to reduce costs and enhance availability. A case study of a European airline shows the relevance of the developed expert system, also considering its reproducibility to face different industrial contexts.

Change management in the ATM system: integrating information in the preliminary system safety assessment

The increasing air transport demand suggests looking at air traffic management (ATM) as a continuously and evolving process. The procedures and equipment we use today will not continue coping with next air traffic requirements. It is thus necessary to provide ATM services for the current operating scenarios. This paper proposes a systematic tool, i.e., the preliminary system safety assessment tool (PSSA-T) to help the decision makers in evaluating safety implications of system changes. PSSA-T relies on the definition of two indexes, based on the aerospace performance factor (APF) methodology. These indexes allow a structured safety analysis of any proposed change: the first compares the evolutionary scenario with the current one and the second one considers the effects of a failure of the changed agent (equipment or procedure) in a future scenario. The paper illustrates a case study for the flight progress strip (FPS) change to electronic FPS.

An Analytic Framework to Assess Organizational Resilience

Background Resilience engineering is a paradigm for safety management that focuses on coping with complexity to achieve success, even considering several conflicting goals. Modern sociotechnical systems have to be resilient to comply with the variability of everyday activities, the tight-coupled and underspecified nature of work, and the nonlinear interactions among agents. At organizational level, resilience can be described as a combination of four cornerstones: monitoring, responding, learning, and anticipating. Methods Starting from these four categories, this article aims at defining a semiquantitative analytic framework to measure organizational resilience in complex sociotechnical systems, combining the resilience analysis grid and the analytic hierarchy process. Results This article presents an approach for defining resilience abilities of an organization, creating a structured domain-dependent framework to define a resilience profile at different levels of abstraction, and identifying weaknesses and strengths of the system and potential actions to increase systems adaptive capacity. An illustrative example in an anesthesia department clarifies the outcomes of the approach. Conclusion The outcome of the resilience analysis grid, i.e., a weighed set of probing questions, can be used in different domains, as a support tool in a wider Safety-II oriented managerial action to bring safety management into the core business of the organization.

Resilience engineering to assess risks for the air traffic management system: a new systemic method

For current socio-technical systems, the need for enhanced methods and models for safety management emerges owing to their increasing inherent complexity. The Air Traffic Management (ATM) system represents one of these systems, for which a new perspective is mandatory in terms of safety management. The traditional perspective on safety (Safety-I) has to be reinforced with a new one (Safety-II), integrating the principles of Resilience Engineering. This latter, recurrent in several domains, is receiving an increasing interest in the area of safety and risk management over the past decade. This paper aims to develop a new method, i.e. the RAG-SAT (Resilience Analysis Grid - State Assessment Tool), to combine the principles of Safety-I and Safety-II. It combines a semi-quantitative analysis of system functioning, linking directly resilience with system state and then system risk exposure. The RAG-SAT integrates the technical, human, procedural and environmental aspects of the ATM system, following the Air Navigation Service Providers (ANSP) perspective. The method is discussed following an explorative conceptual perspective.

Resilience engineering for socio-technical risk analysis: Application in neuro-surgery

Healthcare practitioners are generally forced to adapt their actions to cope with the complexity of daily conditions, taking advantage of their inherent potential for resilient performance. Following the principles of Resilience Engineering, this article details the application of the Functional Resonance Analysis Method (FRAM), for a semi-quantitative risk analysis of patients pathway. The analysis adopts a holistic perspective on the complexity of everyday work in order to manage emergent behaviours, mainly related to iatrogenic disease associated with neuro-anesthesia treatment.

A multicountry comparative survey about organizational resilience in anaesthesia

RATIONALE, AIMS, AND OBJECTIVES The application of resilience in health care requires the shift from a cause-effect approach to a systemic approach, yet few tools have been developed to measure resilience potential in this specific context. This study tests a resilience assessment grid (RAG) questionnaire to measure the resilience of anaesthesiologists, with a cross-country survey. METHOD A study was conducted with an analytic hierarchy process (AHP) questionnaire containing 57 detailed questions; 16 nations and 172 respondents were involved in the study. The data were statistically analysed to identify insights from the questionnaire, main improvements for further assessment, and confirmation of the design of the questionnaire. The questionnaire reliability was assessed by Cronbach analysis. Weak items were identified by a detailed correlations analysis and through a weight-polarization matrix. Construct validity was confirmed by principal component analysis (PCA) and factor analysis (FA). RESULTS The α level of Cronbach analysis is 0.910. PCA and FA confirmed the absence of underlying unexpected factors, with less than 8% from the first factor and a total of just 54% of variability explained by 17 factors. Suggestions for revising the questionnaire ensue from the analysis, with improvements for the questionnaires significance. CONCLUSION The questionnaire shows the potential to assess proxy measures of resilience, even confirming the relevance of a structured weighting approach based on the AHP. The exemplar statistical cross-country analyses encourage the widespread use of a centralized resilience questionnaire to support standardized analyses and the diffusion of best practices among organizations.

A paradigm shift to enhance patient safety in healthcare, a resilience engineering approach: scoping review of available evidence

This review analyses the contributions about resilience engineering as an emerging topic in healthcare literature. Owing to the cross-disciplinarity of the theme, this review takes into account PubMed and Scopus databases through March 2017 as well as other not-indexed papers from the Resilience Engineering Association (REA) symposia and other books in the field. After removing duplicates and screening full-texts, we analysed 63 studies that were categorised into four groups that describe the current research state of resilience engineering in healthcare. This scoping review demonstrates the relevance of resilience in complex healthcare activities, exploring the potential benefits to engineer it. The theoretical background and the preliminary applications confirm the potential of this paradigm shift for safety management to cope with current and future healthcare system needs.

Safety Performance of Complex Systems: Lesson Learned from ATM Resilience Analysis

The Air Traffic Management (ATM) system has become steadily more complex due to rampant technological, procedural and societal developments and to the increase in traffic volume. These factors have become gradually more difficult to understand and manage, mainly because of tight couplings among functions and because of the continuous development characterizing everyday activities. According to this view, traditional safety analyses, basing on the belief that the systems are completely known and a causal-effect link could ever be easily detected may become ineffective. Furthermore, these methodologies can evaluate only linear causal dependencies. It is necessary therefore to evolve ATM risk assessment from its classic view of safety (Safety-I), to a new one, integrating the principles of resilience engineering (Safety-II). This editorial article presents the complexity and the outcomes deriving from resilience engineer methodologies, aiming at illustrating possible guidelines for managers and academics.