873
1 INTRODUCTION
The shipping industry has an essential role in global
trade and commerce, as the majority of goods are
transported by ship. Given the complexity of shipping
operations, ensuring the safety and efficiency of ships
and their crew is of paramount importance. Shipping
operation is understood as a complex socio-technical
system. It requires a complex interaction between
social and technical components to achieve the
intended goals. A complex socio-technical system has
unique properties called emergence phenomena. This
idea explained the situation where the system has
ability beyond its individual component ability when
it is working as a whole. Based on this perspective,
safety in ship operation is acknowledged as an
emergence phenomena arising from the complex
socio-technical system rather than a property of the
system [1].
Resilience engineering [2] is a core representative
of this new safety idea. Along with this initiative, the
Functional Resonance Analysis Method (FRAM) is a
well-established framework that has been introduced
to provide resilience engineering ideas in its
application. This method analyses the interaction
between different elements of a system and
understands how their dependency contributes to
system performance. The FRAM has been successfully
applied in a variety of domains, including safety-
critical industries such as aviation[3], offshore oil and
gas [4], and the maritime industry [5], [6].
The process of ship maneuvering is dynamic with
continuous command and feedback between the
Modelling Ship Officer Performance Variability Using
Functional Resonance Analysis Method and Dynamic
Bayesian Network
I.G.M.S
. Adhita, M. Fuchi, T. Konishi & S. Fujimoto
Kobe University, Kobe, Japan
ABSTRACT: Ship maneuvering is a complex operation with inherent uncertainties. To express this complexity
in system performance during the navigation process, an analysis model has been developed using Functional
Resonance Analysis Method (FRAM) and Dynamic Bayesian Network (DBN). The functional level of dynamic
work onboard is assessed and modeled using FRAM qualitatively, in which a key function and the function’s
potential coupling for specific instantiation are identified. Further analysis is done by integrating the FRAM
analysis with DBN for quantification. The evolution of system performance over time is determined through
changes in the probability of function’s mode, namely strategic, tactical opportunistic, and scrambled. The
model presented in this study concerns the fluctuation of ship officer performance to overcome the obstacles
during the encounter event. As a result, the integration of FRAM-DBN shows promising usability to evaluate
human performance. The essence of human adaptive capacity is also highlighted through system resilience
potency, that is, the potency to learn, respond, monitor, and anticipate. We also discuss how this finding
contributes to enhance safety analysis, in specific, to provide explicit representation of the dynamic in human
performance in ship navigation based on Safety-II idea.
http://www.tra
nsnav.eu
the
International Journal
on Marine Navigation
and Safety of Sea Transportation
Volume 17
Number 4
December 2023
DOI: 10.12716/1001.17.04.
13
874
officer on watch (OOW) and the helmsman. It
escalates in different traffic and environmental
situation. Indeed, the system hardly relays on the
OOW’s capacity to decide on appropriate action. This
implies the necessity of proper performance
adjustment to maintain the system works normally
under dynamic working condition. In this case,
human adaptability and flexibility are essential to
achieve this kind of purpose. The definition of safety
in this manner is introduced by a term called Safety-II
[7]. Hence, under this consideration, it is important to
understand deeper this adaptable performance more,
in specific of how the fluctuation affects system
output.
The application of FRAM in this study is to
identify the functional basis of ship maneuvering
activity and provide a systematic expression of it
through functions and potential couplings. Analysis
in FRAM is qualitative in nature. It provides an
explicit understanding of the system’s functionality in
the form of FRAM model but lacks in function’s
performance representation. One solution that can be
applied is cooperating with the method of
quantitative analysis. Some available studies have
existed regarding this matter, such as the application
of Monte Carlo evolution [3] and modified Fuzzy
FRAM-CREAM with cellular automata simulation [8].
