FRAM: Functional Resonance Analysis Method

2012, Hollnagel, E., Ashgate Publishing, Farnham, U.K., ISBN 1-4094-4551-7

This book represents the culmination of many years of analysis and discussion and offers a detailed description of a systemic non-linear approach to understanding adverse events and critical incidents. While the book is subtitled “Modeling Complex Socio-Technical Systems” one of the more impelling discussions is the author’s distinction between models and methods. FRAM is clearly a method to understand and describe events in the world, from which a model can be constructed if that is desired. This is very much in keeping with complexity science and the concept of emergence. In contrast, when starting with a previously elaborated model of accidents (for example, the Swiss Cheese approach) there is inevitably a temptation to gather and interpret data in a way that “fits” with the model. The author writes in a very clear and easily understood way and the depth of experience is evident in the many examples that are used. This is highly recommended for anyone wishing to explore systemic non-linear approaches to retrospective incident analysis in complex systems.

(RR: October 2012)

Behind Human Error (2nd Edition)

2010, Woods, D.D., Dekker, S.W.A., Cook, R., Johannesen, L., Sarter, N., Ashgate Publishing, Farnham, U.K., ISBN 978-0-7546-7833-5

This book is a brilliant update of a work from 1994 and provides a solid basis for gaining a better understanding of accidents and incidents, especially in complex systems. The authors provide excellent extensive references of relevant research and writing that clarifies the concept of “human error”. This in turn leads the reader to re-evaluate the ease with which unexpected results and harm is so often attributed uniquely to the contributions of human operators in complex environments. Few of the ideas are new but the authors have brought them together, with extensive persuasive supportive data, in a way that begs us to be more rigorous in our search for explanations and understanding of events. This book is a “must-read” for any system safety practitioner and all those with responsibility to provide leadership in safety-critical domains.

(RR: October 2012)