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  • 1.
    Andersson, Roland
    et al.
    KTH, School of Architecture and the Built Environment (ABE).
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE).
    Systemgrupper och innovativ problemlösning2003Book (Other academic)
  • 2. Evenéus, P
    et al.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    In-depth investigation based on a systemic MTO perspective in Vattenfall hydro plants2007Conference paper (Other academic)
  • 3.
    Falk, Thomas
    et al.
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Wahlström, B.
    Nord Safety Management Inst, Stockholm, Sweden.
    Challenges in performing technical safety reviews of modifications: A case study2012In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 50, no 7, p. 1558-1568Article in journal (Refereed)
    Abstract [en]

    The aim of the present study, is to identify strengths and weaknesses of the technical safety review process at a Swedish Nuclear Power Plant (NPP). In this context, the function of safety reviews are understood as expert judgements on proposals for design modifications. 1" Design modifications" are here understood as alterations of an existing design. 1 and redesign of technical systems (i.e. commercial nuclear reactors), supported by formalised safety review processes. The chosen methodology is using two complementary methods: interviews of personnel performing safety reviews, and analysis of safety review reports from 2005 to 2009.The study shows that personal integrity is a trademark of the review staff and there are sufficient support systems to ensure high quality. The partition between primary and independent review is positive, having different focus and staff with different skills and perspectives making the reviews, which implies supplementary roles. The process contributes to " getting the right things done the right way" . The study also shows that though efficient communication, feedback, processes for continuous improvement, and " learning organizations" are well known success factors in academia, it is not that simple to implement and accomplish in real life.It is argued that future applications of safety review processes should focus more on communicating and clarifying the process and its adherent requirements, and improve the feedback system within the process.

  • 4. Jones, BM
    et al.
    Cox, S.J.
    Wahlström, B
    Kettunen, J
    Reiman, T
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    A comparison of organisational learning practices at nuclear reactor sites in Finland, Sweden and the UK'2006Conference paper (Other academic)
  • 5.
    Lindberg, Anna-Karin
    et al.
    KTH, School of Architecture and the Built Environment (ABE), Philosophy.
    Hansson, Sven Ove
    KTH, School of Architecture and the Built Environment (ABE), Philosophy.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy.
    Learning from accidents: what more do we need to know?2010In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 48, no 6, p. 714-721Article in journal (Refereed)
    Abstract [en]

    A model of experience feedback (the CHAIN model) that emphasizes the whole chain from initial reporting to preventive measures is used to identify important research needs in the field of learning from accidents. Based on the model, six quality criteria for experience feedback after an accident or incident are presented. Research on experience feedback from accidents is reviewed. The overall conclusion is that the discipline of experience feedback has not been sufficiently self-reflective. The process of experience feedback can and should be applied to experience feedback itself, but that is rarely done. Evaluation studies are needed that provide hard (evidence-based) information about the effects of various methodologies and organizational structures. Four types of studies are particularly important for the development of evidence-based accident investigation practices: (1) studies of the effects and the efficiency of different accident investigation methods, (2) studies of the dissemination of conclusions from accident investigation, (3) follow-up studies of the extent to which accident investigation reports give rise to actual preventive measures, and (4) studies of the integration of experience feedback systems into overall systems of risk management.

  • 6.
    Lundberg, Jonas
    et al.
    Linköping University, Department of Science and Technology, Campus Norrköping.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy.
    Hollnagel, Erik
    Linköping University, Department of Computer and Information Science.
    What you find is not always what you fix: How other aspects than causes of accidents decide recommendations for remedial actions2010In: Accident Analysis and Prevention, ISSN 0001-4575, E-ISSN 1879-2057, Vol. 42, no 6, p. 2132-2139Article in journal (Refereed)
    Abstract [en]

    In accident investigation, the ideal is often to follow the principle "what-you-find-is-what-you-fix", an ideal reflecting that the investigation should be a rational process of first identifying causes, and then implement remedial actions to fix them. Previous research has however identified cognitive and political biases leading away from this ideal. Somewhat surprisingly, however, the same factors that often are highlighted in modern accident models are not perceived in a recursive manner to reflect how they influence the process of accident investigation in itself. Those factors are more extensive than the cognitive and political biases that are often highlighted in theory. Our purpose in this study was to reveal constraints affecting accident investigation practices that lead the investigation towards or away from the ideal of "what-you-find-is-what-you-fix". We conducted a qualitative interview study with 22 accident investigators from different domains in Sweden. We found a wide range of factors that led investigations away from the ideal, most which more resembled factors involved in organizational accidents, rather than reflecting flawed thinking. One particular limitation of investigation was that many investigations stop the analysis at the level of "preventable causes", the level where remedies that were currently practical to implement could be found. This could potentially limit the usefulness of using investigations to get a view on the "big picture" of causes of accidents as a basis for further remedial actions.