Therefore, in addition to the FRAM, this study
employs a Dynamic Bayesian Network (DBN) for
mathematical modeling. DBN is an extended version
of the Bayesian Network (BN). It is a type of
probabilistic graphical model that can be used to
model complex, dynamic systems over time. BN has
been widely applied in the maritime industry,
especially to predict the probability of ship accidents
[9][11]. One of the advantages of DBN is this method
can handle temporal dependencies and allow for the
modeling of time-varying influences on system
behavior. The basic idea of this quantitative
expression is to model the discrete probabilistic
dependencies between functions at each point in time,
and then to propagate these dependencies over time
to express a dynamic change in the system.
A case study from ship handling simulation has
been chosen to perform the analysis. The FRAM-DBN
integration in this study aimed to develop a
comprehensive model of ship officer variability
performance, providing insights into how changes in
officer performance over time influence system
output. The meaning of using this specific case is to
provide actual-time segregation for every decision
initiative and actual evidence of performance for DBN
analysis. Furthermore, the FRAM model can also be
built for a specific instantiation. This is a simple
analysis that design to present what to expect from
performance adjustment, and how can normal
performance be disrupted and then produce
undesired outcomes. In conclusion, the essence of
human performance for establishing an adapted
system can be addressed, and what strategy must be
built to enhance it to possess a higher level of
resilience.
2 METHOD
This section explains a set of methods applied in this
study. First is the qualitative analysis using FRAM
and build the FRAM model. Second is integrating the
FRAM analysis with quantitative analysis based on
DBN. In addition to that method integration, the
control model from Cognitive Reliability and Error
Analysis Method (CREAM) has been brought to
provide characteristic for FRAM function. This
characteristic includes strategic, tactical,
opportunistic, and scrambled.
2.1 FRAM as a retrospective analysis
The FRAM [12], [13] has been widely implemented to
assess system safety in various fields. System
resilience [2] terminology, as a core of FRAM,
promotes new ideas for safety research by
acknowledging safety as an emergent phenomenon
instead of a property of the system. This implies the
need on looking for what was done in the everyday
operation of the system (Work-As-Done) and how
safety is present in the system. The term function is
used to express the need for something to be done by
the system. The function is classified into three
categories including human, technological, and
organization. FRAM has four basic principles,
including the equivalent of success and failure,
approximate adjustment, the principle of emergence,
and functional resonance.
Function in FRAM is presented as a hexagon with
six aspects to characterize the type of information in
function’s dependency. Input represents the
information or material to trigger the process in
function. Precondition refers to the conditions that
exist prior to the function starting its operation. In this
sense, precondition is complementary information
that explains the pre-event or preparation that has
been done before a function is carried out. Time is the
temporal dimension of the function, including the
timing and sequencing of events. Control represents
the mechanisms used to control the function,
including procedures, rules, and policies. Resource is
something that is used or consumed by the function,
including energy, competence, people, tools,
materials, etc. The output represents the results of the
function’s work. Outputs can be seen as a signal that
starts a downstream function.
The relationship of function is described in two
forms. First is temporal relationships, namely
upstream and downstream functions. This expresses a
function’s dependency on specific time observation.
The downstream function is affecting the process that
happened in the downstream function, and this role
can change over time based on the potential coupling
and time of function activation. Second, the general
role of background and foreground functions.
Background function presents a function that only has
output or input as its aspect. It means the function is
only affecting the other functions in the system. On
the other hand, the foreground function is a function
that has more than 1 aspect. This function receives
information from background or foreground
functions, and also produces an output for other
foreground or background functions. In other words,
875
these roles refer to the relative importance of the
function in the model. The foreground function
denotes the matter being studied in the model, i.e., the
focus of the investigation.
The essence of ship maneuvering events is derived
by conducting an experiment in ship handling
simulators. Furthermore, one specific result of the
simulation has been chosen as factual information to
build the FRAM model. The selected case is a case
where the participants experience a collision during
the simulation. In this case, FRAM is used as a
retrospective analysis. The identification is focused on
how the system should have functioned for achieving
its goal, which is to avoid the target ship safely. As a
result, the change of situation from normal
performance to disrupted performance can be
recognized.
