All posts by David van Valkenburg

Case study: Timing is everything; FRAM for train departures

photo-1415368893216-efb8c4fb04e0In this case study I would like to show a practical application of the Functional Resonance Analysis Method (FRAM) to investigate the process of trains departing the station. The reason for analyzing this process, is that Signal Passed At Danger (SPAD) incidents have a specific category that deals with situations where this incident happens just after leaving the station. So in that case, the first signal seen from the station platform is passed while it shows … Continue Reading ››

Safety Perspectives and Running

UntitledDuring a running training with 15 fellow runners, we had a half hour work-out on stairs that ran along the fire station of my hometown (see picture). The question that arose, after having done this intense but fulfilling training, was about safety. Was this a safely performed training exercise? And this depends a lot on your definition of safety. I will approach this question using the two perspectives Safety I and Safety II. Safety as the absence of … Continue Reading ››

FRAM and System Principles in Practice

OLYMPUS DIGITAL CAMERAA client approached us about a recent incident in a process involving three organizations. They asked for an independent investigation into the incident. During the initial meeting it became clear that there was some relevant history to the process in which the incident happened. A year ago, some of the operational personnel in the process were relocated to a central location to improve the process in terms of use of personnel and other resources such … Continue Reading ››