Listing Relevant Organizational Components 88 Connecting Control Structure Components 95 Generic Connector Types 96 Documenting Organizational Components 107 Analyzing Safety Control Structures 111 Completeness Criteria 112 Consistency Criteria 114 Formal and Informal structures and COnnections 119 New Control Structures vs. Existing Control Structures 119 Monitoring Safety Control Structures 120 From Component to Individuals: Monitoring using Social Networks 121 Summary 122CHAPTER 4: Creating Dynamic Risk Management Models Using Generic Customizable Dynamic Components 124 Model Building Methodology 124 Using Generic Structures, Components, and Archetypes 124 Combining STAMP safety control structures with causal loop structures ... 125 Creating Dynamic Risk Management Models based on STAMP and System Dynamics 127 Step 1: Initial System Characterization 131 Step 2: Mapping of Static Safety Control Structure to Generic Dynamic Components 137 Step 3: Refinement of Dynamic Safety Model Structure 140 Step 4: Mapping of Pressures, Influences and Reporting Channels 141 Step 5: Data Collection and Component Calibration 146 Step 6: Component Testing and Confidence-Building Activities 157 Step 7: Component-Based Model Assembly 161 Step 8: Model Testing and Confidence-Building Activities 164 Moving Forward: Model Analysis 167CHAPTER 5: Analysis of Dynamic Safety and Risk Management Models 169 improving Safety/Risk Decision Making 169 Management Simulators 170 Visualization of Model Structure and Behavior 172 Interactive Scenario-Based Learning and Decision-Aid 175 Analyzing identified risk Scenarios 176 Risk Identification 176 Scenario Creation and Analysis 179 Recommendations and Policy Development based on Scenario Results 182 Policy Robustness and Scenario Sensitivity Analysis 183 Preventing Risk Increase and improving robustness to safety erosion 183 Preventing Time-Dependent Safety Erosion 184 Improving System Robustness to Risk Increase 185 Improving Risk monitoring in complex systems 186 Identifying Leading Indicators 187 Leading Indicator Sensitivity 189 Summary 190CHAPTER 6: Case Study - Risk Management in the Development of NASA’s Space Exploration System 192 ESMD Model-Building Methodology 192 Step 1: ESMD Initial System Characterization 192 Step 2: Mapping of Static Safety Control Structure to Generic Dynamic Components 193 Step 3: Refinement of Dynamic Safety Model Structure 195 Step 4: Mapping of Pressures, Influences and Reporting Channels 196 Step 5: Data Collection and Component Calibration 198 Step 6: Component Testing and Confidence-Building Activities 205 Step 7: Component-Based Model Assembly 206 Step 8: Model Testing and Confidence-Building Activities 206 Individual ESMD Component Documentation 207 Congress and Executive (White House) Component 207 NASA Administration and ESMD Component 207 Exploration Program and Project Management Component 208 System Development Completion and Safety Analyses Component 208 Engineering – Technical Personnel Resources and Experience Component 209 Engineering – Effort and Efficacy of Technical Personnel Component 210 Safety and Mission Assurance - Effort and Efficacy of System Safety Analysts (EESSA) Component 210 Integrated ESMD Model Overview 210 Model Results and Scenario Analysis 213 Scenario 1: Workforce Planning 215 Scenario 2: Investigating Management Reserves 218 Scenario 3: Effect of Schedule Pressure and Safety Priority 221 Scenario 4: Effect of High Safety Influence and Power on Decision-Making 224 Scenario 5: Effect of Changes in Requirements and System Scope 228 Case Study Summary 230CHAPTER 7: Contributions, Future Work and Conclusion 232 Summary 232 Contributions 232 Static STAMP Control Structures Creation and Analysis Guidelines 232 Model-Building Methodology 233 Model-Based Risk Analysis Techniques 234 Interview-Based Model Validation Protocol 234 Project-Specific Insights 235 Future Work 235 Model-Building and Analysis Software Tools 235 Model Visualization Tools 236 Validation in Other Domains 236 Micro-Theories of Risk Increase in Complex Systems 236 Conclusion 238APPENDIX A: Acronyms 239APPENDIX B: Types of Uncertainty 241 Ambiguity 241 Aleatory Uncertainty 241 Epistemic Uncertainty 242 Model 242
Phenomenological 243
Behavioral 243
Interaction 244
APPENDIX C: Organizational Risk THeories 245
Normal Accident Theory (NAT) 245
NAT Limitations 246
High Reliability Organizations (HROs) 247
HRO Limitations 247
Debate and limitations 254
APPENDIX D: Impact of Balancing and Reinforcing Loops: The Case of the NASA Independent Technical Authority 257
ITA Context and Modeling 258
Initial ITA Model Analysis 260
ITA Behavior Mode Analysis 261
Behavior Mode #1: Successful ITA Implementation. 262
Behavior Mode #2: Unsuccessful ITA Implementation 263
APPENDIX E: Repository of Generic Dynamic Components 266
Research Approach for Component Creation
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