2.2 Officer performance quantitative representation using
DBN
DBN is an extension of the Bayesian Network (BN)
with the ability to handle temporal dependency
among nodes that change over time. This advantage
makes DBN suitable to be applied for establishing an
explicit representation of the dynamic in performance
of ship officers during encounter events. DBN
presents a pair of time slices of BN (Xt-1 Xt), where
Xt-1 is the initial BN that defines the initial probability
of P(X), and Xt is the BN in the next time slice that
contains the conditional probability of two-time slice.
This state transition probability can be expressed as:
( )
(
)
1
1
(| ) |
t
n
ii
tt t t
x
P X X P X Pa X
=
=
(1)
where P(X) is the set of variables;
i
t
X
is the i-th node
of time slice t;
is the parent node of
i
t
X
; nt is
the number of nodes in the t-th time slice. In order to
solve this mathematical equation, the SMILE modeler
provided by BAYESFUSION has been applied in this
work. In addition, the DBN modeling has also been
done using the GeNIe software.
Figure 1. Relationship between control mode and common
performance condition
In this study, DBN is used to provide a
quantitative expression of the qualitative analysis that
has been provided by FRAM. To integrate the FRAM
with DBN, it is necessary to define a characteristic for
each function to generate a conditional probability
table (CPT). In this study, we decided to use the
control mode expressed in CREAM [14] to generally
characterize the FRAM function. It consists of
strategic, tactical, opportunistic, and scrambled.
Strategic control mode involves considering the global
context, using a wider time horizon and higher-level
goals, leading to more efficient and robust
performance, and planning based on the functional
dependencies between task steps. Tactical control
mode involves performance based on limited
planning, ad hoc needs, and frequently used
procedures that may seem rule-based due to context
or performance conditions. Opportunistic control
mode entails determining the next action based on
salient features of the current context, frequently
resulting in functional fixation, driven by perceptually
dominant features of the interface or frequently used,
familiar heuristics. Scrambled control mode involves
unpredictable decision-making without much
thought, often occurring during high task demands or
in unfamiliar, rapidly changing situations that lead to
a loss of situational awareness, potentially
culminating in momentary panic. Hence, the temporal
relationship of the function’s mode in which the
explicit representation of changes in performance over
time is presented through Bayesian thinking.
(a)
(b)
Figure 2. Discrete probability distribution of control mode
based on (a) CPC’s output variability [15] and (b)
probabilistic approach [16].
The determination of control mode in CREAM can
be derived by evaluating a defined criterion of a task.
However, in this study, we approach the
determination of the control mode in the form of a
discrete probability distribution. Figure 2 shows one
example of the discrete probability of the control
model in a given context of a common performance
condition. Based on this basis, it is possible to use this
idea to determine the CPT for the initial condition of
DBN. Therefore, the estimation of CPT for FRAM
function in maneuvering event is generated by
coopering discrete probability of CREAM control
876
mode with an adjustment based on the common
knowledge of officer performance in ship navigation.
3 CASE STUDY
A result from a ship handling simulation experiment
has been chosen to provide a factual story of ship
maneuvering events. The chosen simulation contains
an accident event in which the action taken by the
participant in each time slice is recognized. A deeper
understanding of participant’s decisions has also been
elaborated through structured interviews. The
participant is a licensed Officer with one experience
on board a ship as a Cadet. This is partial information
provided for the purpose of providing contextual
evidence for FRAM-DBN analysis. This simulation is
designed with a high level of maneuvering ability
such that the full potency of the participant to cope
with the situation can be observed.
Figure 3. Ship trajectory of the simulation result.
The event is last about six minutes. In this
situation, the target ship is moving from the northeast
and heading southwest. On the other hand, the
participant’s ship is initially heading southwest and
the final destination is in the southwest. The difficulty
is rising because the target’s speed is faster than the
participant’s speed. Therefore, he needs to maneuver
his ship to the destination and avoid the target ship
safely. The clarification of the participant’s decision to
overcome the situation is presented in Table 2. Five
questions were asked of the participant for further
understanding of his decision, including:
When actually do you start to think to make this
decision?
