Search Results (24)

Organizations increasingly rely on Agile software development to navigate the complexities of digital transformation. Agile emphasizes flexibility, empowerment, and emergent design, yet large-scale initiatives often extend beyond single teams to include multiple subsidiaries, business units, and regulatory stakeholders. In such contexts, team-level mechanisms such as retrospectives, backlog refinement, and planning events may prove insufficient to achieve alignment across diverse perspectives, organizational boundaries, and compliance requirements. To address this limitation, this paper introduces a complementary framework and a supporting software tool that enable systematic cross-stakeholder alignment. Rather than replacing Agile practices, the framework enhances them by capturing heterogeneous stakeholder views, surfacing tacit knowledge, and systematically reconciling differences into a shared alignment artifact. The methodology combines individual Functional Resonance Analysis Method (FRAM)-based process modeling, iterative harmonization, and an evidence-supported selection mechanism driven by quantifiable performance indicators, all operationalized through a prototype tool. The approach was evaluated in a real industrial case study within the regulated gaming sector, involving practitioners from both a parent company and a subsidiary. The results show that the methodology effectively revealed misalignments among stakeholders’ respective views of the development process, supported structured negotiation to reconcile these differences, and produced a consolidated process model that improved transparency and alignment across organizational boundaries. The study demonstrates the practical viability of the methodology and its value as a complementary mechanism that strengthens Agile ways of working in complex, multi-stakeholder environments. Full article

Occupational heat stress represents an increasing challenge to safety and operational performance in underground mining, where elevated temperatures, humidity, and limited ventilation are common. This study proposes an integrated framework to analyze the systemic impact of heat stress on human reliability in mining operations. We conducted a systematic literature review to identify empirical studies addressing thermal exposure, extracting key operational functions for modeling. These functions were structured using the Functional Resonance Analysis Method (FRAM) to reveal interdependencies and performance variability. Human reliability was evaluated using Fuzzy CREAM, which quantified the degree of contextual control associated with each function. Finally, we applied the Gaussian Analytic Hierarchy Process (AHP) to prioritize functions based on thermal impact, contextual reliability, and systemic connectivity. The results showed that functions involving subjective or complex judgment, such as assessing thermal stress or identifying psychophysiological indicators, exhibited lower reliability and higher vulnerability. In contrast, monitoring and control functions based on standardized procedures were more stable and resilient. This combined approach identified critical points of systemic fragility and offers a robust decision-support tool for prioritizing thermal risk mitigation. The findings contribute to advancing the scientific understanding of heat stress impacts in mining and support the development of targeted interventions to enhance human performance and safety in extreme environments. Full article

Background: The Functional Resonance Analysis Method (FRAM) analyses discrepancies between written protocols (Work-as-Imagined) and real-world practice (Work-as-Done) in healthcare. Work-as-Done is created based on multiple stakeholders, leading to variability in reported functions. No guidance exists how to manage this variability. This study examines between-stakeholder variation in Work-as-Done and its impact on differences from Work-as-Imagined in FRAM visualisations. Methods: Two FRAM studies were analysed: delirium diagnosis and treatment (1) and perioperative anticoagulant management in two hospitals (2). Heatmaps visualised between-stakeholder variability of reported functions in Work-as-Done. We assessed the impact of including only functions shared by multiple stakeholders on Work-as-Imagined versus Work-as-Done comparisons. Results: In study 1, 23 of 33 functions were shared among at least two stakeholders. In study 2, stakeholders shared 30 of 33 functions in Hospital 1 and 29 of 32 functions in Hospital 2. Including or excluding functions, e.g., only mentioned by one stakeholder, influenced the observed differences between Work-as-Imagined and Work-as-Done. Conclusions: Between-stakeholder variability in both studies influenced differences between Work-as-Imagined and Work-as-Done, which often is the starting point improving the process. Showing between-stakeholder variability in FRAM studies enhances transparency in researcher decision-making. This supports more informed analysis and discussion in process improvement efforts. Full article