  • 7. Lundberg, Jonas
    et al.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Hollnagel, Erik
    What-You-Look-For-Is-What-You-Find: The consequences of underlying accident models in eight accident investigation manuals2009In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 47, no 10, p. 1297-1311Article in journal (Refereed)
    Abstract [en]

    Accident investigation manuals are influential documents on various levels in a safety management system, and it is therefore important to appraise them in the light of what we currently know - or assume about the nature of accidents. Investigation manuals necessarily embody or represent an accident model, i.e., a set of assumptions about how accidents happen and what the important factors are. in this paper we examine three aspects of accident investigation as described in a number of investigation manuals. Firstly, we focus on accident models and in particular the assumptions about how different factors interact to cause - or prevent - accidents, i.e., the accident "mechanisms". Secondly, we focus on the scope in the sense of the factors (or factor domains) that are considered in the models - for instance (hu)man, technology, and organization (MTO). Thirdly, we focus on the system of investigation or the activities that together constitute an accident investigation project/process. We found that the manuals all used complex linear models. The factors considered were in general (hu)man, technology, organization, and information. The causes found during an investigation reflect the assumptions of the accident model, following the 'What-You-Look-For-Is-What-You-Find' or WYLFIWYF principle. The identified causes typically became specific problems to be fixed during an implementation of solutions. This follows what can be called 'What-You-Find-Is-What-You-Fix' or WYFIWYF principle.

  • 8. Lundberg, Jonas
    et al.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Hollnagel, Erik
    Rankin, Amy
    Strategies for dealing with resistance to recommendations from accident investigations2012In: Accident Analysis and Prevention, ISSN 0001-4575, E-ISSN 1879-2057, Vol. 45, p. 455-467Article in journal (Refereed)
    Abstract [en]

    Accident investigation reports usually lead to a set of recommendations for change. These recommendations are, however, sometimes resisted for reasons such as various aspects of ethics and power. When accident investigators are aware of this, they use several strategies to overcome the resistance. This paper describes strategies for dealing with four different types of resistance to change. The strategies were derived from qualitative analysis of 25 interviews with Swedish accident investigators from seven application domains. The main contribution of the paper is a better understanding of effective strategies for achieving change associated with accident investigation.

  • 9. Norstedt, U.
    et al.
    Rollenhagen, Carl
    Vattenfall .
    Eveneus, P.
    Considering Human Factors in Dam Safety2008In: Hydro Safety Review, Vol. 16, no 6Article in journal (Refereed)
  • 10. Rankin, A.
    et al.
    Lundberg, J.
    Woltjer, R.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Hollnagel, E.
    Resilience in everyday operations: A framework for analyzing adaptations in high-risk work2014In: Journal of Cognitive Engineering and Decision Making, ISSN 1555-3434, E-ISSN 2169-5032, Vol. 8, no 1, p. 78-97Article in journal (Refereed)
    Abstract [en]

    Managing complexity and uncertainty in high-risk sociotechnical systems requires people to continuously adapt. Designing resilient systems that support adaptive behavior requires a deepened understanding of the context in which adaptations take place, of conditions and enablers to implement these adaptations, and of their effects on the overall system. Also, it requires a focus on how people actually perform, not how they are presumed to perform according to textbook situations. In this paper, a framework to analyze adaptive behavior in everyday situations in which systems are working near the margins of safety is presented. Further, the variety space diagram has been developed as a means to illustrate how system variability, disturbances, and constraints affect work performance. The examples that underlie the framework and the diagram are derived from nine focus groups with representatives working with safety-related issues in different work domains, including health care, nuclear power, transportation, and emergency services.

  • 11. Reiman, T.
    et al.
    Kahlbom, U.
    Pietikäinen, E.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Nuclear Safety Culture in Finland and Sweden: Developments and Challenges2011Report (Other academic)
  • 12. Reiman, T.
    et al.
    Oedewald, P.
    Kettunen, J.
    Rollenhagen, Carl
    Kahlbom, U.
    Maintenance culture and management of change (NKS/MainCulture): Intermediate report 2004.  Nordic nuclear safety research, .2005Report (Other academic)
  • 13. Reiman, T.
    et al.
    Oedewald, P.
    Rollenhagen, Carl
    Mälardalen University, Eskilstuna, Sweden.
    Characteristics of Organizational Culture at the Maintenance Units of Two Nordic Nuclear Power Plants2005In: Reliability Engineering & System Safety, ISSN 0951-8320, E-ISSN 1879-0836, Vol. 89, no 3, p. 331-345Article in journal (Refereed)
    Abstract [en]

