Skip to main content
SpringerLink
Log in

Challenges of translating Rasmussen’s Accimap into a usable, sustainable, and useful incident reporting system: end-user attitudes following 12-month implementation

  • Original Article
  • Published:
Cognition, Technology & Work Aims and scope Submit manuscript

Abstract

There have been several calls within the accident analysis literature to translate systems thinking-based theories and accident analysis methods into practical and usable tools for practitioners. This paper reports on the findings from a post-implementation evaluation of an incident reporting system underpinned Rasmussen’s (Saf Sci 27(2/3):183–213, 1997) risk-management framework and Accimap. An online survey was used to evaluate end-users’ use and attitudes towards the system after 12 months of implementation. While almost all respondents had used the incident reporting system to collect data, few had undertaken the required training. While the privacy and security of the system were evaluated favourably, significant problems were highlighted with usability, sustainability of the system, and utility of the data for organisations. Overall, the results highlight the significant resource constraints experienced by end-users during the implementation of the new incident reporting system. The challenges for translating a systems thinking-based approach into practice are discussed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Adapted from Rasmussen (1997)

Fig. 2

Similar content being viewed by others

References

  • Barach P, Small SD (2000) Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. Br Med J 320(7237):759

    Article  Google Scholar 

  • Benn J, Koutantji M, Wallace L, Spurgeon P, Rejman M, Healey A, Vincent C (2009) Feedback from incident reporting: information and action to improve patient safety. Qual Saf Health Care 18(1):11–21

    Article  Google Scholar 

  • Braithwaite J, Westbrook MT, Travaglia JF, Hughes C (2010) Cultural and associated enablers of, and barriers to, adverse incident reporting. Qual Saf Health Care 19(3):229–233. https://doi.org/10.1136/qshc.2008.030213

    Article  Google Scholar 

  • Branford K (2011) Seeing the big picture of mishaps: applying the AcciMap approach to analyze system accidents. Aviat Psychol Appl Hum Factors 1:1

    Article  Google Scholar 

  • Carden T, Goode N, Salmon PM (2017) Not as simple as it looks: led outdoor activities are complex sociotechnical systems. Theor Issues Ergon Sci 18(4):318–337. https://doi.org/10.1080/1463922X.2017.1278806

    Article  Google Scholar 

  • Cassano-Piche AL, Vicente KJ, Jamieson GA (2009) A test of Rasmussen’s risk management framework in the food safety domain: BSE in the UK. Theor Issues Ergon Sci 10(4):283–304. https://doi.org/10.1080/14639220802059232

    Article  Google Scholar 

  • Chung AZQ, Shorrock ST (2011) The research-practice relationship in ergonomics and human factors—surveying and bridging the gap. Ergonomics 54(5):413–429

    Article  Google Scholar 

  • Corporation IBM (2013) SPSS Statistics for Windows, Version 22.0. IBM Corporation, Armonk

    Google Scholar 

  • Davies JB, Wright L, Courtney E, Reid H (2000) Confidential incident reporting on the UK Railways: the ‘CIRAS’ system. Cogn Technol Work 2(3):117–125. https://doi.org/10.1007/pl00011494

    Article  Google Scholar 

  • Dekker S (2009) Just culture: who gets to draw the line? Cogn Technol Work 11(3):177–185. https://doi.org/10.1007/s10111-008-0110-7

    Article  MathSciNet  Google Scholar 

  • Dekker S (2011) Drift into failure: from hunting broken components to understanding complex systems. Ashgate, UK

    Google Scholar 

  • Evans SM, Berry JG, Smith BJ, Esterman AJ (2004) Anonymity or transparency in reporting of medical error: a community-based survey in South Australia. Med J Aust 180(11):577–580

    Article  Google Scholar 

  • Evans SM, Berry JG, Smith BJ, Esterman A, Selim P, O’Shaughnessy J, DeWit M (2006) Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care 15(1):39–43. https://doi.org/10.1136/qshc.2004.012559