What information do you need before making this
decision?
What makes you decide to take this action? Why
did you do it at that time?
What was your strategy to avoid this target ship at
this moment? Do you have thought about that?
Please explain.
What factors do you consider the most to decide
this action?
Table 1. Time step and participant’s explanation for each
decision.
________________________________________________
Step Recorded Description
time
________________________________________________
0 ±00:00 Start to perform an action. Monitoring the
target ship’s situation and building a
strategy to reach the destination.
1 ±00:40 An initial decision has been made by
ordering “Port 20.” After seeing the radar
and understanding the target situation, he
made a sharp turn to the portside to avoid
the target. The participant says, “I did not
think much because the target ship was an
overtaking ship and my ship was a
maintenance ship. I admit that I have had a
feeling of colliding at this moment.”
2 Up to Continue to monitor the situation.
±03:00
3 ±03:17 Realize that the first decision was bad. He
tried to overcome the situation by ordering
“starboard 10” but did not work well. The
participant says, ”At about 3:00, I was very
embarrassed as the target ship approached.
I could not think of anything at that
moment. In fact, before making this
decision, I should have asked the target
about her intention.”
4 ±05:41 The collision accident happened
________________________________________________
4 RESULTS
4.1 FRAM model and analysis
The implementation of FRAM in ship navigation to
assess the potency of system resilience has been done
by Adhita et al. [5]. For simplification, the dynamic
FRAM model for ship maneuvering during the
simulation experiment has been introduced as shown
in Figure 4. The model consists of five background
functions, which present the focus function for being
studied, including <To monitor (by OOW>, <To do
direct lookout>, <To watch electronic devices>, <To
decide action (make judgment)>, and <To control the
rudder/engine>. The temporal changes in the
function’s dependency and function’s updated role
over time have also been presented in the model.
Figure 4. Simplified dynamic FRAM model for ship
maneuvering in a simulation experiment.
This simple FRAM model of ship maneuvering
activity (to avoid the target ship) in Figure 4 shows
the intended functional process of system
performance. <To monitor (By OOW)>, <To do direct
877
lookout>, and <To watch electronic devices> plays an
important role for monitoring and learning processes.
<To monitor (By OOW)> produces initial information
such as strategy and expectation about the current
vicinity situation to activate <To do direct lookout>
and <To watch electronic devices>. Once the
information is collected, the system starts to decide
what kind of response should be done to cope with
the situation through <To decide action (make
judgment)>. Soon after that, the anticipation strategy
is start to produce through the connection of <To
decide action (make judgment)> and <To follow-up
monitor (by OOW>. Finally, the process of function
activation is repeated over time until the target ship
can be avoided.
This model shows the potency of functional
resonance can be triggered in any connection that
exists between functions. Furthermore, the continuous
process of function activation can increase the
emergence of functional resonance. The longest the
repetition, the higher the tendency for emerging
resonance. The case of collision accident explained in
Section 3 shows an example of how this resonance
phenomenon affects function performance. An early
signal of high variability performance from
monitoring and lookout functions was felt at around
00:40. This is probably the primary cause of the
amplifying effect that emerges in function <To decide
action (make a judgment)> then produces an
unwanted outcome, in this case, the order of
“starboard 20.” The last adjustment has also
performed “too late” in terms of timing, which
resulting the effort to maintain the system to work
normally cannot be achieved.
4.2 DBN for modeling dynamic performance in ship
maneuvering
To perform the DBN calculation, first, we convert the
FRAM model to be Dynamic Bayesian Network
model as presented in Figure 5. The continuous
expression is marked by the edge with a number [1]
on it. This edge expresses that the information in <To
monitor (by OOW> at t=1 is updated by itself at t=0
and <To decide action (make judgment)> at t=0. Then,
the process is looped exactly as how it expresses in the
FRAM model. The specific time step (t=0 to t=4) to
iterate the calculation is stated based on the case study
in Chapter 3.
