Giving Guidance to Government

This article was published in The Ergonomist, published by the Chartered Institute of Ergonomics and Human Factors, No. 568, Nov-Dec 2018.


From healthcare and patient safety, to the latest developments in driver automation, human factors is not only relevant across many issues of societal concern, it can achieve significant impact too. Steven Shorrock and Sarah Sharples share their experiences contributing to three key government reports.

Human factors and ergonomics seeks to optimise interactions between people and all other elements of the system at all levels. Much of the time, practitioners and researchers are concerned with evaluating and designing work, tools and environments for specific applications. Occasionally, however, opportunities arise at the level of organisational decision-making, regulation and at government level. For many issues of societal concern, human factors expertise is particularly relevant and could have significant impact, if it secures a place at the table.

The following three reports illustrate the span of issues and impact that human factors advisers can achieve when working closely with government.

Learning in the NHS

Steven Shorrock gave oral evidence, with Scott Morrish, father of the late Sam Morrish and Member of the Healthcare Safety Investigation Branch (HSIB) Expert Advisory Group, on Tuesday 8 November 2016 in a meeting Chaired by Bernard Jenkin MP in the Houses of Parliament.

This report focused on the issues arising from the Parliamentary and Health Service Ombudsman’s (PHSO) July 2016 report, ‘Learning from Mistakes: An investigation report by the Parliamentary and Health Service Ombudsman into how the NHS in England failed to properly investigate the death of a three-year old child’.

‘Learning from Mistakes’ was the PHSO’s second report on the tragic death of a three-year old child, Sam Morrish, on 23 December 2010. It set out four key findings:

  1. A defensive culture in the NHS.
  2. A lack of competence and sufficient independence in the conduct of NHS investigations into potentially avoidable harm and death.
  3. Poor coordination and cooperation between NHS organisations involved in investigations, and failure to collectively identify and act on lessons.
  4. Insufficient involvement of families and staff in NHS investigations.

The report made conclusions and recommendations regarding:

  • The Investigative Landscape in the NHS in England.
  • HSIB and the learning culture.
  • Learning and accountability: implementation of the ‘safe space’ .
  • System-wide ‘just culture’.
  • Improving local competence.
  • Measuring improvement.

In response to discussion surrounding a ‘just culture’ taskforce, Steven said that from his experience in aviation, there must be consensus on the need for a just and fair culture that is about learning as a whole. He said that if you don’t have that consensus from a range of stakeholders, you’ll always have something in your system that is pushing against it. “An inclusive taskforce where people are trying to understand each other’s worlds is really the only way to go about it,” he said. “We have certainly learned that that is the only way to get people to understand the need for a just culture, and also to understand each other’s worlds, that the world of the judiciary is very different to the world of practitioners, and both of those worlds do need to co-exist,” he added.

Responding to Scott Morrish’s comments around blame culture, Steven said he felt there that healthcare needed to start looking more at similarities between the ways that things work in different parts of the system. “Fundamentally, most adverse events in healthcare do have at their heart a certain level of pressure, which is one of the system vulnerabilities,” he said.

“Understanding that the system as imagined and system as found, are two different things, is vital,” he said. “The system that we imagine is a very different one to the system that really exists, where resources are often inadequate, the constraints affect the work in a way that is counterproductive, and pressure makes everyone’s job, especially practitioners, much more difficult.” Steven went on to say that healthcare managers must focus on the system as they find it; the work as it’s actually done, and not the one that they imagine. “That means we need to involve an awful lot of people to understand how the system really works if we want to understand and improve it.”

Autonomous vehicles

Oral evidence was provided by Professor Sarah Sharples on Tuesday 22 November 2017 in Committee Room 4A at the Palace of Westminster.

The House of Lords Science and Technology Committee heard evidence from the Department for Transport, the Department for Business, Energy and Industrial Strategy as well as leading academics. The Committee explored with Government Ministers how driverless vehicles fit into wider transport strategy and policy and what the Government is doing to ensure knowledge gained in their development benefits all sectors. The Committee also examined with the academics the socio-economic aspects of the deployment of self-driving cars such as how much is really understood about human interaction with the technology.

The four main findings of the report into connected and autonomous vehicles (CAV) were:

  • The Government is too focused on highly-automated private road vehicles (‘driverless cars’), when the early benefits are likely to appear in other sectors, such as maritime and agriculture.
  • The development of CAV across different sectors needs coordination and the Government, working with key stakeholders, must get a grip on this chiefly by establishing a Robotics and Autonomous Systems (RAS) Leadership Council as soon as possible to play a key role in developing a strategy for CAV.
  • There is a clear need for further Government-commissioned social and economic research to weigh the potential human and financial implications of CAV.
  • This is a fast-moving area of technology and the Government has much to do, alongside industry and other partners, to position the UK so that it can take full advantage of the opportunities that CAV offer in different sectors.