    This study aims to characterize and assess the organizational cultures of two Nordic nuclear power plant (NPP) maintenance units. The research consisted of NPP maintenance units of Forsmark (Sweden) and Olkiluoto (Finland). The study strives to anticipate the consequences of the current practices, conceptions and assumptions in the given organizations to their ability and willingness to fulfill the organizational core task. The methods utilized in the study were organizational culture and core task questionnaire (CULTURE02) and semi-structured interviews. Similarities and differences in the perceived organizational values, conceptions of one's own work, conceptions of the demands of the maintenance task and organizational practices at the maintenance units were explored. The maintenance units at Olkiluoto and Forsmark had quite different organizational cultures, but they also shared a set of dimensions such as strong personal emphasis placed on safety. The authors propose that different cultural features and organizational practices may be equally effective from the perspective of the core task. The results show that due to the complexity of the maintenance work, the case organizations tend to emphasize some aspects of the maintenance task more than others. The reliability consequences of these cultural solutions to the maintenance task are discussed. The authors propose that the organizational core task, in this case the maintenance task, should be clear for all the workers. The results give implications that this has been a challenge recently as the maintenance work has been changing. The concepts of organizational core task and organizational culture could be useful as management tools to anticipate the consequences of organizational changes.

  • 14. Reiman, T.
    et al.
    Oedewald, P.
    Rollenhagen, Carl
    Mälardalen University, Sweden.
    Kahlbom, U.
    Management of change in the nuclear industry. Evidence from maintenance reorganizations: MainCulture Final Report2006Report (Other academic)
    Abstract [en]

    The nuclear industry and especially the maintenance activities havebeen under various restructuring initiatives in addition to continuousincremental change due to e.g. new technologies, ageing plants,deregulation and the change of generation. These changes have beenexperienced as causing stress and uncertainty among the workers.Also, changes have lead to e.g. lowered sense of control, goalunclarity and lowered sense of personal responsibility over one’swork. Organizational changes clearly are issues that have potentialeffects on safety. Both positive and negative cases on safety effectsof organizational changes exist, and various accidents have beenpinpointed to organizational changes in the company. In this reportthe challenges of management of change at nuclear power plants areconsidered mainly from organizational culture -perspective. Thecultural perspective taken in this paper strives to combine technicalapproaches to human resources approaches. The report focuses onevidence gathered from studies made at Nordic NPP maintenanceunits, but the results and models depicted in the report are of generalrelevance in the nuclear industry. The report is based on four casestudies of reorganizing in NPP maintenance units and on a literaturereview of change management at various other safety criticalorganizations. The report presents a framework for consideringorganizational changes and their safety consequences.

  • 15. Reiman, T.
    et al.
    Oedewald, P.
    Wahlström, B.
    Rollenhagen, Carl
    Mälardalen University, Finland.
    Kahlbom, U.
    Organisational reviews: requirements, methods and experience2007Report (Other academic)
    Abstract [en]

    Organisational reviews are important instruments in the continuous quest for improved performance. In the nuclear field there has been an increasing regulatory interest in organisational performance, because incidents and accidents often point to organisational deficiencies as one of the major precursors. Many methods for organisational reviews have been proposed, but they are mostly based on ad hoc approaches to specific problems. The absence of well-established techniques for organisational reviews has already shown to cause discussions and controversies on different levels. The aim of the OrRe project is to collect the experiences from organisational reviews carried out so far and to reflect them in a theoretical model of organisational performance. Furthermore, the project aims to reflect on the criteria for the definition of the scope and content of organisational reviews. Finally, recommendations will be made for guidance for people participating in organisational reviews. This progress report describes regulatory practices in Finland and Sweden together with some case examples of organizational reviews and assessment in both countries. Some issues of concern are raised and an outline for the next year’s work is proposed. Issues of concern include the sufficient depth of the assessment, the required competence in assessments, data and criteria problems, definition of the boundaries of the system to be assessed, and the necessary internal support and organisational maturity required for successful assessments. Finally, plans for next year's work are outlined.

  • 16. Reiman, T.
    et al.
    Oedewals, P.
    Rollenhagen, Carl
    Comparison of Organisational Cultures at Two NPP Maintenance Units: When is Maintenance work motivating and meaningful?2004In: PROBABILISTIC SAFETY ASSESSMENT AND MANAGEMENT, VOL 1- 6 / [ed] Spitzer, C., Schmocher, U., Dang, V.N., London: Springer London, 2004, p. 1057-1063Conference paper (Other academic)
  • 17. Reiman, T.
    et al.
    Pietikäinen, E.
    Kahlbom, U.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Safety Culture in the Finnish and Swedish Nuclear Industries: History and Present2010Report (Other academic)
  • 18. Reiman, T.
    et al.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Competing values, tensions and trade-offs in management of nuclear power plants2012In: Work: A journal of Prevention, Assesment and rehabilitation, ISSN 1051-9815, E-ISSN 1875-9270, Vol. 41, no 1, p. 722-729Article in journal (Refereed)
    Abstract [en]

    The specific goal of the study is to look how tensions, competing values and trade-offs manifest in the management of nuclear power plants. Second goal is to inspect how existing frameworks, such as Competing Values Framework, can be used to model the tensions. Empirical data consists of thirty interviews that were conducted as part of a NKS study on safety culture in the Nordic nuclear branch. Eight trade-offs are identified based on a grounded theory based analysis of the interview data. The competing values and potential tensions involved in the trade-offs are discussed.