Figure 5. DBN model using GeNIe Software.
The number of CPTs in the initial node set
depends on the number of nodes’ characteristics and
the number of edges pointing to the node. In total, 176
combinations of conditional probability of function
have been created. As explained in Chapter 2, the
generated CPTs are determined using the adjusted
description of control mode with common knowledge
of ship navigation. For example, <To do direct
lookout> and <To watch electronic devices> are
treated equally, in which the function is
complementing each other. In the case of one function
performing “strategic”, and the other performing
“scrambled”, it will affect <To decide action (make
judgement)> output more likely to be “tactical” or
“opportunistic” as presented in Table 2. The logical
way of thinking is the same as using if-then rules” in
an intuitive way.
Table 2. Example of discrete CPT for <To decide action>.
________________________________________________
To do Strategic
direct
lookout
________________________________________________
To watch St Ta Op Sc
electronic
devices
________________________________________________
To Strategic 0.9558 0.45 0.0511 0.003
decide Tactical 0.0442 0.545 0.6333 0.4226
action Opportunistic 0 0.005 0.3138 0.4854
Scrambled 0 0 0.0018 0.089
________________________________________________
St Strategic
Ta – Tactical
Op Opportunistic
Sc Scrambled
The adjusted value of CPT is also considering the
situation being assessed. It includes the familiarity
with the situation in the simulation, the difficulty
level of the encounter event given the participant’s
personal experience, etc. This considers important to
produce reasonable results. The proposed DBN is
intentionally exclusive for the case study.
Table 3. Example of discrete CPT for <To do direct lookout>.
________________________________________________
To monitor (by OOW)
________________________________________________
To do Strategic Tactical Opportunistic Scrambled
direct
lookout
________________________________________________
Strategic 0.75 0.05 0 0
Tactical 0.25 0.8 0.1 0
Opportunistic 0 0.15 0.85 0.2
Scrambled 0 0 0.05 0.8
________________________________________________
As a result, Figure 6 shows the expected
performance of the officer to maneuver the ship in the
encounter event. The probability of the performance
to be strategic is around 10% to 16%, tactical is around
32% to 48%, opportunistic is around 30% to 39%, and
scrambled is around 8% to 13%. The up and down in
each time slice shows the updated belief of
performance due to the function’s dependency, which
is quite stable and reasonable. This implies the
suitability of the given CPT and the model proposed
for the analysis has been achieved.
878
Figure 6. The evolution of expected normal performance of
ship officer in each time step.
FRAM analysis has provided qualitative analysis
for the case study. The fact that the emergence of a
scrambled mode of <To decide action (make
judgment)> at t=3 (±03:17) and speculation of the
potency of functional resonance as well as the
possibility of impact from the initial decision
possesses important information for the DBN
evaluation. Therefore, we proposed three
assumptions to present the situation in a more explicit
way.
Figure 7. The evolution of performance in each function
given the evidence of scrambled mode of <To decide action
(make judgment)> at t=3.
The first assumption: the fact that the scrambled
mode of <To decide action (make judgment)> has
emerged at t=3 (±03:17). Figure 7 present what is the
possible situation that happened before t=3 and how
the accident happened at t=4. In this case, the
evidence of <To decide action (make judgment)> is set
to be 100% scrambled. It can be seen, the probability
of scrambled and opportunistic modes before t=3 is
increasing in all functions. Specifically, <To monitor
(by OOW)> shows the worst situation among others.
In addition, the probability of <To control rudder> to
be in a scrambled mode is increasing up to more than
50% presents how bad the decision at t=3 was so that
the accident happened at t=4.
(a)
(b)
Figure 8. The evolution of performance in each function
given the evidence of scrambled mode of <To decide action
(make judgment)> at (a) t=1 and (B) t=3.
(a)
(b)
Figure 9. The evolution of performance in each function
given the evidence of scrambled and opportunistic modes of
<To decide action (make judgment)> at (a) t=1 and (B) t=3.
