Table Of Content

Handbook of Systems Thinking Methods Handbook of Systems Thinking Methods Paul M. Salmon Neville A. Stanton Guy H. Walker Adam Hulme Natassia Goode Jason Thompson Gemma J. M. Read First edition published 2023 by CRC Press 6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742 and by CRC Press 4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN CRC Press is an imprint of Taylor & Francis Group, LLC © 2023 Paul M. Salmon, Neville A. Stanton, Guy H. Walker, Adam Hulme Natassia Goode, Jason Thompson, and Gemma J. M. Read Reasonable efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the consequences of their use. The authors and publishers have attempted to trace the copyright holders of all material reproduced in this publication and apologise to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, access www.copyright.com or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978- 750-8400. For works that are not available on CCC please contact [email protected] Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identification and explanation without intent to infringe. ISBN: 978-0-367-22017-4 (hbk) ISBN: 978-1-032-27238-2 (pbk) ISBN: 978-0-429-28162-4 (ebk) DOI: 10.1201/9780429281624 Typeset in Times by SPi Technologies India Pvt Ltd (Straive) Contents Preface .......................................................................................................................xi Acknowledgements .................................................................................................xiii Author Biographies ..................................................................................................xv SECTION I Introduction to Systems Thinking ������1 Chapter 1 Introduction to Systems Thinking in Human Factors and Ergonomics and Safety Science ...........................................................3 The Call to Action ................................................................................3 A Short Introduction to Systems Thinking ...........................................4 Open Systems ............................................................................6 Complexity Theory ....................................................................6 Evolution of Systems Thinking .................................................8 The Systems Thinking Tenets ..............................................................8 How to Blow Up the Death Star .........................................................11 The Death Star .........................................................................13 The Empire Strikes Back .........................................................18 A Real-Life Thermal Exhaust Port to Find ........................................24 Note ....................................................................................................25 References ..........................................................................................25 SECTION II Risk Assessment Methods ���������������29 Chapter 2 The Networked Hazard Analysis and Risk Management System (Net-HARMS) ....................................................................................31 Background ........................................................................................31 Domain of Application .......................................................................33 Procedure and Advice .........................................................................33 Advantages .........................................................................................40 Disadvantages .....................................................................................41 Related Methods .................................................................................42 Approximate Training and Application Times ...................................42 Reliability and Validity .......................................................................42 Tools Needed ......................................................................................42 Case Study Example: Railway Level Crossings.................................42 Recommended Reading ......................................................................48 References ..........................................................................................48 v vi Contents Chapter 3 The Event Analysis of Systemic Teamwork Broken Links (EAST-BL) .........................................................................................51 Background ........................................................................................51 Domain of Application .......................................................................51 Procedure and Advice .........................................................................52 Advantages .........................................................................................62 Disadvantages .....................................................................................62 Related Methods .................................................................................62 Approximate Training and Application Times ...................................62 Reliability and Validity .......................................................................63 Tools Needed ......................................................................................63 Case Study Example: Darknet Marketplaces .....................................63 Recommended Reading ......................................................................68 References ..........................................................................................68 Chapter 4 The Systems Theoretic Process Analysis (STPA) Method .................71 Background ........................................................................................71 Domain of Application .......................................................................74 Procedure and Advice .........................................................................74 Advantages .........................................................................................83 Disadvantages .....................................................................................84 Related Methods .................................................................................84 Approximate Training and Application Times ...................................84 Reliability and Validity .......................................................................84 Tools Needed ......................................................................................85 Case Study Example: Elite Women’s Road Cycling ..........................85 Results ................................................................................................87 References ..........................................................................................88 SECTION III Systems Analysis and Design Methods ��������������������������������������� 91 Chapter 5 Hierarchical Task Analysis (HTA) .....................................................93 Background and Applications ............................................................93 Domain of Application .......................................................................94 Procedure and Advice .........................................................................94 Advantages .......................................................................................100 Disadvantages ...................................................................................100 Related Methods ...............................................................................101 Approximate Training and Application Times .................................101 Reliability and Validity .....................................................................101 Tools Needed ....................................................................................101 Contents vii Case Study Example: Identifying the Risks Associated with Working at Heights in Aircraft Maintenance .........................101 Recommended Reading ....................................................................103 References ........................................................................................103 Chapter 6 Cognitive Work Analysis (CWA) .....................................................105 Background ......................................................................................105 Procedure and Advice .......................................................................106 Related Methods ...............................................................................114 Approximate Training and Application Times .................................114 Reliability and Validity .....................................................................115 Tools Required .................................................................................115 Case Study Example: Autonomous Vehicles ....................................115 Results ..............................................................................................116 Work Domain Analysis ..........................................................116 Control Task Analysis – Decision Ladders ......................................119 Strategies Analysis ...........................................................................121 Social Organisation and Cooperation Analysis ................................123 Worker Competencies Analysis ........................................................123 Recommended Reading ....................................................................126 References ........................................................................................126 Chapter 7 The Event Analysis of Systemic Teamwork (EAST) .......................129 Background ......................................................................................129 Domain of Application .....................................................................129 Procedure and Advice .......................................................................130 Advantages .......................................................................................140 Disadvantages ...................................................................................140 Approximate Training and Application Times .................................141 Reliability and Validity .....................................................................141 Tools Needed ....................................................................................141 Case Study Example: Submarine Control Room Design .................141 Task Network Analysis .....................................................................141 Social Network Analysis ..................................................................145 Information Network Analysis .........................................................147 Combining Network Models ............................................................148 Task and Social Networks ................................................................149 Information and Social Networks .....................................................151 Information and Task Networks .......................................................152 Combined Task, Social, and Information Networks ........................153 Recommended Reading ....................................................................155 References ........................................................................................155 viii Contents Chapter 8 Causal Loop Diagrams (CLDs) ........................................................157 Background ......................................................................................157 Procedure and Advice .......................................................................157 Advantages .......................................................................................164 Disadvantages ...................................................................................165 Related Methods ...............................................................................165 Approximate Training and Application Times .................................165 Tools Needed ....................................................................................166 Case Study Example: The Fatal Five Causes of Road Trauma ........166 Behaviours Analysed ........................................................................166 CLD Development ............................................................................167 Results ..............................................................................................168 CLDs for Each Fatal Five Behaviour ...............................................169 The Role of Societal Issues in Road Trauma ...................................177 The Role of Work Pressures in Road Trauma ..................................177 Reducing the Requirement to Drive .................................................178 Recommended Reading ....................................................................178 References ........................................................................................178 SECTION IV Accident Analysis Methods ����������181 Chapter 9 The Accident Mapping (AcciMap) Method .....................................183 Background ......................................................................................183 Domain of Application .....................................................................185 Procedure and Advice .......................................................................186 Advantages .......................................................................................194 Disadvantages ...................................................................................194 Related Methods ...............................................................................195 Approximate Training and Application Times .................................196 Reliability and Validity .....................................................................196 Tools Required .................................................................................196 Case Study Example (Single Incident): Air France 447...................196 Case Study Example (Multiple Incidents): Injury Causation in Led Outdoor Activities ......................................................197 Recommended Reading ....................................................................203 References ........................................................................................203 Chapter 10 The Accident Network (AcciNet) .....................................................207 Background and Applications ..........................................................207 Domain of Application .....................................................................208 Procedure and Advice .......................................................................209 Advantages .......................................................................................218 Disadvantages ...................................................................................220 Contents ix Related Methods ...............................................................................220 Approximate Training and Application Times .................................221 Reliability and Validity .....................................................................222 Tools Needed ....................................................................................222 Case Study Application: Uber Volvo Incident Analysis ...................222 References ........................................................................................228 Chapter 11 The Systems Theoretic Accident Model and Process-Causal Analysis based on Systems Theory (STAMP-CAST) Method ........229 Background ......................................................................................229 Domain of Application .....................................................................231 Procedure and Advice (STAMP-CAST) ..........................................231 Advantages .......................................................................................237 Disadvantages ...................................................................................238 Related Methods ...............................................................................238 Approximate Training and Application Times .................................238 Reliability and Validity .....................................................................239 Tools Needed ....................................................................................239 Case Study Example: Medication Administration Error ..................239 Medication Administration Control Structure .......................239 Prescribing Operating Process..........................................................245 Preparation and Administration Operating Processes ......................245 STAMP-CAST Analysis of a Medication Administration Failure ......246 Recommended Reading ....................................................................249 References ........................................................................................249 SECTION V Computational Modelling Methods ��������������������������������������251 Chapter 12 Agent-Based Modelling (ABM) .......................................................253 Background ......................................................................................253 Domain of Application .....................................................................253 Can You Please Just Tell Me What ABMs Are? ...............................255 Thinking ABM-Style ........................................................................256 Procedure and Advice ............................................................258 Training and Application Times .......................................................262 Reliability and Validity Evidence .....................................................262 Tools Required .................................................................................263 Case Study Example: Autonomous Vehicle and Vulnerable Road User Crashes ................................................................263 Background ......................................................................................263 Method .............................................................................................265 Results ..............................................................................................265

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Handbook of Systems Thinking Methods PDF

331 Pages·2022·30.68 MB·English
