Learning Teams, Learning from Communities

Image: Oliver CC BY-NC-ND 2.0 https://flic.kr/p/6JJYQc

Over the last decade, I have spent a lot of time listening to operational, technical, specialist, support and managerial staff in small groups around Europe. The conversations – aimed at learning about safety – have changed over the years. What started off as strongly facilitated workshops to interrogate safety culture questionnaire results, became only loosely based on questionnaire results, and more on what mattered to participants, but still with predetermined issues in mind. Finally, the conversations became much more open still. In small groups, we sat in a circle to understand the issues that mattered to the participants, concerning safety and the effectiveness of work more generally. 

This latter transition has occurred alongside an increasing interest that I have developed over the last few years in natural communities. It is rare that organisations and professions try to learn from communities, and yet there is much to be learned from how healthy communities work. 

Descriptions of healthy communities can be found in asset-based community development (ABCD). ABCD is an approach to understanding and developing communities from the inside based on that they have– assets. As well as being asset-based, it is citizen-led, relationship-oriented, place-based, and inclusion-based (Russell, 2017). 

This interest has paralleled the development of Safety-II – learning from ‘what goes’, including how things normally go right, as well as how thing occasionally go wrong (see EUROCONTROL, 2013). Both resonate with a longstanding interest – humanistic psychology, which is more interested in human potentials than deficits.

Having listened to thousands of people in person, what people most often said was critical to safety was relationships with direct colleagues (including direct managers). This is backed up by quantitative data from tens of thousands of completed questionnaires. Years ago, we would gratefully accept this finding, and ask few more questions of it, focusing only on deficits. Now I find relationships to be fundamental assets – just as people said – worthy of much deeper understanding and development.

A major figure in the history ABCD has been Professor John McKnight. He has worked in activist organisations and civil rights agencies, and learned the Alinsky approach to community organising before developing ABCD, along with John Kretzmann. McKnight went on to create university departments to support urban change agents. Another major figure in community development has been Peter Block, known for work on organisation development, community building, and civic engagement. He works on building the capacity of community to value its gifts and see its own possibility. The work has been developed and applied further by Cormac Russell, a faculty member of the ABCD Institute, who has worked with communities in over 30 countries and has brought ABCD to many. Cormac and I have worked together with 20 or so small group Learning Teams, bringing insights from ABCD to working groups.  

In this article, I refer to some of the ideas and writings of ABCD to reflect on Learning Teams, and small group conversations and action more generally in organisations. I highlight four lessons from ABCD for Learning Teams, health and safety professionals, and their host organisations. The lessons do not form a complete set, and there are of course other lessons from outside of ABCD, but I hope that the lessons are of value to those work with Learning Teams, or plan to. 

Lesson 1: Talk about everyday work

ABCD is about everyday life in communities, and the capacities and potentials that exist and are used (or could be used, or extended) to improve community life. Everyday life is rich, with many values, goals and activities jostling for attention. There is no singular focus. Health, safety, security, education, housing, mobility…all are important, all interact, though each can be more important at particular times for different people. 

As we know, workers are often only marginally interested in ‘health and safety’, and even caricature “elf ‘n’ safety gone mad”as a counter against bureaucratic controls. What workers are interested in is work and worklife. When work is viewed in the whole, rather than through the lens of health and safety (or accidents) alone, many things emerge: the patterns, the goal conflicts, the trade-offs, the dilemmas, the messy details, the joys, the successes, the meanings. Holistic discussions inevitably include health and safety, and other things, all of which are inextricably linked. There are benefits to this broader perspective that extend beyond traditional conceptions of health and safety and connect different values.

Lesson 2: Start with what’s strong, not what’s wrong

Health and safety, like many medical specialities, is one of few professions that views what it wants through the lens of what is doesn’t want – what’s wrong or what could be wrong. This is rather like viewing happiness through the lens of misery. We know that we don’t want people to be harmed in accidents. And so we tend to organise around avoidance. Yet we also know that we don’t get what we want by only avoiding what we don’t want. I don’t want to have an accident on the way to work. One way to guarantee that is not to go work. 