The second assumption: the first assumption
shows that the extreme changes in <To decide action
(make judgment)> at t=4 has a strong tendency to
indicate huge changes happened in the previous time
step. It is strengthened by the participant's argument
about his first action which is not carefully
considering the target situation. Therefore, Figure 8
shows the situation if at t=1 <To decide action (make
judgment)> is in the scrambled mode and at t=3 the
same mode appeared for the second time. This
situation shows that all functions are turned into an
extremely bad situation.
879
The third assumption: the best scenario that was
expected to occur. Given the second assumption, if the
scrambled mode occurred at t=3, there is about 20% to
30% chance for the opportunistic mode to happen in
the next sequence of function activation. Let set <To
decide action (make judgment)> to be opportunistic at
t=3. The result in Figure 9 shows the system
drastically change to the opportunistic mode as
expected. This expresses how the situation could be if
the participant tries to communicate with the target
ship as he mentioned. In addition, this could also
express the possible adjustment if the action to
overcome the bad decision at t=1 was taken before
3:00.
5 DISCUSSION
This study presents the solution for assessing safety
based on the Safety-II perspective using FRAM-DBN
analysis. A case study of a ship collision accident has
been chosen to provide system degraded performance
from normal to disrupted. This collaboration has been
found excellent, especially to assess the dynamic
changes in function performance over time. The
proposed method is able to provide a further
understanding of the function's temporal dependency.
The DBN analysis complements the FRAM analysis
and provides a more in-depth understanding of the
function’s performance in the encounter event.
Moreover, the proposed DBN can be used as a
decision support tool for officers in similar situations,
providing insights into the expected performance and
potential consequences of different actions.
The analysis shows the essence of performance
adjustment for establishing safety in ship
maneuvering. The accident was found to happen due
to the inability of the system to produce a proper
adjustment. This is strengthened by the fact that the
target ship hits the stern side of the participant’s ship.
It indicates that a slightly better adjustment in the
decision at t=3 to overcome the unwanted
performance at t=1 could prevent the collision
accident to happen. Furthermore, the assumptions in
the DBN analysis proposed helped to illustrate these
potential consequences of different decisions made by
the officer, highlighting the importance of decision-
making skills in ship navigation.
The concept of Safety-II strongly encourages
approaching safety from how it is present in everyday
operations. Although the case being studied is the
accident event, the mean is to provide the point of
view of normal and disrupted performance, such that
both situations can be explicitly presented. The
importance of local adjustment in the ship
maneuvering process has been highlighted. From
different instance in different time slice, the officer
performs different strategy to continuously follows
the working dynamic. In this current example, the
unwanted adjustment is presented. However, the
understanding of what is expected could be can also
be provided. It indicates the need for enhancing
human performance flexibility for a better level of
ship resilience. Obviously, there is a boundary for
system flexibility to cope with a certain level of
dynamic situations. Finding a balance of it can be
another problem to solve. Given today’s phenomena
of AI and autonomy, a higher level of ship resilience
can also be achieved by incorporating humans and
technology through human-autonomous interaction.
For a more comprehensive analysis, future studies
must consider a modification in the input data to
determine CPT. Expanding the network can also be
considered for more understanding of specific factors
that influence the change in performance. The FRAM
also facilitates expandability, especially for the
“loose” couplings in function.
6 CONCLUSION
The use of FRAM-DBN analysis in this study provides
a valuable tool for analysing the performance of ship
officers during the maneuvering process. Continuous
expression of changes in officer performance over
time can be greatly presented using the dynamic
FRAM model and discrete probability distribution of
the function’s performance mode in DBN. This
elaborated FRAM analysis shows what is to be
expected in the normal performance of ship
navigation and how the performance degradation
happened based on the case study being assessed. The
application of this proposed method is limited to the
case being analysed in this research. However, the
usability for a more complex implementation has been
recognized. In order to enhance the resilience of ship
navigation, a thorough understanding of human
flexibility and adaptability in response to unexpected
situations is essential.