    Article  Google Scholar 

  • Goode N, Finch C, Cassell E, Lenne MG, Salmon PM (2014a) What would you like? Identifying the required characteristics of an industry-wide incident reporting and learning system for the led outdoor activity sector. Aust J Outdoor Educ 17(2):2–15

    Article  Google Scholar 

  • Goode N, Salmon P, Lenné M, Hillard P (2014b) Systems thinking applied to safety during manual handling tasks in the transport and storage industry. Accid Anal Prev 38:181

    Article  Google Scholar 

  • Goode N, Salmon PM, Lenne M, Finch CF (2014) A test of a systems theory-based incident coding taxonomy for risk managers. In: Arezes P, Carvalho P (eds) Advances in safety management and human factors, Vol. 10 of advances in human factors and ergonomics 2014, pp 5098–5108

  • Goode N, Salmon PM, Lenné MG, Finch CF (2015a) The UPLOADS project: development of an Australian National Incident Dataset for Led Outdoor Activities. Wilderness Environ Med 26(4):574–576. https://doi.org/10.1016/j.wem.2015.04.006

    Article  Google Scholar 

  • Goode N, Salmon PM, Taylor NZ, Grant E, Stevens E (2015b) The UPLOADS National Incident Dataset: the first six months 1 s June to 30th November 2014. University of the Sunshine Coast, Australia

    Google Scholar 

  • Goode N, Read GJ, van Mulken MR, Clacy A, Salmon PM (2016a) Designing system reforms: using a systems approach to translate incident analyses into prevention strategies. Front Psychol 2016:7

    Google Scholar 

  • Goode N, Salmon PM, Taylor NZ, Lenné MG, Finch CF (2016b) Lost in translation: the validity of a systemic accident analysis method embedded in an incident reporting software tool. Theor Issues Ergon Sci 17(5–6):483–506. https://doi.org/10.1080/1463922x.2016.1154230

    Article  Google Scholar 

  • Goode N, Salmon PM, Newnam S, Dekker S, Stevens E, van Mulken M (2016c) Learning the lessons from WMSDs: a framework for reporting and investigation

  • Goode N, Salmon PM, Taylor NZ, Lenne MG, Finch CF (2017) Developing a contributing factor classification scheme for Rasmussen’s AcciMap: reliability and validity evaluation. Appl Ergonom 64:14–26

    Article  Google Scholar 

  • Goode N, Salmon PM, Lenne M, Finch CF (2018) Translating systems thinking into practice: a guide to developing incident reporting systems. Taylor and Francis, Boca Raton

    Book  Google Scholar 

  • Hewitt TA (2013) Incident reporting systems—the hidden story. Saf Reliabil 33(2):13–28. https://doi.org/10.1080/09617353.2013.11716252

    Article  Google Scholar 

  • Johnson CW (2003) Failure in safety-critical systems: a handbook of incident and accident reporting. University of Glasgow, Scotland

    Google Scholar 

  • Leape LL, Abookire S (2005) WHO draft guidelines for adverse event reporting and learning systems: from information to action. World Health Organization, Geneva

    Google Scholar 

  • Leveson N (2011) Applying systems thinking to analyze and learn from events. Saf Sci 49(1):55–64

    Article  Google Scholar 

  • Lundberg J, Rollenhagen C, Hollnagel E (2009) What-you-look-for-is-what-you-find—the consequences of underlying accident models in eight accident investigation manuals. Saf Sci 47(10):1297–1311. https://doi.org/10.1016/j.ssci.2009.01.004

    Article  Google Scholar 

  • Newnam S, Goode N (2015) Do not blame the driver: a systems analysis of the causes of road freight crashes. Accid Anal Prev 76:141–151

    Article  Google Scholar 

  • Newnam S, Goode N, Salmon PM, Stevenson M (2017) Reforming the road freight transportation system using systems thinking: an investigation of Coronial inquests in Australia. Accid Anal Prev 101:28–36

    Article  Google Scholar 

  • Rasmussen J (1997) Risk management in a dynamic society: a modelling problem. Saf Sci 27(2/3):183–213