  • 19. Reiman, T.
    et al.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Identifying the typical biases and their significance in the current safety management approaches2010In: 10th International Conference on Probabilistic Safety Assessment and Management 2010, PSAM 2010: Volume 3, 2010, p. 2186-2197Conference paper (Refereed)
    Abstract [en]

    The aim of the article is to describe a set of biases in safety management practices and their possible consequences for safety. We will outline main biases of safety management in four thematic areas: beliefs about individual behavior, beliefs about organizations, safety models and safety management methods. A common theme underlying the biases is a lack of systems view on safety. A systemic safety management takes into account people, technology and organization and their interaction in equal terms. Furthermore, such an approach can shift focus from people to technology to organizational aspects depending on their current safety significance.

  • 20. Reiman, T.
    et al.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Reconceptualization of the competing values framework tailored for management of nuclear power plants2012In: 11th International Probabilistic Safety Assessment and Management Conference and the Annual European Safety and Reliability Conference 2012, PSAM11 ESREL 2012: Volume 8, 2012, p. 6562-6571Conference paper (Refereed)
    Abstract [en]

    Focus on safety vs. focus on production/economy is often mentioned as opposing goals, at least in the short term. Other potentially conflicting values and goals have also been identified, such as centralization and decentralization. The specific goal of the study is to describe and discuss how tensions, competing values and tradeoffs manifest in the management of nuclear power plants and particularly how safety may be affected. A second goal is to inspect how some existing conceptual frameworks can be used to model these tensions.

  • 21. Reiman, T.
    et al.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Kahlbom, U.
    Oedewald, P.
    Wahlström, B.
    Conducting organisational safety reviews: requirements, methods and experience2008Report (Other academic)
  • 22. Reiman, T.
    et al.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Pietikäinen, E.
    Professionals' beliefs about nuclear safety - An interview study in the nordic nuclear branch2012In: 11th International Probabilistic Safety Assessment and Management Conference and the Annual European Safety and Reliability Conference 2012, PSAM11 ESREL 2012: Volume 8, 2012, p. 6533-6541Conference paper (Refereed)
    Abstract [en]

    The aim of the study was to characterize the definitions of nuclear safety among technical and safety professionals in the Nordic nuclear industry. Secondly, the aim was to inspect the relation between the definition of nuclear safety and the kind of indicators the respondents would use to evaluate nuclear safety in a power plant. The study illustrated that there was no shared definition of nuclear safety among the Nordic nuclear safety community. The definitions formed six groups: safety as limiting the consequences of radiation, safety as process control, safety as a way of working, safety as a mindset, safety as adherence to standards, and unclear or circular argument. These safety definitions had no direct relationship to the evaluation focus the respondents favoured. Four major evaluation foci were identified: 1) focus on organizational practices and processes, 2) focus on technical and structural safety, 3) focus on operating experience and 4) focus on plant management. In order to integrate the many aspects of risk and safety found among professionals, it seems essential to develop at least some sort of basic model which people can agree upon. Indicators discovered in this study can be one starting point in formulating such a model.

  • 23. Reiman, Teemu
    et al.
    Oedewald, Pia
    Rollenhagen, Carl
    Mälardalen University.
    Eriksson, Irene
    Contextual assessment of maintenance culture at Olkiluoto and Forsmark: NKS-R/MainCulture 2002 – 2003 Final Report2004Report (Other academic)
  • 24. Reiman, Teemu
    et al.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Does the concept of safety culture help or hinder systems thinking in safety?2014In: Accident Analysis and Prevention, ISSN 0001-4575, E-ISSN 1879-2057, Vol. 68, p. 5-15Article in journal (Refereed)
    Abstract [en]

