How To Do Safety-II

Safety-II, its cousin Resilience Engineering (and offshoots such as resilient healthcare), as well as predecessor concepts and theories, have attracted great interest among organisations and their staff. People, especially front-line staff, understand the need to understand all outcomes – wanted and unwanted – and the systems and associated patterns of system behaviour that generate these outcomes. The trouble is, people are not sure where to start with ‘doing Safety-II’. Some methods and seemingly complicated words and ideas might seem off-putting. They don’t need to be. In this post, I will provide some initial ideas and inspiration for getting started. The ideas are in plain language without reference to any specific techniques.

Steven Shorrock CC BY-NC-SA 2.0)

Idea 1: Collaborate

Safety-II and Resilience Engineering are not solo efforts. You can do little of practical benefit alone. In fact, going alone will almost guarantee a miserable work life. You will start to see the reality of how patterns, system structures and mental models are connected to produce events, both wanted and unwanted. But you will have to stand back and watch how this complexity is boiled down to mechanistic thinking and methods that don’t describe how safety is created, or even how unsafe events really occur. You will also have to observe foes of intervention in action, which almost guarantee unintended consequences. For the sake of sanity, it is almost better not to know how complex systems fail, let alone how they work on a day-to-day basis. Finding a small number of open-minded people who are willing to expand their thinking and listen to ideas and experiences without prejudgement, and not hamstrung by personal barriers, is a good place to start. A diverse group that traverses organisational silos is helpful.

Idea 2: Read

If you want to do Safety-II, you have to read. At least a bit. You might find that you don’t have enough time to read technical books. You don’t have to, though you may well want to, at some point. Start by reading some short articles on Safety-II, and associated concepts, by authors with a pedigree in this area. You might want to expand your search terms to ‘systems thinking‘, ‘resilience engineering‘, ‘systems ergonomics and human factors‘. From here you might start to explore methods from social science (e.g., action research, practice theory, ethnography). See where the search takes you, from blog posts (search this blog for a few, as a start), through to White Papers, articles (email the author if you can’t access them), and books. A couple of short articles a week and you’ll be on your way to understanding the key ideas. Be mindful that some of what is written may be way off the mark (what Safety-II isn’t), as Safety-II, like anything else, is subject to the bandwagon effect.

Idea 3: Think

It might seen strange to suggest thinking as a way to do Safety-II or Resilience Engineering. But in many lines of work, we somehow manage to avoid taking a step back to think more holistically about outcomes, work, systems, and the mental models that give rise to all of this. I teach a systems thinking course which is about…thinking. At the end of the most recent course, one participant said that it was the first course that they had participated in where they actually had to think, and not just learn content or follow a process. The course doesn’t provide a process, but rather a space to think and challenge one’s own assumptions. The thinking required involves going up and out to the system as a whole, switching perspectives (stakeholders and situations), and generally questioning how things go. Thinking through situated examples is especially useful, so long as there are links to theory.

Idea 4: Listen and Talk

From the above, and the below, prepare some topics or questions on concepts, methods and everyday work for discussion. Find a room, get some drinks and snacks, and arrange some chairs in a circle. Try to get rid of tables and anything else that gets between you. The questions may emerge from your reading or from your experience…preferably both. E.g. If you had to explain to a neighbour why your organisation operated safely, what would you say? What do we do well? What dilemmas do we face? What surprises do we experience? How do we handle them? What unintended consequences have we experienced from interventions? What factors are at play when things go right and wrong? What is the role of designed artefacts and processes versus adaptive performance in creating safety? A good discussion will harvest new insights, including multiple perspectives and thick descriptions.

Idea 5: Write and Draw

Write about your experiences of work in the frame of Safety-II or Resilience Engineering. Think deeply about your own work and the situations you encounter and write in a way that you would explain it to a neighbour. Start to think about patterns of interactions inside and outside of your organisation – micro, meso, and macro. But keep it concrete. How do things influence each other at technical, individual, team, organisational, regulatory, governmental, media, and economic levels, to create patterns and associated wanted and unwanted outcomes? Put the concepts that you read about into the context of your practice and experience of the systems that you are a part of, or interact with. The concepts you encounter will make sense not only from the points of view of what you observe in others’ work, but in what you experience in your own. Keep it short and snappy. Think short vignettes, not a treatise. Sketch out the images that come to mind (e.g., rich pictures) and start to map out some influences that you come across. Remember, thinking is more important than method, and should always precede it.

Idea 6: Observe

Arrange to observe ordinary work. It is best to observe work that you are not intimately involved with, but that you can understand well enough to know what’s going on. This might be another hospital or ward, or another air traffic control room or sector, for instance. It is essential is that you have the right attitude – apprentice, not master. It is also essential that the people you are observing consent, and understand the purpose of the observation. If you have another role that may conflict with learning how things work (e.g., competency assessor) then you have some work to do to deconflict these roles and the mindsets and perceptions that may be associated. Don’t go with a checklist. Just hang out. Notice how people resolve the dilemmas created by goal conflicts, what trade-offs and compromises are necessary, how people work around a degraded environment (staffing and competency gaps, equipment problems, procedural complexity, etc), and how – despite the context – things work reasonably well most of the time.

Idea 7: Design

At this point, you may well have ideas about improving the system structure and patterns of system behaviour (including work), to help create the conditions for success to emerge. This effort will always start with understanding the system. You’ll need to understand interactions between people, their activities, their tools, and the contexts of work (micro, meso and macro). It is advisable to avoid major initiatives and ‘campaigns’. Small designed interventions are a good way forward. You may wish, for instance to: a) make small changes to work-as-done that help balance multiple goals; b) review procedures to remove or reconcile those that are problematic (e.g., conflicting, defunct, over-specified); c) help managers and support staff to become familiar with how the work works; d) adjust buffers or margins for performance; e) review onerous analyses of events could be better directed at patterns (e.g., onerous safety analysis of multiple events outside of one’s control); f) create a means of getting regular outside perspectives on your work (perhaps an observer swap arrangement); g) create a means to simulate unusual circumstances and allow experimental performance (not a competency check). The interventions may aim at reducing unhelpful gaps between the varieties of human work (e.g., the ignorance and fantasy, taboo, PR and subterfuge, defunct archetypes). After designing, iterate to the previous ideas.

Posted in Human Factors/Ergonomics, Safety, systems thinking | Tagged , , , , , , , , ,

The Reality of Goal Conflicts and Trade-offs

by Steven Shorrock

This article is the Editorial published in HindSight 29October 2019 by EUROCONTROL (available soon at SKYbrary)

Jesper Sehested CC BY 20

“Safety is our number 1 priority!” It’s a phrase that’s sometimes used by trade and staff associations alike, and occasionally by pilots when we are encouraged to listen to the safety briefing, or when a departure is delayed for technical reasons. But I’ve noticed something. Over the last couple of decades that I’ve worked in aviation, I am hearing the phrase less and less. 

Perhaps this is something to do with the so-called ‘rhetoric-reality gap’. There are two kinds of goals, which relate to individuals and organisations. On the one hand, we have stated, declared goals. On the other, we have the goals that are evident from behaviour. In other words, ‘the purpose of a system is what it does’ (POSIWID) – a phrase coined by business professor Stafford Beer. The purpose of aviation is not to be safe per se, but to transport people and goods. In doing so, there are a number of goals. So how can we focus on what the system does and why it does what it does, in the way that it does? What a system does is subject to demand and pressure, resources, constraints, and expected consequences. 

So let’s look at the situation now. Demand is rising faster than at any time in history. According to Airbus, the number of commercial aircraft in operation will more than double in the next 20 years to 48,000 planes worldwide. And according to Boeing, 790,000 new pilots will be needed by 2037 to meet growing demand. But capacity is a critical concern. While average delays in Europe are down, capacity and staffing takes the lion’s share of delays, according to EUROCONTROL data. Airports are another major part of the capacity problem. IATA chief Alexandre de Juniac said last year, “We are in a capacity crisis. And we don’t see the required airport infrastructure investment to solve it.” 

Growing demand and increased capacity conflicts with environmental pressures. At a local level, this can be seen in the ongoing third runway saga at Heathrow, the busiest airport in Europe by passenger traffic. Despite receiving approval from Members of Parliament, expansion is opposed by local and climate groups. In Sweden, the word ‘flygskam’ or flight shame is becoming more than just a buzzword. Fewer passengers are flying to or from Swedavia’s ten airports. At a global level, Greta Thunberg recently headlined the UN Climate summit. She was photographed arriving not by plane, but by yacht, fitted with solar panels and underwater turbines. 