    Article  Google Scholar 

  • Reason J (1997) Managing the risks of organizational accidents. Ashgate, Aldershot

    Google Scholar 

  • Salmon PM (2016) Bridging the gap between ergonomics methods research and practice: methodological Issues in Ergonomics Science Part II. Theor Issues Ergon Sci 17(5–6):459–467. https://doi.org/10.1080/1463922X.2016.1200693

    Article  Google Scholar 

  • Salmon PM, Williamson A, Lenné M, Mitsopoulos-Rubens E, Rudin-Brown CM (2010) Systems-based accident analysis in the led outdoor activity domain: application and evaluation of a risk management framework. Ergonomics 53(8):927–939. https://doi.org/10.1080/00140139.2010.489966

    Article  Google Scholar 

  • Salmon PM, Cornelissen M, Trotter MJ (2012) Systems-based accident analysis methods: a comparison of Accimap, HFACS, and STAMP. Saf Sci 50(4):1158–1170

    Article  Google Scholar 

  • Salmon PM, Goode N, Archer F, Spencer C, McArdle D, McClure RJ (2014a) A systems approach to examining disaster response: using Accimap to describe the factors influencing bushfire response. Saf Sci 70:114–122. https://doi.org/10.1016/j.ssci.2014.05.003

    Article  Google Scholar 

  • Salmon PM, Goode N, Lenné MG, Finch CF, Cassell E (2014b) Injury causation in the great outdoors: a systems analysis of led outdoor activity injury incidents. Accid Anal Prev 63:111–120. https://doi.org/10.1016/j.aap.2013.10.019

    Article  Google Scholar 

  • Salmon PM, Goode N, Taylor NZ, Lenne MG, Dallat C, Finch CF (2016) Rasmussen’s legacy in the great outdoors: a new incident reporting and learning system for led outdoor activities. Appl Ergon 59:637–648. https://doi.org/10.1016/j.apergo.2015.07.017

    Article  Google Scholar 

  • Salmon PM, Goode N, Taylor N, Lenne MG, Dallat CE, Finch CF (2017) Rasmussen’s legacy in the great outdoors: a new incident reporting and learning system for led outdoor activities. Appl Ergon 59(Pt B):637–648. https://doi.org/10.1016/j.apergo.2015.07.017

    Article  Google Scholar 

  • Sanne JM (2008) Incident reporting or storytelling? Competing schemes in a safety-critical and hazardous work setting. Saf Sci 46(8):1205–1222. https://doi.org/10.1016/j.ssci.2007.06.024

    Article  Google Scholar 

  • Shorrock ST, Williams CA (2016) Human factors and ergonomics methods in practice: three fundamental constraints. Theor Issues Ergon Sci 17(5–6):468–482

    Article  Google Scholar 

  • Spigelman AD, Swan J (2005) Review of the Australian incident monitoring system. ANZ J Surg 75(8):657–661. https://doi.org/10.1111/j.1445-2197.2005.03482.x

    Article  Google Scholar 

  • Stanton NA (2016) On the reliability and validity of, and training in, ergonomics methods: a challenge revisited. Theor Issues Ergon Sci 17(4):345–353. https://doi.org/10.1080/1463922X.2015.1117688

    Article  Google Scholar 

  • Stanton NA, Young MS (1999) What price ergonomics? Nature 399(6733):197–198

    Article  Google Scholar 

  • Thoroman B, Goode N, Salmon P (2018a) System thinking applied to near misses: a review of industry-wide near miss reporting systems from the safety-critical domains. Theor Issues Ergon Sci 6:712–737

    Article  Google Scholar 

  • Thoroman B, Goode N, Salmon P, Wooley M (2018b) What went right? An analysis of the protective factors in aviation near misses. Ergonomics 62:191

    Google Scholar 

  • Underwood P, Waterson P (2013) Systemic accident analysis: examining the gap between research and practice. Accid Anal Prev 55:154–164. https://doi.org/10.1016/j.aap.2013.02.041