The air transportation system is composed of multiple elements and belongs to a complex socio-technical system. It is difficult to assess the risk of an aircraft fault because it could constantly change during operation and is influenced by numerous factors. Although traditional methods such as Failure Mode, Effects, and Criticality Analysis (FMECA) and Fault Tree Analysis (FTA) can reflect the degree of fault risk to a certain extent, they cannot accurately quantify and evaluate the fault risk under the multiple influences of human factors, random faults, and external environment. In order to solve these problems, this article proposes a fault risk assessment method for aircraft control systems based on a fault risk composite assessment framework using the Improved Risk Priority Number (IRPN) as the basis for the fault risk assessment. Firstly, a Bayesian network (BN) and Gated Recurrent Unit (GRU) are introduced into the traditional evaluation framework, and a hybrid prediction model combining static and dynamic failure probability is constructed. Subsequently, this paper uses the functional resonance analysis method (FRAM) by introducing a risk damping coefficient to analyze the propagation and evolution of fault risks and accurately evaluate the coupling effects between different functional modules in the system. Finally, taking the fault of a jammed flap/slat drive mechanism as an example, the risk of the fault is evaluated by calculating the IRPN. The calculation results show that the comprehensive failure probability of the aircraft control system in this case is 3.503 × 10⁻⁴. Taking into account the severity, the detection, and the risk damping coefficient, the calculation result of IRPN is 158.00. According to the classification standard of the risk level, the failure risk level of the aircraft belongs to a controlled risk, and emergency measures need to be taken, which is consistent with the actual disposal decision in this case. Therefore, the evaluation framework proposed in this article not only supports a quantitative assessment of system safety and provides a new method for fault risk assessments in aviation safety management but also provides a theoretical basis and practical guidance for optimizing fault response strategies. Full article

A multi-unit nuclear accident is an accident that damages the nuclear core and occurs in multiple units simultaneously in a nuclear power plant. Its massive consequences have triggered extensive studies on accident prevention and mitigation. In this study, we are interested in the emergency-response teams involved in multi-unit accident management. Multiple emergency-response teams need to interact with each other during multi-unit accident-management tasks, and the basis of team interactions is communication. Thus, we propose a team-communication modeling framework consisting of three models, i.e., a team-communication investigation model, process model, and performance-factor model. The methods used to develop each model are described. Also, an analysis methodology is provided to guide the application of the modeling framework, and a case study based on a multi-unit accident scenario is performed to confirm the feasibility of our study. The final results of the case study are four specialized models developed by applying the functional resonance analysis method (FRAM), each covering a specific scope of the accident scenario, with the functions and aspects elaborated to support team-communication analysis. Modeling insights are collected and can be applied to improve accident-training scenarios, procedure/guideline development, and accident-management support systems. Full article

The safety of flight operations and passengers is one of the main criteria for evaluating airport performance. Risk analysis and assessment are used to ensure safety in the airport’s decision-making process. This paper aims to formally analyze these processes and look for weaknesses that can lead to erroneous assessments and, thus, ineffective decisions. Given the specific nature of the issue, which requires the Safety II approach, it was assumed that the analysis would be carried out using a systems approach, considering all factors and relationships affecting the effectiveness of the examined processes. As relatively small-scale deviations from the planned operation of individual system functions are observed in real-world analyses, the Functional Resonance Analysis Method (FRAM) was selected as adequate for such situations. A formal study of the risk assessment process was carried out, focusing on two cases chosen during the initial identification of possible hazards. Applying the FRAM proved an effective way to analyze and search for functional resonance in the airport risk assessment process. It also enabled the identification of mitigating actions, which allows for breaking the chain of variability that leads to an unfavorable course of the process. Full article

In the recent literature, numerous tools have been found that have been used to evaluate and improve the resilience of socio-technical systems such as hospitals. The Functional Resonance Analysis Method (FRAM) is certainly one of the most diffused, as it can provide information on the system structure and its components through a systemic analysis approach. FRAM has been successfully applied in different contexts. However, in the healthcare sector, only a few studies propose practical analyses that can support practitioners in systematically observing and analyzing events, both when things go right and when they go wrong. To reduce such a research gap, the current study focuses on the application of FRAM to two different case studies: (1) an accident that occurred in a hyperbaric oxygen therapy unit, and (2) the risk assessment of a magnetic resonance imaging unit. The results show the effectiveness of FRAM in detecting discrepancies and vulnerabilities in the practical management of these devices, providing valuable insights not only regarding the analysis of adverse events (i.e., retrospectively) but also concerning the improvement of safety procedures (i.e., prospectively). Full article