While aviation is particularly newsworthy with regard to climate change, the Intergovernmental Panel on Climate Change has estimated that aviation is responsible for around 3.5 percent of anthropogenic climate change, including both CO2- and non-CO2- induced effects. However, the media and public interest in aviation creates significant pressure. In 2008, aviation sector leaders signed a declaration committing to carbon-neutral growth from 2020, and by 2050 a cut in net emissions to half 2005 levels. 

As well as capacity and environmental demands and pressures, there are increasing concerns about cybersecurity (e.g., GNSS spoofing) and drones. Then there are more familiar financial pressures. At the time of writing, Thomas Cook, the world’s oldest travel company, collapsed and Adria Airways suspended flights. 

And now we come to safety. Accidents remain few in number, and flying continues to be the safest form of long-distance travel. But 2018 was a bad year for aviation safety, with 523 on-board fatalities, compared to 19 in 2017, according to IATA. Accidents involving B737 MAX aircraft raised new questions about safety at all levels. Unlike most goals, safety is a ‘background goal’ that tends to come into the foreground only when things suddenly go very badly wrong, or ‘miraculously’ right.

This is only one way in which goals differ. Some goals have a short-term focus, while others are longer term. Some goals are externally imposed, while others are internally motivated. Some goals concern production, others concern protection. Some goals relate well to quantitative measures, while others don’t. Some goals are more reactive, while others are more proactive. Sometimes, goals are compatible and can work together, while at other times they conflict and compete for resources and attention. 

Goal conflicts create dilemmas at all levels, from front line to senior management, regulation and government. Dilemmas create a need for trade-offs and compromises. These decisions are influenced by how we perceive capability, opportunities, and motivation. There are many kinds of trade-off decisions. A familiar trade-off to everyone is between thoroughness and efficiency. Too much focus on either can be a problem. Day-to-day pressures tend to push us toward greater efficiency, but when things go wrong, we realise (and are told) that more thoroughness was required. Another familiar trade-off is between the short- and long-term – the acute-chronic trade-off. Combined with pressure on efficiency, short-term goals tend to get the most attention. And we trade off individual and collective needs and wants, or a focus on components and the whole system. All of these trade-offs have implications for goals relating to safety, security, capacity, cost-efficiency, and the environment. To understand them, we need to understand five truths. 

Five Truths about Trade-offs 

1. Trade-offs occur at all levels of systems. Trade-offs occur in every layer of decision-making, from international and national policy-making to front-line staff. They occur over years and seconds. They occur in the development of strategy, targets, measures, policies, procedures, technology, and in operation. They are often invisible from afar. 

2. Trade-offs trickle down. Trade-offs at the top, especially concerning resources, constraints, incentives and disincentives, trickle down. If training is reduced for cost or staffing reasons, then staff will be less able to make effective trade-offs. If user needs are not met in a commercial-off-the-shelf system, staff will have to perform workarounds. 

3. Trade-offs combine in unexpected ways. Trade-offs made strategically, tactically and opportunistically combine to create both wanted and unwanted outcomes that were not foreseen or intended. We often treat this simplistically.

4. Trade-offs are necessary for systems to work. Trade-offs are neither good nor bad. They are necessary for systems – transport, health, education, even families – to work. And most trade-off decisions can only be made and enacted by people. 

5. Trade-offs require expertise. Trade-off decision-making often cannot be prescribed in procedures or programmed into computers. Decision-making therefore requires diverse expertise, which in turn needs time and support for development. In effect, expertise is about our ability to make effective trade-offs. 

An interesting thing about trade-offs is that they are tacitly accepted, but rarely discussed. Might ‘Safety first!’ risk making us complacent about safety? Reality always beats rhetoric in the end. So we have to talk about goal conflicts and trade-offs. Let us bring reality into the open.

Posted in Human Factors/Ergonomics, Safety, systems thinking | Tagged , , , , | 1 Comment

Shorrock’s Law of Limits

Last year, I noticed a tweet from The European Cockpit Association (ECA), on EU flight time limitations (Commission Regulation (EU) 83/2014, applicable from 18 February 2016). The FTLs have been controversial since their inception. The ECA’s ‘Dead Tired‘ campaign website lists a number of stories from 2012-13, often concerning the scientific integrity of the proposals, and goal conflicts between working conditions and passenger safety versus commercial considerations. Consecutive disruptive schedules, night-time operations and inadequate standby rules have been highlighted as problems by the ECA. Didier Moraine, an ECA FTL expert, stated that “basic compliance with EASA FTL rules does not necessarily ensure safe rosters. They may actually build unsafe rosters.”

In May 2018, the ECA twitter account reported that EASA’s Flight Standards Director Jesper Rasmussen reminded a workshop audience that FTLs are to be seen as hard limits, not as targets.

A February 2019 study published by the European Union Aviation Safety Agency (EASA) found that that prescriptive limits alone are not sufficient to prevent high fatigue during night flights.

“When you put a limit on a measure, if that measure relates to efficiency, the limit will be used as a target.

This relates to Goodhart’s Law, expressed succinctly by anthropologist Marilyn Strathern as follows: “When a measure becomes a target, it ceases to be a good measure.” It also relates to The Law of Stretched Systems, expressed as follows by David Woods: “Every system is stretched to operate at its capacity; as soon as there is some improvement, for example in the form of new technology, it will be exploited to achieve a new intensity and tempo of activity.” Woods also notes that this law “captures the co-adaptive dynamic that human leaders under pressure for higher and more efficient levels of performance will exploit new capabilities to demand more complex forms of work.” But this particular aspect of system behaviour concerning limits, simple as it is, is not quite expressed by either.

An everyday example of the Law of Limits can be found in driving. As in most countries, British roads have speed limits, depending on the road type. In 2015, on 30 mph speed limit roads, the average free flow speed at which drivers choose to travel as observed at sampled automatic traffic counter (ATC) locations was 31 mph for cars and light goods vehicles. (The figure was 30 mph for rigid and articulated heavy goods vehicles [HGVs], and 28 mph for buses.) In the same year, on motorways with a 70 mph speed limit for cars and light goods vehicles, the average speed was 68 mph for cars and 69 mph for light goods vehicles. Most drivers will be familiar with the activity of driving as close to the limit as possible. Many things contribute to this, primarily a drive for efficiency coupled with a fear of consequences of exceeding the limit. Many more examples can be found in everyday life, where limits relating to any measure are imposed, and treated as targets when efficiency gains can be made.

The following is a post on Medium by David Manheim, a researcher and catastrophist focusing on risk analysis and decision theory, including existential risk mitigation, computational modelling, and epidemiology. It is reproduced here with kind permission.

Shorrock’s Law of Limits

Written by David Manheim, 25 May 2018

I recently saw an interesting new insight into the dynamics of over-optimization failures stated by Steven Shorrock: “When you put a limit on a measure, if that measure relates to efficiency, the limit will be used as a target.” This seems to be a combination of several dynamics that can co-occur in at least a couple of ways, and despite my extensive earlier discussion of related issues, I think it’s worth laying out these dynamics along with a few examples to illustrate them.

When limits become targets

First, there is a general fact about constrained optimization that, in simple terms, says that for certain types of systems the best solution to a problem is going to involve hitting one of the limits. This was formally shown in a lemma by Dantzig about the simplex method, where for any convex function the maximum must lie at an extreme point in the space. (Convexity is important, but we’ll get back to it later.)

When a regulator imposes a limit on a system, it’s usually because they see a problem with exceeding that limit. If the limit is a binding constraint — that is, if you limit something critical to the process, and require a lower level of the metric than is currently being produced, the best response is to hug the limit as closely as possible. If we limit how many hours a pilot can fly (the initial prompt for Shorrock’s law), or that a trucker can drive, the best way to comply with the limit is to get as close to the limit as possible, which minimizes how much it impacts overall efficiency.

There are often good reasons not to track a given metric, when it is unclear how to measure it, or when it is expensive to measure. A large part of the reason that companies don’t optimize for certain factors is because they aren’t tracked. What isn’t measured isn’t managed — but once there is a legal requirement to measure it, it’s much cheaper to start using that data to manage it. The companies now have something they must track, and once they are tracking hours, it would be wasteful not to also optimize for them.

Even when the limit is only sometimes reached in practice before the regulation is put in place, formalizing the metric and the limitation means that it becomes more explicit — leading to reification of the metric. This isn’t only because of the newly required cost of tracking the metric, it’s also because what used to be a difficult to conceptualize factor like “tiredness” now has a newly available albeit imperfect metric.

