استفاده از چارچوب مدیریت ریسک راسموسن برای حوادث بداهه

Effective, appropriate improvisation has the potential to enhance system resilience, yet the phenomenon is currently not well understood. This research tests the notion that improvisation is a systems phenomenon and examines the appropriateness of Rasmussen’s (1997) Risk Management Framework and Accimap methodology for examining the factors influencing improvisation in safety critical situations. Impromaps (improvisation Accimaps) were used to determine whether the factors identified as influencing improvisation in two case studies met the predictions made by Rasmussen’s Risk Management Framework. The findings indicate improvisation is a systems phenomenon and support the use the Framework and Impromaps as an analysis methodology for the examination of improvisation incidents. The methodology allowed the identification of factors across all levels of both systems, and was able to describe the relationships between factors both within and across the system levels. It is concluded that Impromaps are applicable to improvisations occurring in different domains and resulting in positive as well as negative outcomes.