ACKNOWLEDGEMENT
We would like to acknowledge the Japan Society for the
Promotion of Science (JSPS KAKENHI Grant Number
22K04598) for funding this research. In addition, the DBN
models discussed in this paper were constructed with the
GeNIe Modeler, a tool freely available for academic research
and teaching use from BayesFusion, LLC.
REFERENCES
[1] E. Hollnagel, R. L. Wears, and J. Braithwaite, “From
Safety-I to Safety-II: A White Paper From Safety-I to
Safety-II: A White Paper Professor Erik Hollnagel
University of Southern Denmark , Institute for Regional
University of Florida Health Science Center Jacksonville
, United States of America Prof,” no. October, 2015.
[2] E. Hollnagel, D. D. Woods, and N. Leveson, Resilience
Engineering: Concepts and Precepts. Ashgate, 2006.
[3] R. Patriarca, G. Di Gravio, and F. Costantino, “A Monte
Carlo evolution of the Functional Resonance Analysis
Method (FRAM) to assess performance variability in
complex systems,” Saf. Sci., vol. 91, no. October, pp. 49
60, 2017.
[4] J. E. M. França, E. Hollnagel, and G. Praetorius,
“Analysing the interactions and complexities of the
operations in the production area of an FPSO platform
using the functional resonance analysis method
(FRAM),” Arab. J. Geosci., vol. 15, no. 7, 2022.
[5] I. G. M. S. Adhita, M. FUCHI, T. KONISHI, and S.
FUJIMOTO, “Ship Navigation from a Safety-II
880
Perspective: A Case Study of Training-ship Operation in
Coastal Area,” Reliab. Eng. Syst. Saf., p. 109140, Feb.
2023.
[6] I. G. M. S. Adhita and M. Furusho, “Ship-to-Ship
Collision Analyses Based on Functional Resonance
Analysis Method,” J. ETA Marit. Sci., vol. 9, no. 2, pp.
102109, 2021.
[7] E. Hollnagel, Safety-I and Safety-II: The Past and Future
of Safety Management. CRC Press, 2014.
[8] T. Hirose and T. Sawaragi, “Extended FRAM model
based on cellular automaton to clarify complexity of
socio-technical systems and improve their safety,” Saf.
Sci., vol. 123, no. November 2019, p. 104556, 2020.
[9] M. Hänninen and P. Kujala, “The effects of causation
probability on the ship collision statistics in the Gulf of
Finland,” Mar. Navig. Saf. Sea Transp., vol. 4, no. 1, pp.
267272, 2009.
[10] Q. Yu and K. Liu, “An expert elicitation analysis for
vessel allision risk near the offshore wind farm by using
fuzzy rulebased bayesian network, TransNav, vol. 13,
no. 4, pp. 831837, 2019.
[11] R. Billard, J. Smith, M. Masharraf, and B. Veitch, “Using
Bayesian networks to model competence of lifeboat
coxswains,” TransNav, vol. 14, no. 3, pp. 585594, 2020.
[12] E. Hollnagel and Ö. Goteman, “The Functional
Resonance Accident Model,” Proc. Cogn. Syst. Eng.
Process plant, pp. 155161, 2004.
[13] E. Hollnagel, FRAM: the Functional Resonance Analysis
Method. England: Ashgate, 2012.
[14] E. Hollnagel, Cognitive Reliability and Error Analysis
Method (CREAM), First Edit. Elsevier Ltd, 1998.
[15] T. Bedford, C. Bayley, and M. Revie, “Screening,
sensitivity, and uncertainty for the CREAM method of
Human Reliability Analysis,” Reliab. Eng. Syst. Saf., vol.
115, pp. 100110, 2013.
[16] M. C. Kim, P. H. Seong, and E. Hollnagel, “A
probabilistic approach for determining the control mode
in CREAM,” Reliab. Eng. Syst. Saf., vol. 91, no. 2, pp.
191199, 2006.