Lastly, there is the motivation to cheat. Before fuel efficiency standards, there was no incentive for companies to explicitly target the metric. Once the limit was put into place, companies needed to pay attention — and paying attention to a specific feature means that decisions are made with this new factor in mind. The newly reified metric gets gamed, and suddenly there is a ton of money at stake. And sometimes the easiest way to perform better is to cheat.

So there are a lot of reasons that regulators should worry about creating targets, and ignoring second-order effects caused by these rules is naive at best. If we expect the benefits to just exceed the costs, we should adjust those expectations sharply downward, and if we haven’t given fairly concrete and explicit consideration to how the rule will be gamed, we should expect to be unpleasantly surprised. That doesn’t imply that metrics can’t improve things, and it doesn’t even imply that regulations aren’t often justifiable. But it does mean that the burden of proof for justifying new regulation needs to be higher that we might previously have assumed.

Posted in systems thinking | Tagged , , , ,

What Human Factors isn’t: 4. A Cause of Accidents

‘Human Factors’ (or Ergonomics) is often presented as something that it’s not, or as something that is only a small part of the whole. Rather than just explain what Human Factors is, in this sporadic series of short posts I will explain what it isn’t. The posts outline a number of myths, misunderstandings, and false equivalencies.

In this series:

  1. What Human Factors isn’t: 1. Common Sense
  2. What Human Factors isn’t: 2. Courtesy and Civility at Work
  3. What Human Factors isn’t: 3. Off-the-shelf Behaviour Modification Training
  4. What Human Factors isn’t: 4. A Cause of Accidents (this post)

Royal Navy Media Archive CC BY-NC 2.0

Human Factors Isn’t a Cause of Accidents

An unfortunate use of the term ‘human factors’ in industry, and in the media, is as an explanation for failure. Through this lens, human factors is (or ‘are’, since the phrase tends to be used as a plural in this context) seen as a cause of accidents or other unwanted events. This immediately confuses the discipline and profession of Human Factors with a narrow, unsystemic view of factors of humans – human factors in the vernacular. (Much as I dislike capitalisation, I will use it here to separate the two.) While human limitations are relevant to accident analysis (and the analysis of work more generally), and indeed form part of many analytical methods, neither the vernacular ‘human factors’ nor the discipline of Human Factors is an explanation for failure. Below, I outline a few problems with this all-too-common perspective.

‘Failure’ means not achieving planned objectives. Since people set objectives, make plans and execute actions to achieve objectives, then almost all failure is associated with humans, unless there is some chance agency or natural phenomena involved (e.g., weather). Even then, one could take a counter-factual perspective, as is often done in accident analysis, and say that humans could have or should have predicted and planned for this.

Logically, ‘success’ has the same characteristics. Humans set objectives, make plans, and execute actions at all levels of system functioning, from law-making to front-line performance. So if failure is down to ‘human factors’ then so is success, which arguably accounts for the majority of outcomes in day-to-day work.

By this reasoning, ‘human factors’ as a cause of accidents is a monolithic explanation – even more so than ‘safety culture’. ‘Human factors’ as a cause of accidents explains both everything and nothing. Having said this, ‘human factors’ is often seen more specifically as a set of factors of humans (humans being unreliable and unpredictable elements of an otherwise well-designed and well-managed system) that are proximal to accidents.

This interpretation has been reinforced by the use of the word ‘organisational’ alongside ‘human’ in some quarters. For instance, the UK Health and Safety Executive used the term ‘Human and Organisational Factors‘ to broaden out the perceived scope of the ‘HOF’ contribution (to incidents and accidents), and there is a growing ‘Human and Organisational Performance’ movement, which has grown from ‘Human Performance‘. This is curious to many Human Factors professionals, because organisations – being created by, comprised of, and run by humans – were always within the scope of Human Factors (sometimes called ‘macro ergonomics‘) from the beginning.

The proximalisation and narrowing of ‘human factors’ becomes especially important with the post hoc ergo propter hoc fallacy, that because an event happened after something (an action or omission) then it happened because of that something. This is especially problematic in complex, high-hazard systems that are highly regulated and where systems are required to account for performance variability, in terms of design, management, and operation.

An example of proximalisation can be seen in the aftermath of the train that crashed at Santiago de Compostela in July 2013. Human error was immediately reported as the cause. A safety investigation by CIAF (here in Spanish), published in June 2014, found that driving staff failed to follow the regulations contained in the train timetable and the route plan”. Subsequently, the European Railway Agency (now the European Union Agency for Railways) found that the emphasis of the CIAF report is put on the direct cause (one human error) and on the driver’s (non-) compliance with rules, rather [than] on the underlying and root causes. Those causes are not reported as part of the conclusions of the report and typically are the most likely to include the organisational actions of Adif and Renfe.” As reported here, “many survivors, campaigners and rail analysts…questioned why rail officers in charge of the train and rail network had not factored in the possibility of human error – particularly at a bend as potentially dangerous as the Angrois curve – and had failed to put in place technology that could mitigate it”.

The safety investigation seemed to mirror a view of causation that allows for counterfactual reasoning only in the proximate sense – who touched it or failed to touch it last. In this case, and many others, it seemed that omissions are only causal when they occur at the sharp-end, even though sharp-end omissions typically occur over the course of seconds and minutes, not months and years.

In the case of Santiago de Compostela, the driver Francisco José Garzón Amo was the only person facing trial for much of the time since July 2013. However, several officials have been named in, and dropped from, judicial proceedings over the years. Their causal contributions seem to be harder to ascertain. At the time of writing, Adrés María Cortabitarte López, Director of Traffic Safety of ADIF, is also facing charges for disconnecting the ERTMS (European Railway Traffic Management System) without having previously assessed the risk to make that decision. (Ignacio Jorge Iglesias Díaz, director of the Laboratory of Railway Interoperability of Cedex said that ERTMS has a failure every billion hours, while part of the security provided by the ASFA system “rests on the human factor”.) As yet, over seven years later, there is no date set for the oral trial to find out if the accused are finally convicted of eighty crimes of involuntary manslaughter and 144 crimes of serious professional imprudence.

All of this is to say that there are consequences for both safety and justice of the framing of ‘human factors’ as a cause of accidents, and the scope of ‘human factors’ that is expressed or implied in discourse also has consequences. By framing people as the unreliable components of an otherwise well-designed and well-managed system, ‘human factors as a cause of accidents’ encourages brittle strategies in response to design problems – reminders, re-training, more procedures. But this is not all. This perspective, focusing on ‘human factors’ as the source of failure, but not the overwhelming source of success, encourages technological solutionism – more automation. This changes the nature of human involvement, rather than ‘reducing the human factor‘, and comes with ironies that are even less well understood.

So ‘human factors’ isn’t an explanation, but Human Factors theory and method can help to explain failure, and moreover, everyday work. Human factors isn’t a reason for failure, but Human Factors helps to reason about failure and – moreover – about everyday work.

Unfortunately, some Human Factors methods that have emerged from a Safety-I mindset (curiously different to the progressive mindset that created the discipline) may have encouraged a negative frame of understanding. The Human Factors Analysis and Classification System (HFACS), for instance, classifies accidents according to ‘unsafe acts’ (errors and violations), ‘preconditions for unsafe acts’, ‘unsafe supervision’, and ‘organizational influences’. The word ‘unsafe’ here is driven by outcome and hindsight biases. Arguably, it should not be attached to other words, since safety in complex sociotechnical systems is emergent, not resultant. Such Human Factors analysis tools typically classify ‘error’ (difficult as it is, to define) and ‘violation’ only at the sharp end (blunt end equivalents are seen as ‘performance shaping factors’ or in the case of HFACS – influences). So, inadvertently, Safety-I Human Factors may have encouraged proximalisation to some degree, linguistically and analytically, since errors are only errors when they can be conveniently bound, and everything else is a condition or influence – ever weakening with more time and distance from the outcomes. Again, this has implications for explanation and intervention.

Still, in the main, Human Factors is interested primarily in normal work, and sociotechnical system interaction is the primary focus of study, not accidents. Within this frame is the total influence of human involvement on system performance, and the effects of system performance on human wellbeing. Even within safety research and practice, there is an increasing emphasis in Human Factors on human involvement in how things go right, or just how things go – Safety-II.

But the term ‘human factors’ will probably be used in the vernacular for some time yet. My best advice for those who use the term ‘human factors’ in their work is to think very carefully before using the term as a cause of, or explanation for, failure. Doing so is not only meaningless, but has potential consequences for safety and justice, and even the future of work, which may be hard to imagine.