Nowadays, services related to IT technologies have assumed paramount importance in most sectors, creating complex systems involving different stakeholders. Such systems are subject to unpredictable risks that differ from what is usually expected and cannot be properly managed using traditional risk assessment approaches. Consequently, ensuring their reliability represents a critical task for companies, which need to adopt resilience engineering tools to reduce the occurrence of failures and malfunctions. With this goal in mind, the current study proposes a risk assessment procedure for cloud migration processes that integrates the application of the Functional Resonance Analysis Method (FRAM) with tools aimed at defining specific performance requirements for the suppliers of this service. In particular, the Critical-To-Quality (CTQ) method was used to define the quality drivers of the IT platform customers, while technical standards were applied to define requirements for a security management system, including aspects relevant to the supply chain. Such an approach was verified by means of its application to a real-life case study, which concerns the analysis of the risks inherent to the supply chain related to cloud migration. The results achieved can contribute to augmenting knowledge in the field of IT systems’ risk assessment, providing a base for further research. Full article

Collision risk in ship pilotage process has complex characteristics that are dynamic, uncertain, and emergent. To reveal collision risk resonance during ship pilotage process, a hybrid probabilistic risk analysis approach is proposed, which integrates the Functional Resonance Analysis Method (FRAM), Dempster–Shafer (D–S) evidence theory, and Monte Carlo (MC) simulation. First, FRAM is used to qualitatively describe the coupling relationship and operation mechanism among the functions of the pilotage operation system. Then, the D–S evidence theory is used to determine the probability distribution of the function output in the specified pilotage scenario after quantitatively expressing the function variability, coupling effect, and the influence of operation conditions through rating scales. Finally, MC simulation is used to calculate the aggregated coupling variability between functions, and the critical couplings and risk resonance paths under different scenarios are identified by setting the threshold and confidence level. The results show that ship collision risk transmission is caused by function resonance in the pilotage system, and the function resonance paths vary with pilotage scenarios. The critical coupling ‘F2-F7(I)’ emerges as a consistent factor in both scenarios, emphasizing the significance of maintaining a proper lookout. The hybrid probabilistic risk analytical approach to ship pilotage risk resonance with FRAM can be a useful method for analysing the causative mechanism of ship operational risk. Full article

Paediatric homecare is an advancing field of healthcare, bringing care direct to patients in their own homes. Risk management is an integral component of homecare services, including incident and risk assessment management. The objective of the study was to investigate risk management in homecare focusing on two aspects: incident reporting and risk assessments. A Grounded Theory approach was used to gather key functions of these aspects; these were then mapped using the Functional Resonance Analysis method (FRAM). Nineteen nurses working in paediatric homecare services were interviewed for the study. The interviews were semi-structured and focused on risk, quality, complaints, audit, care, and management. The interview data were transcribed and coded using Nvivo; the data were then converted into functions for utilization in the FRAM tool. The FRAM detailed the process of incident reporting and risk assessment management of the actual work carried out as viewed by the participants of the study. The information was then analysed and contrasted with the organizational policy to gain an understanding of the systems of incident reporting and risk assessments, which then led to the development of a refined process that could have less variability in function. Consequently, changes to policy and training in risk management were recommended to enhance the systems. Full article

The levels of informatization, automation, and intelligence are continuously improving; however, the risks associated with the increased design and operational complexity of ship systems are increasing. Large-scale ship accidents can occur for several reasons. Existing accident analysis methods that examine marine accidents from the perspective of causal one-to-one correspondence have limitations in systematically analyzing complex marine risks during cause identification for the prevention of similar accidents. This study focuses on a systematic causality analysis of the factors related to human error in marine accidents that may occur during the arrival and departure of mega container ships. In particular, a representative case of the Motor Vessel (MV) Milano Bridge crane contact accident at Busan New Port is considered. To explore the complex organizational–technical, human–technical, and organizational–human relationships relevant to this case, human factors (seafarer, pilot, etc.) that are closely related to the linked causes were analyzed using the functional resonance analysis method. This study aims to reduce human error and prevent marine accidents, including pilotage. Full article