    The concept of safety culture has become established in safety management applications in all major safety-critical domains. The idea that safety culture somehow represents a "systemic view" on safety is seldom explicitly spoken out, but nevertheless seem to linger behind many safety culture discourses. However, in this paper we argue that the "new" contribution to safety management from safety culture never really became integrated with classical engineering principles and concepts. This integration would have been necessary for the development of a more genuine systems-oriented view on safety; e.g. a conception of safety in which human, technological, organisational and cultural factors are understood as mutually interacting elements. Without of this integration, researchers and the users of the various tools and methods associated with safety culture have sometimes fostered a belief that "safety culture" in fact represents such a systemic view about safety. This belief is, however, not backed up by theoretical or empirical evidence. It is true that safety culture, at least in some sense, represents a holistic term a totality of factors that include human, organisational and technological aspects. However, the departure for such safety culture models is still human and organisational factors rather than technology (or safety) itself. The aim of this paper is to critically review the various uses of the concept of safety culture as representing a systemic view on safety. The article will take a look at the concepts of culture and safety culture based on previous studies, and outlines in more detail the theoretical challenges in safety culture as a systems concept. The paper also presents recommendations on how to make safety culture more systemic.

  • 25. Reiman, Teemu
    et al.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Human and organizational biases affecting the management of safety2011In: Reliability Engineering & System Safety, ISSN 0951-8320, E-ISSN 1879-0836, Vol. 96, no 10, p. 1263-1274Article in journal (Refereed)
    Abstract [en]

    Management of safety is always based on underlying models or theories of organization, human behavior and system safety. The aim of the article is to review and describe a set of potential biases in these models and theories. We will outline human and organizational biases that have an effect on the management of safety in four thematic areas: beliefs about human behavior, beliefs about organizations, beliefs about information and safety models. At worst, biases in these areas can lead to an approach where people are treated as isolated and independent actors who make (bad) decisions in a social vacuum and who pose a threat to safety. Such an approach aims at building barriers and constraints to human behavior and neglects the measures aiming at providing prerequisites and organizational conditions for people to work effectively. This reductionist view of safety management can also lead to too drastic a strong separation of so-called human factors from technical issues, undermining the holistic view of system safety. Human behavior needs to be understood in the context of people attempting (together) to make sense of themselves and their environment, and act based on perpetually incomplete information while relying on social conventions, affordances provided by the environment and the available cognitive heuristics. In addition, a move toward a positive view of the human contribution to safety is needed. Systemic safety management requires an increased understanding of various normal organizational phenomena - in this paper discussed from the point of view of biases - coupled with a systemic safety culture that encourages and endorses a holistic view of the workings and challenges of the socio-technical system in question.

  • 26. Reiman, Teemu
    et al.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Pietikainen, Elina
    Heikkila, Jouko
    Principles of adaptive management in complex safety-critical organizations2015In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 71, p. 80-92Article in journal (Refereed)
    Abstract [en]

    This paper contributes to safety management by bringing in ideas from organizational complexity theories. Much of the studies and the literature on organizations as complex adaptive systems have focused on how to produce new innovations or how to increase financial effectiveness. We take the view that safety-critical organizations can be perceived as complex adaptive systems, and we discuss what this means for the management of safety. Our aim is to elaborate on the issue of what kinds of principles the management of safety should be based on in complex adaptive systems. In brief, we suggest that safety management should be adaptive, building on several different principles. Based on literature on complex adaptive systems we first identify the general features of complex adaptive systems, such as self-organizing and non-linearity, which need to be considered in management. Based on the features of complex adaptive systems, we define eight key principles of adaptive safety management and illustrate usefulness of the principles in making sense of the practice of safety management.

  • 27. Reiman, Teemu
    et al.
    Rollenhagen, Carl
    Viitanen, Kaupo
    On the relation between culture, safety culture and safety management2014In: PSAM 2014 - Probabilistic Safety Assessment and Management, 2014Conference paper (Refereed)
    Abstract [en]

    Safety can be considered an emergent phenomenon, making a systems view imperative if the aim is to evaluate or develop the safety of an entire sociotechnical system. This paper deals with one important component of the systems view - the relation between culture and management. Specifically, we will inspect how the concepts of culture and safety culture can be used in conjunction with the concept of safety management in facilitating a more dynamic systems view on safety. The paper proposes a model of eight cultural archetypes and illustrates how these relate to both safety culture and safety management in organizations.

  • 28. Rollenhagen, Carl
    Att utreda olycksfall: Teori och praktik2003Book (Other academic)
  • 29.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy.
    Can focus on safety culture become an excuse for not rethinking design of technology?2010In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 48, no 2, p. 268-278Article in journal (Refereed)
    Abstract [en]

    Two generic organisational contexts associated with technological designs in relation to safety culture are discussed: (1) operating organisations using existing technologies, and (2) design organisations as producers of technologies. It is argued that the concept of safety culture, if misused, may lead to the adoption of non-effective change strategies in the operational context. On the other hand, it is also argued that design organisations should invest more attention to issues commonly subsumed under the concept of safety culture. In this case, however, the concept of safety culture has to be adapted to fit the demands facing design organisations. Issues of morality and their association with the safety culture concept will be discussed. It is suggested that a stronger focus on understanding innovation and safety together should nourish future research about culture's influence on design and safety.