Posted in Human Factors/Ergonomics | Tagged , , , , , , ,

What Human Factors isn’t: 3. Off-the-shelf Behaviour Modification Training

‘Human Factors’ (or Ergonomics) is often presented as something that it’s not, or as something that is only a small part of the whole. Rather than just explain what Human Factors is, in this sporadic series of short posts I will explain what it isn’t. The posts outline a number of myths, misunderstandings, and false equivalencies.

In this series:

  1. What Human Factors isn’t: 1. Common Sense
  2. What Human Factors isn’t: 2. Courtesy and Civility at Work
  3. What Human Factors isn’t: 3. Off-the-shelf Behaviour Modification Training (this post)
  4. What Human Factors isn’t: 4. A cause of accidents

Royal Navy Media Archive CC BY-NC 2.0

Human Factors Isn’t Off-the-shelf Behaviour Modification Training

Human Factors and behaviour modification training have a somewhat complicated relationship. It is not easy to explain, especially in a way that everyone would agree. I will start by saying that one thing is certain: Human Factors and training-based behaviour modification are not equivalent. But, in my view, training-based behaviour modification can be an application of Human Factors. In other words, the two are not equivalent, but one can be an application of the other. I’ll try to explain.

Human Factors has a core focus that can be described in a few words as ‘fitting the work to the people’ or ‘designing for human use’. It does this in the context of the system as a whole. More formally, there are a number of definitions that help to make the point, but they tend include two foci: understanding system interactions as the method of understanding and design as the method of intervention. These foci are not contentious: they are core to many definitions and are the foci of Human Factors textbooks and degrees. My preferred definition was offered by my late PhD supervisor, Prof. John Wilson:

“Understanding the interactions between people and all other elements within a system, and design in light of this understanding.” (Wilson, 2014, p.12)

The word that is sometimes subject to discussion is the word ‘design’. In the context of Human Factors, it can be described as a process for solving problems and realising opportunities relating to interactions between people and all other elements within a system. Some definitions flesh this out a little more, including also the goals of Human Factors, e.g.:

“Ergonomics (or human factors) is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance.” (International Ergonomics Association)

(Note that the terms ‘Human Factors’ and ‘Ergonomics’, which originate in the US and Europe respectively, are usually treated as synonymous within the discipline, but often one is chosen over the other in the profession, and in practice more generally, depending also on the country.)

Going back to the origins of Human Factors in WWII aviation, it began with observations around the lack of fit or compatibility between designed artefacts on the one hand, and human capabilities, limitations and needs on the other. While the intention of early researchers was not to create a new discipline, that is effectively what happened, as is the case, I suspect, with many disciplines.

In 1977, the Tenerife runway accident occurred. This led a renewed focus on behaviour, especially communication and teamwork, and ultimately the development of crew resource management (CRM). The term CRM was invented by American aviation psychologist John Lauber, who defined it as “using all the available resources – information, equipment, and people – to achieve safe and efficient flight operations”. The concept was further developed and tested by other applied psychologists, such as psychologist Bob Helmreich, drawing especially from social psychology.

It is worth saying here that Human Factors and Applied Psychology are closely related, sometimes indistinguishably so in practice. Applied Psychology is one of several core disciplines of HF, and a large proportion HF specialists, including those involved in the initial development of CRM and TEM, are psychologists. But the fields are also distinct disciplines and professions. Going back to the ICAO SHELL model, psychology tends to focus on the ‘liveware’ and ‘liveware-liveware’ interactions – people, individually and collectively. Human Factors tends to focus on the patterns of interactions between ‘liveware’, ‘software’ (including policies and procedures), ‘hardware’ and the ‘environment’ – the relationships between elements are more interesting and relevant than the elements themselves. Psychology is a human science focused on mind and behaviour. Human Factors is a design discipline focused on system interactions.


Since ‘Human Factors’ was better embedded as a term in aviation, CRM was soon associated with Human Factors in a cockpit and crew context. In an sense, it is an aspect of ‘Human Factors in Operations‘, though even then, it is only one aspect – one application. CRM training typically comprises a training course and subsequent monitoring of CRM skills during simulator flights (line-oriented flight training, or LOFT). CRM training is now a regulatory requirement for commercial pilots under most regulatory bodies.

Threat and error management (TEM) also emerged, which is often seen as another application of HF, used alongside with normal operations safety survey (NOSS) in aviation. Interestingly, ICAO notes in a circular on TEM that,

It must be made clear from the outset that TEM and NOSS are neither human performance/Human Factors research tools, nor human performance evaluation/assessment tools. TEM and NOSS are operational tools designed to be primarily, but not exclusively, used by safety managers in their endeavours to identify and manage safety issues as they may affect safety and efficiency of aviation operations.

CRM, and to a lesser extent TEM, has since become widespread not only in aviation, but also in rail, shipping, healthcare, and other sectors.

The downside of this success is the perceived (but false) equivalence of ‘Human Factors’ and ‘training-based behaviour modification’. This perception is more prevalent among those who have received such training (e.g., pilots and clinicians), and where there are no or few Human Factors practitioners working more systemically. Unfortunately, the perception has spread to managers, who have come to see Human Factors as ‘done’ once training has been delivered. This creates a moral hazard. If there are now inadequate funds available to address wider systems problems, and if failure is seen as focused on individual and team performance, then failure is both more likely and more punishable.

So it is fair to say that Human Factors researchers and practitioners are uncomfortable with training as an intervention for problems that are not fundamentally associated with competency, at least in the first instance. Since training is about modifying people – fitting people to tasks – it seems to go against the philosophy of Human Factors. If interaction problems are rooted more in the design of activities, tools, and contexts of work, then those are the first ports of call when it comes to modification. “It’s easier to bend metal than twist arms”, wrote Sanders and McCormick (1993), while James Reason wrote “You cannot change the human condition, but you can change the conditions in which humans work” (2000).

From a practical point of view, training to modify behaviour is expensive and often ineffective in the short or long term, unless done in a way that integrates a thorough understanding of Human Factors. More is said on this by Russ et al‘s The science of human factors: separating fact from fiction, an excellent paper written by Human Factors specialists from psychological, engineering and clinical backgrounds.

But to put it into perspective, consider the National Health Service in England, which employs around 1.5 million people (1.1 FTE). Around half a million of these are doctors, nurses, midwives and ambulance staff. Training is essential for all staff, in order to do their jobs. But imagine training 500,000 staff to modify their behaviour in order to address problems. You’d still be left with inadequate staffing, poor rosters, confusing medicine packaging, badly designed equipment and facilities, too many policies and guidelines, shallow investigations, and stressful jobs and tasks, to pick just a few remaining problems. (And you’d still have to train the 140,000 or so pharmacists, radiographers, operating theatre practitioners and other scientific, therapeutic and technical staff.) During this training process, many staff would also have left, and new staff would have joined. And after a year or so, training would need to be refreshed. Training staff in behaviour modification can make painting the Forth bridge look easy.

Ultimately, all training aims to modify behaviour or practice, but it would be nonsensical to call all training ‘Human Factors’. ‘Human Factors’ is often invoked for so-called ‘non-technical’ skills rather than ‘technical skills’ – a false dichotomy on both theoretical and practical grounds, with unfortunate unintended consequences.

Still, I would argue that, if done well, behaviour modification training can be an application of Human Factors. If you’ve read this far, then you might be wondering how. One argument can be seen in in the example of CRM, which can be found in Human Factors journals and in some textbooks. However, to reinforce the point about non-equivalence, training-based behaviour modification approaches are indeed a minority of articles. Given the number of pages of journals and textbooks on Human Factors, I would estimate that training-based behaviour modification solutions are mentioned in fewer than 1 in every 100 pages.

So what might make training-based behaviour modification a ‘Human Factors’ intervention, since all training aims to modify behaviour? The conditions might involve the following sorts of activities, laid out below in a process.

  1. A problem or opportunity relating to the interaction between humans and other elements of a system has been identified and investigated.
  2. The interactions between people, activities, contexts and tools/technologies are analysed and understood using Human Factors methods.
  3. Needs arriving from 1 and 2 above are analysed and understood, considering both system performance and human wellbeing criteria.
  4. A range of solutions is considered, as ways of meeting these needs.
  5. Training is identified as an appropriate solution (typically, along with others).
  6. Training requirements are defined.
  7. A prototype training solution is developed (typically in conjunction with other prototype solutions).
  8. The prototype training solution is implemented and evaluated, ideally in conditions that are reasonably reflective of real working conditions.
  9. If the needs are not met, then the process returns to any of the steps 1 to 7 (the activities may need to be done more thoroughly, perhaps, or the problem or context may have changed).
  10. If the needs are met, then the training solution is implemented and sustained.