This article proposes an improved FRAM method based on the traditional FRAM method, using the study of aircraft take-off quality as an example to illustrate the operation method of the improved FRAM. To address the impact of pilot operations on take-off instructions during aircraft take-off, a functional network model was constructed based on the improved FRAM (functional resonance analysis method) method for the take-off and roll stages of the aircraft. On the basis of the aircraft take-off taxiing model, a simulation was used to sample the take-off data from the pilot many times under different conditions, and the data were put into the safety envelope for comparative analysis to find functional modules with abnormal changes. Using the functional network model, the resonance relationship between the abnormal module and other related functional modules was determined. According to the resonance relationship, setting up a safety barrier can reduce the risk of accidents. Finally, the safety barrier was substituted back into the improved FRAM method to verify the effectiveness of the safety barrier. Compared with the traditional FRAM method, the improved FRAM method can make full use of historical data, loop iteration, repeated verification, and continuous improvement until the final result reaches the user’s expected goal. The improved FRAM method reduces the dependence on expert evaluation and experience, so its conclusions have higher objectivity and reference value. Full article

In nuclear power plants, a severe accident is a critical accident involving significant nuclear core damage and it is managed by using a set of Severe Accident Management Guidelines (SAMG). Prepared as a guideline that provides lists of suggestions rather than strict instructions, SAMG’s contents require frequent decision-making by the operators, causing high cognitive load and creating an error-prone situation that is also amplified by the stressful environment during the severe accident mitigation efforts. A decision support system (DSS), designed by considering the human decision-making process and the system’s holistic view, can help the operators in making informed and appropriate decisions. In this study, we aim to identify the information requirements in designing such DSS for severe accident management of nuclear power plants. We combined two methods: Functional Resonance Analysis Method (FRAM) and decision ladder to identify the information requirements. FRAM provides a systematic analysis of the functions involved in severe accident management and decision ladder captures the human decision-making processes. We developed the FRAM model and the decision ladder model based on SAMG’s contents to identify the set of information requirements. The identified information requirements and their implementation suggestions are provided. This study is the first step in designing a decision support system that considers human cognitive load and holistic system concepts. The method used in this study shall contribute to the design and implementation of a DSS capable of supporting the operators in achieving safer decision-making, not only in nuclear power plants’ severe accident management but also in similar safety-critical systems. Full article

Automated driving promises great possibilities in traffic safety advancement, frequently assuming that human error is the main cause of accidents, and promising a significant decrease in road accidents through automation. However, this assumption is too simplistic and does not consider potential side effects and adaptations in the socio-technical system that traffic represents. Thus, a differentiated analysis, including the understanding of road system mechanisms regarding accident development and accident avoidance, is required to avoid adverse automation surprises, which is currently lacking. This paper, therefore, argues in favour of Resilience Engineering using the functional resonance analysis method (FRAM) to reveal these mechanisms in an overtaking scenario on a rural road to compare the contributions between the human driver and potential automation, in order to derive system design recommendations. Finally, this serves to demonstrate how FRAM can be used for a systemic function allocation for the driving task between humans and automation. Thus, an in-depth FRAM model was developed for both agents based on document knowledge elicitation and observations and interviews in a driving simulator, which was validated by a focus group with peers. Further, the performance variabilities were identified by structured interviews with human drivers as well as automation experts and observations in the driving simulator. Then, the aggregation and propagation of variability were analysed focusing on the interaction and complexity in the system by a semi-quantitative approach combined with a Space-Time/Agency framework. Finally, design recommendations for managing performance variability were proposed in order to enhance system safety. The outcomes show that the current automation strategy should focus on adaptive automation based on a human-automation collaboration, rather than full automation. In conclusion, the FRAM analysis supports decision-makers in enhancing safety enriched by the identification of non-linear and complex risks. Full article

To improve the ergonomic reliability of medical equipment design during the operation process, a method for evaluating the operating procedure of a medical equipment interface according to functional resonance analysis method (FRAM)-Moran’s I and cognitive reliability and error analysis method (CREAM) is proposed in this study. The novelty of this research is to analyze the ergonomic reliability of medical equipment in a more systematic manner and to minimize the impact of human subjectivity and individual differences on the evaluation results of the operation process. To solve the calculation problem of functional resonance in FRAM and to make the evaluation results more objective, Moran’s I was introduced to quantify the deviation degree caused by the individual differences of the subjects. By giving weights based on Moran’s I, the influence of individual differences and subjectivity on the evaluation results can be minimized, to a certain extent. Considering the importance of a special environment, which is not fully considered by the conventional CREAM, the weighting values based on Moran’s I, Delphi survey, and technique for order preference by similarity to an ideal solution (TOPSIS) were adopted to assign weights to common performance conditions (CPCs) in CREAM. The optimal design scheme was selected more objectively than in the conventional method. The validity and practicability of this operation process evaluation method was verified by a statistical method based on ergonomic reliability experiments. Full article