  • 30.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Event investigation at nuclear power plants in Sweden: Practical and theoretical considerations2008Conference paper (Other academic)
  • 31.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy.
    Event investigations at nuclear power plants in Sweden: Reflections about a method and some associated practices2011In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 49, no 1, p. 21-26Article in journal (Refereed)
    Abstract [en]

    The MTO-E method for event investigation is described in the light of almost 20 years of usage in the Swedish nuclear industry. Various problems are addressed in the context of the method, e.g. accident models, causality, the use of the barrier concept, the meaning of safety culture, and the process of going from problem identification to problem solving. It is argued that future applications of in-depth investigations should focus more on (innovative) methods when suggesting remedial actions as a consequence of information derived from event investigations.

  • 32.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Safety Culture and Safety Quality2013In: Social and Ethical Aspects of Radiation Risk Management, Volume 19 (Radioactivity in the Environment), Elsevier, 2013, p. 215-237Chapter in book (Refereed)
    Abstract [en]

    Although much used, the concept of safety culture is associated with many meanings. In this chapter, it is argued that there are reasons to define safety culture in terms of values and competence related to safety, and to differentiate safety culture from what is here called "safety quality". It is argued that safety culture should be perceived as a relative construct in terms of how the value of safety relates to the manifold of other values simultaneously strived for. Safety culture is discussed in the context of value research (individual and organizational values) and safety quality is discussed in the context of human reliability analysis. Implications for safety management and assessment of safety culture and safety quality are discussed.

  • 33.
    Rollenhagen, Carl
    Mälardalens Högskola and SwedPower.
    Safety Management of Nuclear Power Plants: Values and Balance of Attention2006In: Nordic perspectives of safety management in high reliability organisations: Theory and application / [ed] Ola Svenson et al, Stockholm: Stockholm University, 2006, p. 75-94Chapter in book (Other academic)
    Abstract [en]

    This paper suggests a theoretical framework for interpretation of issues associated with safetymanagement of nuclear power plants (NPPs). A model is suggested that differentiatesbetween four focus areas tentatively labelled; (1) Strategic economy issue management; (2)Technology management; (3) Competence and Human Relations management (HRM), and(4) Quality system management. For each of these areas, called internal organisational focustopics, sets of matching external focus areas are identified. Management of NPPs are analysedas movement in a problem space in which the organisation seeks to optimise and trade offpartly conflicting values in search of integration and adaptation to external demands.

  • 34. Rollenhagen, Carl
    Sambanden människa, teknik organsation1997Book (Other academic)
  • 35. Rollenhagen, Carl
    Säkerhetskultur2005Book (Other academic)
  • 36.
    Rollenhagen, Carl
    Vattenfall Power Consultant, Stockholm, Sweden.
    Säkerhetskultur och säkerhetsklimat2007In: I rättvisans namn: Ansvar, skuld och säkerhet i vården / [ed] Synnöve Ödegård, Liber, 2007Chapter in book (Other academic)
  • 37. Rollenhagen, Carl
    et al.
    Alm, Helen
    Karlsson, Karl-Henrik
    Experience feedback from in-depth event investigations: How to find and implement efficient remedial actions2017In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 99, p. 71-79Article in journal (Refereed)
    Abstract [en]

    The present research focuses on the processes of identifying remedial actions subsequent to incidents at two Swedish nuclear power plants. Data from 106 in-depth analyses were analysed together with interviews with event investigators. The results and previous research in the domain indicated a need to further develop the process for identifying remedial actions. A method was developed that focuses on process descriptions and identifications of strengths and weaknesses inherent in the process(es) in which an incident occurred. The method uses a participatory approach with actors from the relevant process (es). A case study was conducted which showed promising results. The method is discussed in terms of generalising to a more process-oriented experience feedback than usually is applied.

  • 38.
    Rollenhagen, Carl
    et al.
    Vattenfall Power Consultant, Stockholm, Sweden.
    Evenéus, P.
    Development of a systemic MTO perspective on dam safety management2007In: International Symposium on Modern Technology of Dams, 2007Conference paper (Other academic)
  • 39.
    Rollenhagen, Carl
    et al.
    Philosophy and History, KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Falk, Thomas
    KTH.
    Hansson, Sven Ove
    Philosophy and History, KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Challenges, dilemmas, and quality criteria for safety reviews2017In: Journal of Radiological Protection, ISSN 0952-4746, E-ISSN 1361-6498, Vol. 37, no 1, p. 279-295Article in journal (Refereed)
    Abstract [en]

    Five generic dilemmas shared by most safety reviews are identified, namely the complexity dilemma, the specialisation dilemma, the criteria dilemma, the independence dilemma and the ethical dilemma. These dilemmas are not always made sufficiently transparent, which may lead to a too optimistic view of what can be achieved by safety reviews. A two-dimensional characterisation of safety reviews is suggested; the dimensions are the degree of independence and the scope of the review. In conclusion ten quality criteria are proposed that can be used to cope with the dilemmas of conducting safety reviews.