With such a process, we can say that training is a well-designed solution to a well-understood problem or opportunity. Training, in this context, is part of the work context, and must be designed. Where training is simply provided en masse without these steps (accepting that there will be compromises – the above is intended as a fairly robust process), then we would have to question whether training is a well-designed solution to a well-understood problem or opportunity.

What about simply teaching people about ‘factors of humans‘ – memory, attention, decision making, fatigue, and the like? Again, if something like the process above is followed, then one can be confident that this is a ‘Human Factors solution’. If the process is heavily compromised, or not followed at all, then there may well be too many assumptions about:

  • the problem or opportunity
  • the people, activities, contexts and tools (PACT) that are exposed to the problem or opportunity
  • the suitability of training as a solution
  • the adequacy of the development, evaluation and implementation of training
  • competing systems and behaviours that affect the behaviour targeted by training, and
  • the sustainability of training as a solution.

So how can you know training-based behaviour modification is a Human Factors intervention, or…just training? If a training-based behaviour modification solution is offered off the shelf, without following something like the 10 steps above, then it is probably fair to say that it isn’t a Human Factors intervention. One quick test is to check how soon training is proposed in response to an identified problem or opportunity. If any of steps 1 to 4 have been missed in any significant way (regarding the understanding of the problem/opportunity, context and possible solutions), then it’s probably not a Human Factors intervention, and it would be more appropriate (and helpful) to describe such training as something else (much ‘Human Factors Training’ would be better described as something more contextual and specific). If any of steps 6 to 9 have been missed (regarding the development, evaluation and implementation of training), then the training solution may not be well-designed, no matter how it is branded.

Posted in Human Factors/Ergonomics | Tagged , , , , ,

What Human Factors isn’t: 2. Courtesy and Civility at Work

‘Human Factors’ (or Ergonomics) is often presented as something that it’s not, or as something that is only a small part of the whole. Rather than just explain what Human Factors is, in this sporadic series of short posts I will explain what it isn’t. The posts outline a number of myths, misunderstandings, and false equivalencies.

In this series:

  1. What Human Factors Isn’t: 1. Common Sense
  2. What Human Factors isn’t: 2. Courtesy and Civility at Work
  3. What Human Factors isn’t: 3. Off-the-shelf Behaviour Modification Training
  4. What Human Factors isn’t: 4. A cause of accidents

ResoluteSupportMedia CC BY 2.0

Human Factors Isn’t Courtesy and Civility at Work

Some myths about Human Factors are just plain wrong, such as the common sense myth. Others are more subtly wrong. One of these is the false equivalence of ‘Human Factors’ with ‘good behaviour at work’. Courtesy and civility and are fundamental human values, expressed differently in different cultures, and as such may be seen as ‘factors of humans‘ in the vernacular sense. They are themes that are increasingly common in healthcare in particular. These are undoubtably important aspects of life, including work-life. Research reported in healthcare journals has shown that rudeness has adverse consequences on the diagnostic and procedural performance of clinical team members, staff satisfaction and retention, among other outcomes. It is the focus of campaigns such as Civility Saves Lives. Reseach on social media indicates that incivility is a growing problem: it seems to be perceived as the norm of online interaction, rather than the exception. So courtesy and civility may also be seen as specific ‘factors affecting humans‘, and important aspects of professionalism, in a work context.

But to equate these values with Human Factors as a discipline or field of study (and practice) is erroneous. The terms rarely come up in the Human Factors and Ergonomics literature. I was unable to find either in the title, keywords or abstracts of any article published in ‘Human Factors’, ‘Ergonomics’ or ‘Applied Ergonomics’ – the top three journals in the discipline. Nor are the terms listed in any indices of Human Factors textbooks (at least the ones that I have). Human Factors practitioners are unlikely to have specific expertise the topic, though those working in healthcare may well be aware of some of the related healthcare literature. They would probably see these topics as a better fit with other disciplines.

So this wouldn’t be a surprise researchers and practitioners of Human Factors, since the terms seem not to fit the scope of Human Factors:

Ergonomics (or human factors) is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance.

Practitioners of ergonomics and ergonomists contribute to the design and evaluation of tasks, jobs, products, environments and systems in order to make them compatible with the needs, abilities and limitations of people.

International Ergonomics Association (2019)

Courtesy and civility are critically important, and crop up in disciplines such as psychology, sociology, anthropology, organisational behaviour and human resources management, as well as professional studies, interdisciplinary studies and healthcare in particular. But an association with the term ‘Human Factors’ is unhelpful. First, it reduces the essential focus of Human Factors on design (of work), though one might argue that courteous and civil interactions can be designed and reinforced, for instance through teamwork training. (That being the case, courtesy and civility are aspects of a specific application of Human Factors, but should not be equated with the term.) Second, the terms distort the focus of Human Factors on ‘fitting the task to the person’. Third, a false equivalence with Human Factors may reinforce the myth that Human Factors is (or that human factors are) ‘common sense’; most people would understand their importance, and how to be courteous and civil in every day life, even if these behaviours lapse from time to time.

Courtesy and civility should be an important topic for social dialogue in all aspects of life. They are also important aspects of training – fitting the person to the job. But we should be careful in overemphasising courtesy and civility in conversations about ‘Human Factors’. The false equivalence of courtesy and civility with Human Factors risks diluting its scope to ‘everything human’ – all humanities – along with its essential focus on designing for system performance and human wellbeing.

Posted in Human Factors/Ergonomics | Tagged , , , ,

What Human Factors isn’t: 1. Common Sense

‘Human Factors’ (or Ergonomics) is often presented as something that it’s not, or as something that is only a small part of the whole. Rather than just explain what Human Factors is, in this sporadic series of short posts I will explain what it isn’t. The posts outline a number of myths, misunderstandings, and false equivalencies.

In this series:

  1. What Human Factors isn’t: 1. Common Sense (this post)
  2. What Human Factors isn’t: 2. Courtesy and Civility at Work
  3. What Human Factors isn’t: 3. Off-the-shelf Behaviour Modification Training
  4. What Human Factors isn’t: 4. A cause of accidents

NATS – UK air traffic control, CC BY-NC-ND 2.0,

Human Factors Isn’t Common Sense

People sometimes assert that ‘Human Factors’ is common sense. The same is less often said of ‘ergonomics’ (which is equivalent within the discipline or knowledge base) and rarely said of ‘human factors engineering’ (also equivalent, but seems different because of the ‘engineering’ bit). ‘Common sense’ is also notoriously uncommon. Common frustrations with everyday door handles, shower controls, and websites are testament to this. So ‘Human Factors is common sense’ betrays a lack of understanding of both Human Factors and common sense.

Anyone who describes Human Factors as common sense implies that the interaction of physical, biological, social and engineering sciences, and the application of this to the design of work (including the artefacts and environments of work), is obvious and straightforward, and can therefore be done by anyone based on knowledge and skills that are commonly available. This couldn’t be further from the truth. Most aspects of Human Factors are difficult and complex, including: 1) the research and experience bases that contribute to the knowledge base of Human Factors; 2) the interaction of the empirical findings from the research in these fields; 3) the extrapolation and application of the knowledge base to work environments, including highly-regulated safety-critical environments that require specific evidence for claims; and 4) the practice skills, relationships and resources that are needed to do this in environments as diverse as healthcare, power generation, defence, manufacturing, transportation, and agriculture, between which Human Factors practitioners, and others who apply Human Factors methods and knowledge, often traverse.

The ‘common sense’ claim betrays a lack of understanding of the foundation, scope and application of Human Factors. Typically, the claim comes from those who confuse Human Factors with ‘behaving safely’. While human performance is a key aspect of Human Factors, the primary method of intervention is (work) design, not behaviour modification. Behaviour modification is usually best filed under ‘Applied Psychology’ (also – related – Human Performance as a sphere of professional activity).

Even when the aim and scope of Human Factors are better understood, the ‘common sense’ claim confuses hindsight with foresight. When a task, artefact or environment is well-designed – it is more likely to be unremarkable, or even unnoticable. It blends in with, and subtly assists, the purposive flow of experience. It is part of ‘how things ought to be’. So it may intuitively feel like common sense because it doesn’t make the day longer and harder than it needs to be. But the activities to bring about these things, including the competencies, relationships, tools, time, project arrangements, and other resources, are not common. In sectors such as air traffic control, rail, defence, and major hazard industries, including regulators, designing for system effectiveness and human wellbeing requires the support of suitably qualified and experienced practitioners working as part of teams in multiple organisational divisions – operational, design and engineering, safety and R&D.