    Article  Google Scholar 

  • Underwood P, Waterson P (2014) Systems thinking, the Swiss Cheese Model and accident analysis: a comparative systemic analysis of the Grayrigg train derailment using the ATSB, AcciMap and STAMP models. Accid Anal Prev 68:75–94

    Article  Google Scholar 

  • Van Merriënboer JJ, Kirschner PA (2017) Ten steps to complex learning: a systematic approach to four-component instructional design. Routledge, Abingdon

    Google Scholar 

  • van Mulken M, Clacy A, Grant E, Goode N, Finch CF, Stevens E, Salmon PM (2016) The UPLOADS national incident dataset the first twelve months: 1st June 2014 to 31st May 2015. Centre for Human Factors and Sociotechnical Systems University of the Sunshine Coast, Australia

    Google Scholar 

  • Vincente KJ, Christoffersen K (2006) The Walkerton E. coli outbreak: a test of Rasmussen’s framework for risk management in a dynamic society. Theor Issues Ergon Sci 7(2):93–112

    Article  Google Scholar 

  • Wallace B, Ross AJ (2006) Beyond human error: taxonomies and safety science. CRC Press, Boca Raton

    Google Scholar 

  • Waterson P, Catchpole K (2016) Human factors in healthcare: welcome progress, but still scratching the surface. BMJ Qual Saf 25(7):480–484

    Article  Google Scholar 

  • Waterson P, Robertson MM, Cooke NJ, Militello L, Roth E, Stanton NA (2015) Defining the methodological challenges and opportunities for an effective science of sociotechnical systems and safety. Ergonomics. https://doi.org/10.1080/00140139.2015.1015622

    Article  Google Scholar 

  • Wiegmann DA, Shappell SA (2003) A human error approach to aviation accident analysis. The human factors analysis and classification system. Ashgate Publishing Ltd, Burlington

    Google Scholar 

  • Wu JH, Shen WS, Lin LM, Greenes RA, Bates DW (2008) Testing the technology acceptance model for evaluating healthcare professionals’ intention to use an adverse event reporting system. Int J Qual Health Care 20(2):123–129. https://doi.org/10.1093/intqhc/mzm074

    Article  Google Scholar 

Download references

Acknowledgements

This project was supported by funding from the Australia Research Council (ARC) in partnership with Australian Camps Association, Outdoor Council of Australia, The Outdoor Education Group, Sport and Recreation Victoria, Victorian YMCA Accommodation Services Pty Ltd, Outdoors Victoria, Outdoor Recreation Industry Council (Outdoors NSW), Outdoors WA, Outdoors South Australia, Queensland Outdoor Recreation Federation, Wilderness Escape Outdoor Adventures, Venture Corporate Recharge, and Christian Venues Association (LP150100287). Paul Salmon’s contribution was funded through his current Australian Research Council Future Fellowship (FT140100681). Natassia Goode’s contribution was funded through the University of the Sunshine Coast. Professor Caroline Finch was supported by an NHMRC Principal Research Fellowship (ID: 565900).

Author information

Authors and Affiliations

  1. Centre for Human Factors and Sociotechnical Systems, Faculty of Arts, Law and Business, University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, QLD, 4558, Australia

    N. Goode & P. M. Salmon

  2. Australian Centre for Research into Injury in Sport and its Prevention (ACRISP), Federation University Australia, PO Box 663, Ballarat, VIC, 3353, Australia

    L. Shaw

  3. Edith Cowan University, 270 Joondalup Drive, Joondalup, WA, 6027, Australia

    C. F. Finch

Authors
  1. N. Goode
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. L. Shaw
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. C. F. Finch
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. P. M. Salmon
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to N. Goode.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Goode, N., Shaw, L., Finch, C.F. et al. Challenges of translating Rasmussen’s Accimap into a usable, sustainable, and useful incident reporting system: end-user attitudes following 12-month implementation. Cogn Tech Work 23, 39–49 (2021). https://doi.org/10.1007/s10111-019-00596-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10111-019-00596-x

Keywords

Search

Navigation