by  Paul M. Salmon, Neville A. Stanton, Guy H. Walker, Adam Hulme, Natassia Goode, Jason Thompson, Gemma J.M. Read
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Handbook of Systems Thinking Methods Handbook of Systems Thinking Methods Paul M. Salmon Neville A. Stanton Guy H. Walker Adam Hulme Natassia Goode Jason Thompson Gemma J. M. Read First edition published 2023 by CRC Press 6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742 and by CRC Press 4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN CRC Press is an imprint of Taylor & Francis Group, LLC © 2023 Paul M. Salmon, Neville A. Stanton, Guy H. Walker, Adam Hulme Natassia Goode, Jason Thompson, and Gemma J. M. Read Reasonable efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the consequences of their use. The authors and publishers have attempted to trace the copyright holders of all material reproduced in this publication and apologise to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, access www.copyright.com or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978- 750-8400. For works that are not available on CCC please contact [email protected] Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identification and explanation without intent to infringe. ISBN: 978-0-367-22017-4 (hbk) ISBN: 978-1-032-27238-2 (pbk) ISBN: 978-0-429-28162-4 (ebk) DOI: 10.1201/9780429281624 Typeset in Times by SPi Technologies India Pvt Ltd (Straive) Contents Preface .......................................................................................................................xi Acknowledgements .................................................................................................xiii Author Biographies ..................................................................................................xv SECTION I Introduction to Systems Thinking ������1 Chapter 1 Introduction to Systems Thinking in Human Factors and Ergonomics and Safety Science ...........................................................3 The Call to Action ................................................................................3 A Short Introduction to Systems Thinking ...........................................4 Open Systems ............................................................................6 Complexity Theory ....................................................................6 Evolution of Systems Thinking .................................................8 The Systems Thinking Tenets ..............................................................8 How to Blow Up the Death Star .........................................................11 The Death Star .........................................................................13 The Empire Strikes Back .........................................................18 A Real-Life Thermal Exhaust Port to Find ........................................24 Note ....................................................................................................25 References ..........................................................................................25 SECTION II Risk Assessment Methods ���������������29 Chapter 2 The Networked Hazard Analysis and Risk Management System (Net-HARMS) ....................................................................................31 Background ........................................................................................31 Domain of Application .......................................................................33 Procedure and Advice .........................................................................33 Advantages .........................................................................................40 Disadvantages .....................................................................................41 Related Methods .................................................................................42 Approximate Training and Application Times ...................................42 Reliability and Validity .......................................................................42 Tools Needed ......................................................................................42 Case Study Example: Railway Level Crossings.................................42 Recommended Reading ......................................................................48 References ..........................................................................................48 v vi Contents Chapter 3 The Event Analysis of Systemic Teamwork Broken Links (EAST-BL) .........................................................................................51 Background ........................................................................................51 Domain of Application .......................................................................51 Procedure and Advice .........................................................................52 Advantages .........................................................................................62 Disadvantages .....................................................................................62 Related Methods .................................................................................62 Approximate Training and Application Times ...................................62 Reliability and Validity .......................................................................63 Tools Needed ......................................................................................63 Case Study Example: Darknet Marketplaces .....................................63 Recommended Reading ......................................................................68 References ..........................................................................................68 Chapter 4 The Systems Theoretic Process Analysis (STPA) Method .................71 Background ........................................................................................71 Domain of Application .......................................................................74 Procedure and Advice .........................................................................74 Advantages .........................................................................................83 Disadvantages .....................................................................................84 Related Methods .................................................................................84 Approximate Training and Application Times ...................................84 Reliability and Validity .......................................................................84 Tools Needed ......................................................................................85 Case Study Example: Elite Women’s Road Cycling ..........................85 Results ................................................................................................87 References ..........................................................................................88 SECTION III Systems Analysis and Design Methods ��������������������������������������� 91 Chapter 5 Hierarchical Task Analysis (HTA) .....................................................93 Background and Applications ............................................................93 Domain of Application .......................................................................94 Procedure and Advice .........................................................................94 Advantages .......................................................................................100 Disadvantages ...................................................................................100 Related Methods ...............................................................................101 Approximate Training and Application Times .................................101 Reliability and Validity .....................................................................101 Tools Needed ....................................................................................101 Contents vii Case Study Example: Identifying the Risks Associated with Working at Heights in Aircraft Maintenance .........................101 Recommended Reading ....................................................................103 References ........................................................................................103 Chapter 6 Cognitive Work Analysis (CWA) .....................................................105 Background ......................................................................................105 Procedure and Advice .......................................................................106 Related Methods ...............................................................................114 Approximate Training and Application Times .................................114 Reliability and Validity .....................................................................115 Tools Required .................................................................................115 Case Study Example: Autonomous Vehicles ....................................115 Results ..............................................................................................116 Work Domain Analysis ..........................................................116 Control Task Analysis – Decision Ladders ......................................119 Strategies Analysis ...........................................................................121 Social Organisation and Cooperation Analysis ................................123 Worker Competencies Analysis ........................................................123 Recommended Reading ....................................................................126 References ........................................................................................126 Chapter 7 The Event Analysis of Systemic Teamwork (EAST) .......................129 Background ......................................................................................129 Domain of Application .....................................................................129 Procedure and Advice .......................................................................130 Advantages .......................................................................................140 Disadvantages ...................................................................................140 Approximate Training and Application Times .................................141 Reliability and Validity .....................................................................141 Tools Needed ....................................................................................141 Case Study Example: Submarine Control Room Design .................141 Task Network Analysis .....................................................................141 Social Network Analysis ..................................................................145 Information Network Analysis .........................................................147 Combining Network Models ............................................................148 Task and Social Networks ................................................................149 Information and Social Networks .....................................................151 Information and Task Networks .......................................................152 Combined Task, Social, and Information Networks ........................153 Recommended Reading ....................................................................155 References ........................................................................................155 viii Contents Chapter 8 Causal Loop Diagrams (CLDs) ........................................................157 Background ......................................................................................157 Procedure and Advice .......................................................................157 Advantages .......................................................................................164 Disadvantages ...................................................................................165 Related Methods ...............................................................................165 Approximate Training and Application Times .................................165 Tools Needed ....................................................................................166 Case Study Example: The Fatal Five Causes of Road Trauma ........166 Behaviours Analysed ........................................................................166 CLD Development ............................................................................167 Results ..............................................................................................168 CLDs for Each Fatal Five Behaviour ...............................................169 The Role of Societal Issues in Road Trauma ...................................177 The Role of Work Pressures in Road Trauma ..................................177 Reducing the Requirement to Drive .................................................178 Recommended Reading ....................................................................178 References ........................................................................................178 SECTION IV Accident Analysis Methods ����������181 Chapter 9 The Accident Mapping (AcciMap) Method .....................................183 Background ......................................................................................183 Domain of Application .....................................................................185 Procedure and Advice .......................................................................186 Advantages .......................................................................................194 Disadvantages ...................................................................................194 Related Methods ...............................................................................195 Approximate Training and Application Times .................................196 Reliability and Validity .....................................................................196 Tools Required .................................................................................196 Case Study Example (Single Incident): Air France 447...................196 Case Study Example (Multiple Incidents): Injury Causation in Led Outdoor Activities ......................................................197 Recommended Reading ....................................................................203 References ........................................................................................203 Chapter 10 The Accident Network (AcciNet) .....................................................207 Background and Applications ..........................................................207 Domain of Application .....................................................................208 Procedure and Advice .......................................................................209 Advantages .......................................................................................218 Disadvantages ...................................................................................220 Contents ix Related Methods ...............................................................................220 Approximate Training and Application Times .................................221 Reliability and Validity .....................................................................222 Tools Needed ....................................................................................222 Case Study Application: Uber Volvo Incident Analysis ...................222 References ........................................................................................228 Chapter 11 The Systems Theoretic Accident Model and Process-Causal Analysis based on Systems Theory (STAMP-CAST) Method ........229 Background ......................................................................................229 Domain of Application .....................................................................231 Procedure and Advice (STAMP-CAST) ..........................................231 Advantages .......................................................................................237 Disadvantages ...................................................................................238 Related Methods ...............................................................................238 Approximate Training and Application Times .................................238 Reliability and Validity .....................................................................239 Tools Needed ....................................................................................239 Case Study Example: Medication Administration Error ..................239 Medication Administration Control Structure .......................239 Prescribing Operating Process..........................................................245 Preparation and Administration Operating Processes ......................245 STAMP-CAST Analysis of a Medication Administration Failure ......246 Recommended Reading ....................................................................249 References ........................................................................................249 SECTION V Computational Modelling Methods ��������������������������������������251 Chapter 12 Agent-Based Modelling (ABM) .......................................................253 Background ......................................................................................253 Domain of Application .....................................................................253 Can You Please Just Tell Me What ABMs Are? ...............................255 Thinking ABM-Style ........................................................................256 Procedure and Advice ............................................................258 Training and Application Times .......................................................262 Reliability and Validity Evidence .....................................................262 Tools Required .................................................................................263 Case Study Example: Autonomous Vehicle and Vulnerable Road User Crashes ................................................................263 Background ......................................................................................263 Method .............................................................................................265 Results ..............................................................................................265

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