If Human Factors is common sense, then so are architecture, surgery, and electrical engineering, or (as foundation disciplines of Human Factors) psychology, biological sciences, and industrial design.

The common sense claim wouldn’t matter much if it were not for the false and dangerous conclusion that follows: that because ‘Human Factors’ is common sense, then no competent design support is needed. People can carry on and ‘Human Factors’ will just happen as the natural order of things. The ‘natural order’ came to light in the 1940s, when ‘common sense’ cockpits led to many gear-up crash landings. Today, the ‘human factors as common sense’ myth leaves heathcare workers with dangerously confusing devices, medicine packaging, and unforgiving work environments, the consequences of which are inherited by them, by patients, by families, and by society generally.


Posted in Human Factors/Ergonomics | Tagged , , ,

The Organisational Homelessness of ‘Human Factors’

Most fields of professional activity have a settled home within the divisional and departmental structures of organisations. Operational staff work in operational divisions. Engineering staff work in engineering divisions. Everyone else tends to know their place: finance, human resources, legal, safety, environment, quality, security, corporate communications, and so on.

Not so for human factors (or ergonomics; HF/E). Within organisations that are large enough to have a divisional structure, ‘human factors’ can be found in a variety of divisions.

In this post, I outline four common homes for HF/E within organisations (after Kirwan, 2000), drawing on personal experience in each of the four organisational divisions in different organisations over the past 21 years, and some of the little literature on this (Kirwan, 2000; Shorrock and Williams, 2016). I conclude with some of the implications of organisational homelessness.


Photo: Dave Gray, Design by Division, CC BY-ND 2.0,

Human Factors in Operations Divisions

‘Human performance’ is, naturally, core to HF/E (but not equivalent), and in sectors such as transportation, energy production, manufacturing, power generation. and mineral extraction, HF/E is sometimes located in operational divisions of organisations. When housed here, HF/E practitioners may assist with the design and assessment of work, training, non-technical skills and team [team/bridge/rail] resource management, procedure and job aid design, observational safety, assessments and advice on fatigue and shiftwork, staffing and rostering, maintenance, personal resilience and confidence, stress management, safety investigation, quality improvement, and advice and support on human performance more generally. Such issues are reflected in texts such as Flin et al’s Safety at the sharp end and Davies and Matthews’ Human performance: Cognition, stress and individual differences.

Being close to operational teams and work-as-done can be especially rewarding. It is the only way to really understand The Messy Reality and Taboo issues. Problems and opportunities for work-as-done are hard to see from afar (if you want to understand risk, you need to get out from behind your desk). This divisional location can provide credibility with front-line operational staff, the beneficiaries of most HF interventions, and allow for the development of the relationships required for problem solving and opportunity management.

The other side of this coin is that there is a particular risk in Ops of becoming too close to operational staff, while also under the operational management structure. Independence can be compromised.

Housed in operations, human factors – as a design discipline – may also be in the unhappy position of inheriting upstream design decisions…and any resulting problematic situations. Without proper involvement to the design process, problems may come to light late in the design and development process. At this stage, there is considerably less opportunity for influence. HF/E practitioners in this context can also risk losing design skills, and also lose track of research; the research-practice gap can seem especially wide from Ops, where it tends to be valued least of all.

The shorter term focus of operations also brings an acute-chronic trade-off: when time is limited (i.e., all the time) handling today’s problems and opportunities leaves less time for future problems and opportunities.

Human Factors in Engineering Divisions

Human factors is, fundamentally, a design discipline. This is sometimes a surprise to some who perceive it as a behavioural (or ‘human performance’) discipline, which might be seen to be more naturally aligned with operations. However, human factors – by definition – operates primarily through design, not behaviour modification. This is exemplified by various textbooks, including old classics such as Sanders and McCormick’s Human Factors in Engineering and Designand Wilson and Sharples’ Evaluation of Human Work and, more generally, ISO 9241 – Ergonomics of hums-system interaction, especially Part 210: Human-centred design for interactive systems).

The international Ergonomics Association – the umbrella organisation for all HF/E societies and associations around the world – defines the profession as that which “applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance”. So HF/E specialists can often be found in engineering divisions of organisations.

In this organisational context, HF/E can help to address the design of equipment, tools, artefacts and infrastructure, such as control rooms, buildings, and signage. In such cases, the costs of not integrating human factors are extremely high. Compared to procedures and work routines in operational contexts, equipment, tools, artefacts and infrastructure are difficult and expensive to modify. Often, operations inherit design problems and have to adjust to them, sometimes with HF/E support in operations…

There are downsides to be aligned with the engineering divisions of organisations. Practitioners will tend to find they have to work within existing design and engineering processes, which may not be ideal for iterative human factors design. Being part of the design and engineering tribe brings some distance from operations – socially and culturally.  As a result of organisational silos, the practitioner embedded in this context may well be closer to work-as-imagined and work-as-prescribed than work-as-done. Some who identify as human factors specialists – especially when previously integrated in safety or operations – will need to develop new design and engineering skills to be accepted. Designers and engineers, meanwhile, can naturally find it frustrating to have to pass a ‘human factors test’, or depend on knowledge that they do not have.

Human Factors in Safety (and Health) Divisions

Many organisations have a division of safety, focusing on operational safety (major hazards) or occupation safety, or both. Human Factors practitioners in this context – especially n high-risk industries – are likely support activities such as safety investigation, safety assessment (e.g., human reliability assessment), safety surveys, specific activities such as fatigue and stress management, and perhaps safety policy and the development of safety management systems. Safety departments may exist within a broader safety, health, environment, quality and, increasingly, security, in which cases other activities may be supported (e.g., concerning noise, vibration, the thermal environment, vision).

This context can be a good compromise between operations and engineering, affording close cooperation with both engineering project teams and operations, given sufficient attention to forging relationships across organisational boundaries. High level independent influence on strategic decisions (e.g., via safety management system requirements) can also be a benefit.

Safety divisions (and departments) are, however, often seen as external to both operations and engineering (both culturally and organisationally, requiring, for instance, internal contracting for services). HF/E may be seen as an interference, or supporting only one aspect of system performance (accident prevention), and not activities that support effectiveness more generally. Safety (and health) is only one of the goals of HF/E, which seeks to optimise system performance and human well-being.

Human Factors in R&D Divisions

For some HF/E practitioners outside of academia, R&D divisions offer a chance to do industry-centred research and development from the inside. Within government, inter-government or commercial organisations, HF/E practitioners conduct applied research on all aspects of the discipline – physical, cognitive, social, and organisational.

It is intellectually stimulating and offers a chance to generate and apply knowledge, with a longer time horizon (see Chung et al, 2016). It can offer the chance to imagine future work, and understand work-as-done now. From a professional development perspective, R&D offers the best chance to try to keep up with the impossible task of keeping up with the literature for any particular aspect of HF/E.

But of the four options outlined above, practitioners in R&D may experience the greatest distance both from front-line staff and senior management. This is reflected in outputs. As Kirwan (2000) notes, “There are three main types of papers, in order of importance to the company: trade journals, conference papers, and journal papers. The order of importance to the company and to the success of the unit is the reverse of the academic ordering of importance” (p. 668). This can be a surprise to practitioners. While Kirwan also noted, that “[journal] papers will be of greater perceived importance to the company if the HF group is located within a research division in that company”, there are in practice several barriers to publication as well as research application in organisations (Chung and Shorrock, 2010; Salmon and Williams, 2016), helping to explain the small minority of industry practitioners that author HF/E journal articles; as low as 3% in 2000 and 2010, compared to 76% and 81% of papers authored by research institution authors only, in the same years (Chung and Williamson, 2018).

This may reflect a decline in in-house HF/E R&D. Some major organisations that were previously heavy hitters in R&D no longer have a large R&D function, or no longer perform HF/E R&D.

Organisational Misfits…or Connectors at the Edge?

To many, the organisational homelessness of human factors brings confusion about the nature of the discipline and profession. Is it about design, or engineering, or operations, or safety, or health…? Human factors has a sort of identity problem.

This identity problem might be seen as fundamentally exogenous, existing in large part because of the functional structures of (especially) large organisations, which divide decision making from work, design and engineering from operations, research from practice, system performance from human well-being. These are all within the scope of HF/E; none can be excluded. But organisations are what they are, and command-and-control structures resist systems thinking.

So HF/E is indeed an organisational misfit, which might seem ironic since HF/E is concerned with the fit between system elements. HF/E is no more at home in operations, engineering, safety, R&D, or other organisational functions. Individual practitioners, may feel more at home in one context in particular, but will often be found at the edge of functions, interfacing with other functions at the organisational system as a whole. Organisations, meanwhile, may see a better fit for HF/E in one division, or indeed – perhaps ideally – spread over several. But there is no universally appropriately home. Traditional organisational structures are simply at odds with systems disciplines that work across functional divisions, especially those that do not reflect the flow of work or influence in a system.