Asked for her view on full-scale trials and live testing, Sarah recommended a mixed-methods approach. Referencing early data from a Transport Systems Catapult demonstration, she said public attitude towards the vehicles was very positive. “It’s only when the public see those vehicles deployed in a real situation that we can start to understand what people might think when they see these new technologies implemented in the context they are so familiar with,” she said.

“Humans are fallible, but humans are also brilliant,” said Sarah in response to the notion that people could be the biggest barrier to autonomous vehicle success. “We know that humans are great at adapting to new situations and changing the way they work with new technologies, but we need to be aware of their capabilities and limitations when we design those technologies.”

Commenting on the potential loss of skills and the responsibility of the driver, Sarah highlighted the control task of the vehicle and the need to maintain both the skills and understanding, and that people gain an appropriate level of competence through a driving test. “Even with fully automated vehicles we need to build in contingency for when the driver will need to take control,” she said.

She went on to suggest that within the conventional driving test, an understanding of the capabilities of those different types of vehicles could be introduced.

Gross negligence manslaughter

Oral evidence was provided by Steven Shorrock at De Vere Grand Connaught Rooms, London, on 6 April 2018.

The Williams Review was a rapid policy review into gross negligence manslaughter in healthcare and was chaired by Professor Sir Norman Williams. The review was set up to make recommendations to support a more just and learning culture in the healthcare system. It covered:

  • The process for investigating gross negligence manslaughter.
  • Reflective practice of healthcare professionals.
  • The regulation of healthcare professionals.

The review heard evidence from a variety of organisations and individuals. It was set up to look at the wider patient safety impact of concerns among healthcare professionals that simple errors could result in prosecution for gross negligence manslaughter, even if they happen in the context of broader organisation and system failings.

Providing evidence

Based on Steven and Sarah’s experience of providing evidence, they offer nine pieces of advice:

  1. Ask for a list of topics or likely questions. You can then consider the kinds of things that you want to discuss. Prepare, but don’t rehearse answers to the questions.
  2. Get advice from people who have done it before. There are likely to be CIEHF members who have participated in similar kinds of committees or reviews.
  3. Maintain good contact with the clerks. They’ll help you to understand what is expected and when.
  4. Find out whether the evidence will be recorded, and how. Evidence may be televised, or transcribed, or not. If the evidence is not recorded, then you may wish to take notes on the themes of your answers during and after the session, in case the notes don’t reflect your answers.
  5. Be comfortable with yourself as an expert. You are expected to base your views on the state of the art, but your opinions are also respected.
  6. Don’t campaign. You need to be objective and evidence-based where possible, and not political. Your answers may be professional opinion or fact, but this must be clearly distinguished.
  7. Follow up with resources and information. There will be things that you won’t mention during oral evidence, or that were not recorded, that you think are pertinent and it’s fine to send these to the clerk after you have given evidence.
  8. Check what extra input will be required and when. You may be sent information to fact check, with very little notice, maybe 24 hours.
  9. Be mindful that your evidence may be used selectively. On publication, you may find that your evidence is used very partially or not in a way that you expect. This may relate to the terms of reference of the review or committee.

Authors’ affiliations

Steven Shorrock is a Chartered Psychologist and Chartered Ergonomist & Human Factors Specialist with experience in various safety-critical industries, including aviation, rail, chemical manufacturing and healthcare.

A former CIEHF President, Sarah Sharples is Faculty Pro-Vice-Chancellor for Research & Knowledge Exchange, and Professor of Human Factors at the Faculty of Engineering at the University of Nottingham. She is also Non-Executive Director of the Transport Systems Catapult.

Further reading

Learning from Mistakes: Oral evidence was given, recorded and broadcast at The evidence transcription is at The report is available at

Autonomous vehicles: The evidence transcription is at Supplementary written evidence is at The report is available at

The Williams Review report is available at

Author: stevenshorrock

This blog is written by Dr Steven Shorrock. I am interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives. My main interest is human and system behaviour, mostly in the context of safety-related organisations. I am a Chartered Ergonomist and Human Factors Specialist with the CIEHF and a Chartered Psychologist with the British Psychological Society. I currently work as a human factors and safety specialist in air traffic control in Europe. I am also Adjunct Associate Professor at University of the Sunshine Coast, Centre for Human Factors & Sociotechnical Systems. I blog in a personal capacity. Views expressed here are mine and not those of any affiliated organisation, unless stated otherwise. You can find me on twitter at @stevenshorrock or email contact[at]humanisticsystems[dot]com.

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