Abstract:
In order to manage the performance of socio-technical systems in a safe and sustainable way, the importance of looking at human and organisational factors (HOF) and their contribution to adverse events is widely recognised. In reality, however, the scope of accident and incident investigations stays usually limited to investigating the immediate causes and decision-making processes related to the accident sequence (e.g. Antonsen, 2009). Important factors, including design and planning decisions, contributing to accidents are hereby often overlooked and the weaknesses in the Safety Management System are hardly ever analysed. The SAfety FRactal ANalysis (SAFRAN) method (Accou and Reniers, 2019) can guide investigators in an intuitive and logic way, to ask questions that help to gain deeper understanding of the capability of organisations to monitor and manage safety critical variability…