For any individual practitioner, experience of a variety of organisational functions is helpful to understand the internal processes and sub-cultures that exists within organisations, and to identify the formal and informal bridges that exist, or can be built, between them.

So organisational homelessness can be a weakness, but also a source of strength. As a systems discipline, HF/E sees the whole, and focuses on interaction and influence, not just parts. As well as providing technical HF/E support, practitioners using an HF/E approach might ideally combine a systems and humanistic approach, mediating, bridging and connecting different organisational functions as connectors. This quote, from an interview on learning from communities with Cormac Russell, describes well this ideal:

“There are people who are loosely called ‘connectors’ at the edge, who move quite fluidly.  I think about them as multicultural in a sense, in that they can move in between any groupings really but they have that competency and capability.” Cormac Russell

In organisations that divide by design, bridging is just as important as bonding…or more so. Organisational homelessness can help practitioners to navigate different worlds, without getting entrenched in one.


Chung, A.Z.Q. and Shorrock, S.T. (2011). The research-practice relationship in ergonomics and human factors – surveying and bridging the gap. Ergonomics, 54(5), 413-429. [pdf]

Chung, A.Z.Q., Shorrock, S., and Williamson, A. (2016). Chapter 9: Integrating research into practice in human factors and ergonomics. In S. Shorrock and C. Williams (Eds.), Human factors and ergonomics in practice: Improving system performance and human well-being in the real world. CRC Press.

Chung, A.Z.Q., and Williamson, A. (2018). Theory versus practice in the human factors and ergonomics discipline: Trends in journal publications from 1960 to 2010. Applied Ergonomics,66, 41-51.

Davies, D.R. and Matthews, G. (2013). Human performance: Cognition, stress and individual differences.Psychology Press.

Flin, R., O’Connor, P., Chrichton, M. (2008). Safety at the sharp end: A guide to non-technical skills. Ashgate.

Kirwan, B. (2000). Soft systems, hard lesson. Applied Ergonomics, 31, 663-678.

McCormick, E.J. and Sanders, M.S. (1992). Human Factors in Engineering and Design. McGraw-Hill.

Salmon, P. and Williams, C. (2016). Chapter 10: The challenges of practice-oriented research. In S. Shorrock and C. Williams (Eds.), Human factors and ergonomics in practice: Improving system performance and human well-being in the real world. CRC Press.

Shorrock, S. and Williams, C. (2016). Chapter 8: Organisational contexts for human factors and ergonomics in practice. In S. Shorrock and C. Williams (Eds.), Human factors and ergonomics in practice: Improving system performance and human well-being in the real world. CRC Press.

This is a repost of a the original, posted 06/04/2018, then lost to the technical vagaries of WordPress.

Posted in Human Factors/Ergonomics, systems thinking | Tagged , , , , ,

Reflections from the edge

Image: Steven Shorrock CC BY-NC-SA 2.0

I have ‘worked on work’ for my whole professional career. For the majority of that time, I have worked primarily in aviation. Unlike many in the industry my primary interest is not in aviation, any more than it is in any other activity. My primary interest is not even in safety. My professional interest is, and always has been, in work and people. 

I grew up in a family business. My family, on both sides, were very much working class, though my parents were entrepreneurial and opened a market stall, which grew into a small number of shops and a small distribution business. My siblings and I were co-opted into this effort and this took up our Saturdays and holidays for as long as I can really remember. 

I was the more sensitive and reflective of the older siblings, ill-suited to some of the work, though truck driving was enjoyable in later years. So, I was the first in our known family history to decide to – or be able to – enter higher education.

Being raised in a family business, at least of the sort that I was, is not something that I can recommend, and was not a choice. This upbringing did, however, give me an immense interest in work. And so it was clear to me, from teenage years, that I would study work. This was reflected in every subject choice through high school, college and universities.

Growing up in a family business also helped me to develop a particular capacity for observation from the edge. In a sense, my whole late childhood was an exercise in crude ethnography, though I never wrote up my observations. Some of these observations related to myself and our family dynamics, such as the confusing role transitions, blends and conflicts between life as a son, brother, and employee.

Of course, I was never really asked about my observations on work. No one was. Work was just something you got on with, under a particular power structure, with particular unspoken assumptions, and particular pressures. As an inside-outsider, I could see these, and in organisations of all sorts, insider-outsiders have a particular edge on seeing things from a different – less acculturated – perspective.

This made me think about the ‘outsiders within’. There are always people who are more naturally on the edge, of groups, departments, divisions, professions. They may be more interested in the edges, in the connections, and may be naturally drawn to connecting the disconnected. From the edge, they may not be fully accepted as a ‘true’ member of any particular tribe, and so may have relatively little power and may not be heard often. But they may be accepted into many tribes, as a guest, which may well afford them an understanding of the bigger picture, as well as the unseen within. 

As Kurt Vonnegut’s character Finnerty said in Player Piano, “I want to stay as close to the edge as I can without going over. Out on the edge you see all kinds of things you can’t see from the center.” 

So in your organisations, who would these people be? What might they see from the edge that others don’t? 

Posted in Culture, Humanistic Psychology, systems thinking | Tagged , , , | 1 Comment

‘Human Factors’ and ‘Human Performance’: What’s the difference?

The term ‘Human Performance’ (and ‘Human and Organisational Performance’ (or HOP) has become increasingly common in recent years in a number of industries, especially those with a safety focus. It is often associated with ‘Human Factors’, or even used as a replacement for the term. But in some cases, different practitioners have identified with one term or both. So I thought it might be useful to clarify a few important distinctions between the two.


Clement127 CC BY-NC-ND 2.0

In this post, I use ‘Human Factors’ and ‘Human Performance’ (mixed case) to refer to spheres of academic research/teaching and practice in applied contexts by internal and consultants (e.g., Human Factors Specialist, Human Performance Specialist). But there is another, more ordinary meaning of ‘human performance’ (lower case), as simply what people do and how. This ordinary meaning is not the focus of this post.

Human Factors emerged from many disciplines. ‘Human Factors’ (or Ergonomics) emerged from disciplines including psychology, anatomy, physiology, biomechanics, anthropometry, industrial design and engineering, industrial medicine, industrial hygiene, sociology, architecture, illumination engineering, interaction design, visual design, and user interface design. Still today, journals and textbooks cover all of these disciplines, and none dominates singly, but Human Factors now sits as a discipline itself (see later). Those who practise as qualified Human Factors professionals today tend to come mainly from psychology, engineering and physiology/biomedical academic backgrounds.

Human Performance is related primarily to psychology and physiology. ‘Human Performance’ as a sphere of research and practice is related primarily to psychology in industry, and to physiology and sports science in sport and leisure. For industrial applications, psychology dominates in discussions (evident on social media), and in research, though theory is not particularly well-connected to practice (arguably less so than for Human Factors). One of the very few academic textbooks for industrial applications with ‘Human Performance’ in the title (Matthews et al, 2000) is written by four academic psychologists, and covers cognition, stress, and individual differences. (Other books that mention Human Performance in the subtitle mostly concern sport and exercise.)

‘Human Factors’ emerged from many disciplines, with none dominating completely. Human Performance is related primarily to psychology, physiology, and sports science, with psychology dominating industrial applications. 

Human Factors is a discipline. ‘Human Factors’ emerged as a distinct field of academic study – taught and researched as part of higher education – over time since WWII (see this chapter and this article by Pat Waterson). The first learned Society (now CIEHF) was set up in 1949, and during the 1950s and 1960s, Professorial Chairs, postgraduate degree courses, and scientific journals were established. But for some time, Human Factors/Ergonomics was a “convenient gathering place” (Rodgers, 1959) for a variety of stakeholders, including other disciplines. Human Factors is now considered a distinct scientific and design discipline, with university departments/schools, research institutes, professors, conferences, and scientific journals, including Human Factors, Ergonomics, and Applied Ergonomics (the top three journals in the discipline).

Human Performance is an interdisciplinary focus. ‘Human Performance’ is not a discipline as such, but rather an interdisciplinary focus. It has long been associated with sport and exercise, with performance in extreme environments, and with work, but as a focus of activity for sports scientists, physiologists and industrial-organizational psychologists. There are scientific journals associated with the term Human Performance (but not many). Examples include Human Performance, Journal of Human Performance in Extreme Environments, and Organisational Behaviour and Human Performance (1966-1984). There are few university schools/departments and Professors of ‘Human Performance’. Those that exist tend to focus on sport and exercise science.