  • 40.
    Rollenhagen, Carl
    et al.
    Vattenfall Power Consultant, Stockholm, Sweden.
    Wahlström, B.
    Management Systems and Safety Culture: Reflections and Suggestions for Research2007In: 2007 IEEE 8TH HUMAN FACTORS AND POWER PLANTS AND HPRCT 13TH ANNUAL MEETING, 2007, p. 145-148Conference paper (Other academic)
    Abstract [en]

    Management systems can be seen as the software of an organisation. Present views on managements systems have emerged from several sources and have now been integrated into the guiding documents produced by IAEA. A discussion of the new documents has in Sweden been initiated within the Vattenfall Nordic Production Safety Management Institute (NSMI), which recently has been established to support the production units in Sweden. The paper starts with a brief description of NSMI and its main tasks. Management systems are then discussed in more detail to suggest research needs within management systems and safety managements. A conclusion of the paper is that a better understanding of the structure and management systems is needed to remove present difficulties in the application of management systems at the nuclear power plants.

  • 41.
    Rollenhagen, Carl
    et al.
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Wahlström, Björn
    Ledning av säkerhetskritiska organisationer2013 (ed. 1)Book (Other academic)
  • 42.
    Rollenhagen, Carl
    et al.
    Vattenfall Power Consultant, Stockholm, Sweden.
    Westerlund, J.
    Development of a Safety Climate Questionnaire for Nuclear Power Plants2007In: 2007 IEEE 8TH HUMAN FACTORS AND POWER PLANTS AND HPRCT 13TH ANNUAL MEETING, 2007, p. 4-8Conference paper (Other academic)
    Abstract [en]

    The present work describes the development of a safety climate questionnaire adapted for nuclear power installations. The survey was administered to all personnel at a Swedish nuclear power plant. Exploratory factor analysis revealed 8 factors together explaining 62% of the variance. The first factor was interpreted as Safety management and. explained 38% of the variance. The other factors were labelled; Safety knowledge, Resources (time, personnel), Management/change management, Small group climate, Contractors, Documentation/experience feedback, and Occupational safety. The results are discussed and related to theoretical and methodological issues in safety culture and safety climate research.

  • 43.
    Rollenhagen, Carl
    et al.
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Westerlund, J.
    Näswall, K.
    Professional subcultures in nuclear power plants2013In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 59, p. 78-85Article in journal (Refereed)
    Abstract [en]

    Using a safety climate survey as the point of departure, the present study explores some aspects of plant cultures vs. professional subcultures in three Swedish nuclear power plants (named A, B and C). The ratings on the safety climate survey by workers on power plant A were subjected to an exploratory factor analysis. A six-factor solution explained a total of 56.0% of the variance in the items included. The six factors were considered to measure Safety management, Change management and experience feedback, Immediate working group, Knowledge and participation, Occupational safety, and Resources. The six factor model was tested by running a confirmatory factor analysis on the ratings by workers on power plant B and C, respectively. The model fit for both plants was acceptable and supported the six factor structure. For each of the six factors, a 3 × 3 ANOVA was conducted on the ratings, with the three largest departments (Operation, Maintenance, Engineering support) and power plants (A, B, C) as the between-subjects factors. Differences between power plants as well as differences between departments were found for several factors. Overall, the differences between departments were larger than those between power plants. The results are discussed in terms of challenges for creating safety climate in organizations that harbor several professional subcultures.

  • 44.
    Rollenhagen, Carl
    et al.
    KTH, School of Architecture and the Built Environment (ABE), Philosophy.
    Westerlund, Joakim
    Lundberg, Jonas
    Hollnagel, Erik
    The context and habits of accident investigation practices: A study of 108 Swedish investigators2010In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 48, no 7, p. 859-867Article in journal (Refereed)
    Abstract [en]

    The context and habits of accident investigation practices were explored by means of questionnaire data obtained from accident investigators in the healthcare, transportation, nuclear and rescue sectors in Sweden. Issues explored included; resources, training, time spent in different phases of an investigation, methods and procedures, beliefs about causes to accidents, communication issues, etc. Examples of findings were: differences in the extent to which the 'human factor' was perceived as a dominant cause to accidents; manning resources to support investigations were perceived as rather scarce; underutilization of data from safety related processes such as risk analysis and auditing data; the phase of suggesting remedial actions (recommendations) were comparatively brief and generally not well supported. A majority of the investigators thought that the investigations were free from pressures to follow a specific direction; the investigators also thought that performing an investigation in itself (regardless of the specific results) had positive influences on safety. A majority of the investigators thought that upper management had a relatively strong influence on safety in the organizations. The results are discussed in terms of suggestions for strategies to strengthen investigation practices - particularly those conducted as part-time work in organizations.