‘Human Factors’ is a distinct discipline, as well as a forum for other disciplines that share a similar focus. ‘Human Performance’ is not a distinct discipline, though it is a focus of, or umbrella for, allied human sciences. 

Human Factors is a profession. The profession of ‘Human Factors Engineer’/’Ergonomist’ emerged (unexpectedly) over 50 years ago, and is now associated with specialised education, recognised qualification routes, professional associations, and associated codes of conduct. Specialists are now employed in many industries – especially safety critical industries – such as aviation, rail, military, nuclear, oil and gas, and healthcare. These roles tend to require formal, post-graduate degree qualifications in Human Factors (or Ergonomics), and/or certification (‘Chartership’ in the UK) by recognised professional bodies. Membership of professional bodies requires adherence to a Code of Conduct (such as this from CIEHF).

Human Performance is not yet a profession. ‘Human Performance’ cannot be described as a profession, with specialised education, recognised qualification routes, professional associations, and associated codes of conduct. This may emerge in the future. Sometimes, those who identify as ‘Human Performance Specialists’ are full members of professional associations for disciplines such as Human Factors, Industrial/Organisational Psychology, Medicine, Sports Science, etc. More commonly, Human Performance (or Human and Organisational Performance) is a term adopted by health and safety practitioners, and is sometimes described as a ‘movement’.

‘Human Factors’ is a distinct profession, and is also sometimes used by other allied professions with similar aims and scopes. ‘Human Performance’ is not a profession, but is a focus of interest for allied professions.

Human Factors and Ergonomics are considered roughly equivalent. Within the discipline and profession, the terms ‘Human Factors’ and ‘Ergonomics’ are generally considered equivalent. The scope of research units, schools, and journals, and the official internationally-accepted definition, is equivalent. Different terms are, however, used in different industries and contexts. Human Factors Specialists tend to be happy with either title, depending on the context (the formal Chartered title in the UK is ‘Chartered Ergonomist and Human Factors Specialist’.)

Human Performance and Ergonomics are considered more distinct. While human performance (what people do and how they do it – concerning physical, cognitive, social aspects) is of course of critical interest to Ergonomics, the terms are not equivalent. Those who identify as ‘Human Performance Specialists’ tend not to identify as ‘Ergonomists’, unless they are qualified in Ergonomics. ‘Ergonomics’ has clear design connotations, while ‘Human Performance’ tends to have training connotations, or (lowercase) human performance is simply seen as something that people do – perform.

Human Factors and Ergonomics are considered roughly equivalent within the discipline, and by many in the profession. Human Performance is of interest to Ergonomics (Human Factors), but also of many other disciplines.

Human Factors has a design focus. ‘Human Factors’ interventions tend to have a design focus. This has been the method of intervention since the inception of HF in WWII, and since then in many definitions, including that of the International Ergonomics Association (adopted by all Human Factors [or Ergonomics] professional associations), to apply “theory, principles, data and methods to design in order to optimize human well-being and overall system performance” (IEA). ‘Design thinking’ is therefore inseparable from Human Factors.

Human Performance has a behavioural focus. ‘Human Performance’ interventions by those who identify as Human Performance Specialists tend to have a more direct behaviour modification focus, frequently associated with safe behaviour, leadership, culture, and teamwork. The primary methods of intervention for Human Performance are primarily training, coaching, awareness-raising, and behaviour change methods that tend not to be design-led. ‘Design thinking’ is not necessarily associated with Human Performance (though it may be, in some interventions and publications).

Human Factors and Human Performance tend to have different modes of intervention. Human Factors tends to have a design focus, while Human Performance tends to have a behaviour modification focus.

Human Factors is concerned with system performance. ‘Human Factors’ concerns “interactions among humans and other elements of a system” (IEA). It has an military-industrial heritage, with a focus on the sociotechnical system. This system focus can be confusing, especially outside of the discipline, where it is sometimes associated with ‘factors of humans’ (which is, confusingly, more aligned with Human Performance). The focus is therefore not only human performance per se, but system performance more generally, with human performance being a key influence on this. Human performance at an individual or team level could be considered effective (locally), but – by the nature of system interactions – produce unwanted effects at a higher system level, or in another part of the system, or be detrimental to human wellbeing. ‘Systems thinking’ is inseparable from Human Factors.

Human Performance is concerned with individual and team performance. ‘Human Performance’ is primarily focused on the performance of individuals and teams (and organisations, in the case of Human and Organisational Performance) – what people do, and how. Academically, it has a human science heritage, in sport and exercise science, physiology (endurance and survival in extreme environments), and also industrial-organisational psychology. ‘Systems thinking’ is not necessarily associated with Human Performance (though it may be, in some interventions and publications)

Human Factors, despite the name, is concerned with system performance, as a discipline and profession. Human Performance tends to be concerned with individual and team performance, as a focus for various disciplines and professions.

Summing up

‘Human Performance’ is seemingly self-evident in its focus; it is about what it says on the tin – human performance. It is not a distinct discipline or profession, but offers a convenient gathering place for those who are interested in improving human performance. ‘Human Performance’, as used by some health and safety professionals now (who sometimes identify as Human Performance or Human and Organisational Performance specialists) is, in some respects, in a similar position to that of ‘Human Factors’ (and ‘Ergonomics’) in the 1960s. It is also in a similar position to ‘User Experience’ or UX a decade or two ago (compared to Human Computer Interaction, Usability Engineering or Interaction Design).

Whether ‘Human Performance’ should become a discipline and profession is a matter of opinion. But since there are already a number of academic disciplines and professions concerned with human performance, I would say this is unnecessary and unhelpful. I would also say that it is unhelpful to call it a ‘movement’. Rather, the term ‘human performance’ is more useful in a multi-disciplinary, non-professionalised (or multi-professional) way concerning what people do, and how, and to bring people together to talk about this, somewhat like ‘systems thinking’. It is something of interest to many stakeholders

But I see three key future risks for ‘Human Performance’ as a ‘movement’. The first risk is that – disconnected from a discipline – it becomes allied with populist science, without an evidence base in pragmatic science. Populist science can appeal to industry, but takes practice further from theory, to the point that intervention may be ineffective or counterproductive.

The second risk for the Human Performance movement is that – disconnected from a profession – clients of services related to Human Performance do not really know who or what they are getting, and have no recourse to a code of conduct and associated professional association. Clients therefore have to ensure the person employed or contracted is suitably qualified and experienced for the work, whether it is labelled as ‘Human Performance’ or ‘Human Factors’.

The third risk is that the term ‘Human Performance’, as often used by HP/HOP consultants, may reinforce behavioural approaches to improvement (training, coaching, supervision, monitoring, behaviour-based safety), at the expense of system and design approaches, which may well be more effective. As Sanders and McCormick (1987) stated in their textbook Human Factors in Engineering and Design, “it is easier to bend metal than twist arms”. And so we should be wary of abandoning ‘Human Factors’ for a term that may be on trend, but risks taking us back to an ideology of only fitting the human to the task, rather than (first) fitting the task to the human.


This post reflects on developments in a number of industries concerning the growth of ‘Human Performance’ as a movement or sphere of activity for internal and external consultants – separate from, equivalent to, an aspect of, or even subsuming ‘Human Factors’ as a discipline and profession. In some cases, the terms Human Factors and Human Performance refer to rather different things as spheres of professional activity. In others, and for some publications, they refer to closely related things or the same thing, but with one term or the other being used depending on the purpose, scope and readership. This White Paper on Human Performance in Air Traffic Management Safety, for instance (for which I was lead editor) is arguably more about Human Factors, though it does not include human wellbeing in its scope (which is core to the definition of Human Factors and Ergonomics). This Human Performance Standard of Excellence (also within air traffic management) similarly includes design and behavioural approaches, and also mentions wellbeing. Again, this is more aligned with Human Factors (in a non-professionalised way), but the term human performance is used. So ‘Human Performance’ as movement or a sphere of research and professional activity is different to ‘human performance’ as simply what people do and how. Both of the above publications essentially concern ‘human performance’ (lowercase) in the ordinary sense – what people do and how they do it, and how to improve that using training, design, management, and other interventions. In summary, in some applications, publications, and contexts, either term may be used with essentially the same meaning, while in others, the terms have somewhat different meanings and implications, and even the meaning of ‘human performance’/’Human Performance’ (and even ‘human factors‘/’Human Factors‘) can differ.

Posted in Human Factors/Ergonomics, Safety, systems thinking | Tagged , , , , , , , , , | 5 Comments