  • 45. Viitanen, K.
    et al.
    Reiman, T.
    Rollenhagen, C.
    KTH. Vattenfall AB, Stockholm, Sweden.
    Gotcheva, N.
    Mapping methodical change in safety culture2018In: PSAM 2018 - Probabilistic Safety Assessment and Management, International Association for Probablistic Safety Assessment and Management (IAPSAM) , 2018Conference paper (Refereed)
    Abstract [en]

    Evoking positive changes in safety culture or accentuating its positive characteristics has been a long-lasting challenge in safety-critical organizations. While a variety of methods exist to facilitate this process, an understanding of the main factors to take into consideration when leading methodical change in safety culture is often limited. In this paper, the authors describe twelve principles that attempt to summarize the essential good practices of safety culture change. Examples of failed safety culture change initiatives are then analyzed from the perspective of these principles to provide a tentative proof-of-concept of their usefulness. We propose that safety (culture) practitioners can utilize these principles as a reference when leading methodical change in safety culture.

  • 46. Wahlstrom, Bjorn
    et al.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Safety management: A multi-level control problem2014In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 69, p. 3-17Article in journal (Refereed)
    Abstract [en]

    Activities in safety management build on a control metaphor by which control loops are built into the man, technology, organisational and information (MTOI) systems to ensure a continued safety of the operated systems. In this paper we take a closer look on concepts of control theory to investigate their relationships with safety management. We argue that successful control relies on four necessary conditions, i.e. a system model, observability, controllability and a preference function. The control metaphor suggests a division of the state space of the modelled system into regions of safe and unsafe states. Models created for selected subsystems of the MTOI-system provide a focus for control design and safety assessments. Limitations in predicting system response place impediments to risk assessments, which suggest that new complementary approaches would be needed. We propose that polycentric control may provide a concept to consider in a search for a path forward. We investigate approaches for modelling management systems and safety management. In spite of promises in the use of a control metaphor for safety management there are still dilemmas that have to be solved case by case. As a conclusion we argue that the control metaphor provides useful insights in suggesting requirements on and designs of safety management systems. The paper draws on experience from the Vattenfall Safety Management Institute (SMI), which started its operation in 2006.

  • 47. Wahlström, B.
    et al.
    Rollenhagen, Carl
    SwedPower AB, Stockholm.
    Issues of Safety Culture: Reflections from the Learnsafe Project2004In: American Nuclear Society 4th International Topical Meeting on Nuclear Plant Instrumentation, Control and Human Machine Interface Technology, 2004, p. 207-216Conference paper (Other academic)
    Abstract [en]

    The LearnSafe1 project has been investigating processes of management of change and organizational learning at nuclear power plants across Europe. The focus of the project has been upon senior managers at nuclear power plants, who are responsible for strategic choice and resource allocation. This focus was selected due to the importance of their role in decisions, approaches and attitudes that have an influence on the safety and economy of the plants. In the project two large data sets have been collected with senior management perceptions at nuclear power plants in five European countries. The first data set contains challenges the managers see for continued operation of the nuclear power plants. The second data set contains views on facilitators and hindrances for organizational learning. The data sets have been analyzed to investigate similarities and differences between plants and countries. The results provide many interesting insights on issues related to safety culture.

  • 48. Wahlström, B.
    et al.
    Rollenhagen, Carl
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Safety management - A multi-level control problem2012In: 11th International Probabilistic Safety Assessment and Management Conference and the Annual European Safety and Reliability Conference 2012, PSAM11 ESREL 2012: Volume 8, 2012, p. 6552-6561Conference paper (Refereed)
    Abstract [en]

    Safety management is a crucial activity in maintaining acceptable safety levels of large hazardous industrial facilities. Risk analysis and safety engineering are two important activities of safety management by which safe designs of such facilities can be achieved. A continued safety during the operation of the facilities relies furthermore on successful and efficient experience feedback and management of change. Activities in safety management build on a control metaphor by which control loops built into the technical, peoples and organisational systems ensure safety of the facilities. In this paper we take a closer look on concepts of control theory to investigate their relationships with safety management. A conclusion of the paper is that the control metaphor provides useful insights in suggesting requirements to be placed on safety management. The paper draws on experience from the Vattenfall Safety Management Institute (SMI), which started its operation in 2006.

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