In The Careless Society: Community And Its Counterfeits, John McKnight (1995) noted that “The obvious centre of the medical mentality is the focus upon malady, deficiency, disease, and need – the empty half of the glass. Clearly, the empty half is present. And just as clearly, the half full is present.” (p.75). He also made a remark that challenges many ‘helping’ professions: “The medical system needs the empty half. The healthful community needs the full half …The raw material of community is capacity. The raw material of medicine is deficiency.”(p.76). In health and safety, do we need the empty half more than the organisation and workers needs the full half? Perhaps such a ‘need’ is legitimate, as a counter against an organisational focus on efficiency and productivity. But what are the unintended consequences of a deficit-based approach? How does it affect our view of the world?

In Cormac Russell’s (2018) conversation with McKnight on the heritage of ABCD, McKnight remarked that “many people, and even whole institutional systems, live by inaccurate maps; they have incorrect definitions or perceptions of people, places and things. They judge people and events through the labels they assign them, such as “needy”, rather than through observable actions and verifiable accounts.” (p. 84). 

In health and safety, we can fall into the trap of viewing work, those who do the work, and their behaviour, through a deficit lens. This is easy to demonstrate. Take the content and glossary of any safety report, or the minutes of a safety meeting. The language and terms tend to be overwhelmingly negative. And yet, everyday work is mostly rather effective. Our lens reflects a sort of ‘déformation professionelle’ or ‘trained incapacity’ – a tendency to look at things from our limited professional perspective, developed via professional acculturation, means that our abilities function as inadequacies or blind spots (see Shorrock, 2013).

When we view people through a deficit lens, we tend to view them also in terms of their needs, as we imagine them. But our imagination of the work and needs of others is vastly simplified. It is also wrong in important ways. Imagined work and imagined needs is the wrong way to look and the wrong place to start. We need to startwith their assets, as they understand them. This is the startingplace for ABCD, and is a way of thinking that resonates with Safety-II. It is valuable to focus firston what we have and what is working well, including our gifts, skills and passions, which can be illuminated, connected and mobilised in Learning Teams. Starting on an asset footing results in a profoundly different conversation compared with starting on a deficit footing.

The valuable capacities of people, and other assets, that create safetyneed to be illuminated and connected. I find it helpful to start discussions with questions like, “What is going well for you/us in the day-to-day work”, or “If you had to explain to a neighbour why things work well here, what would you say?”I’m trying to understand the assets (relating to people, environments, activities, processes). I’m also interested in what people perceive to be limits of these. If everyone’s answer is very local to their self or immediate team, I’d have more questions to ask about the organisation as a whole.  

Lesson 3: Find ways to cross departmental boundaries

When we think of a ‘team’, we often think of people who routinely work together doing similar sorts of things. When it comes to Learning Teams, this means that people understand their own work and know the relevant health and safety issues. And there will be bonding social capital, bringing trust, commitment, and reciprocity. But people in teams also tend to be more like-minded, and less diverse. There will be unstated assumptions and taboo topics. Drifts in behaviour may be hard to see. There will tend to be pressure to conform (to opinions, beliefs, behaviour patterns, etc) in order to belong. These latter features of teams are, unfortunately, often the enemies of learning. The ‘divisional’ design of organisations can reinforce this. Divisions and departments, and the teams within them, can make it hard to see how our work interacts with that of others.

John McKnight recalled to Cormac Russell a story about John’s ‘County Labrador Retriever Owner Association’, where people and their Labrador dogs got together. One day, someone with a beautiful dog approached the group. The trouble was, it wasn’t a Labrador. It was a German Shepherd. In a delightfully Monty Python-esque scenario, it illustrated something about the often arbitrary boundaries that we create and maintain. In organisations, we tend to organise around function instead of the flow of work and information. 

Teams exist within a much larger, interconnected network, and a flow of work. ABCD would encourage us to think about the boundaries of Learning Teams. Where are the edges? Is there an invitation to the stranger at the edge? Crossing boundaries requires invitation, participation and connection (see Shorrock, 2017). 

In my podcast conversation with Cormac Russell (see Shorrock, 2018), he highlighted roles in ABCD discourse that are important in crossing organisational boundaries. ‘Gappers’ link together functions and people at the edges or boundaries, often quite purposively. ‘Connectors’ connect individuals in a special and natural way. Connectors are well connected, see the best of others, are trusted & create trust. They believe in community & move around comfortably between different groups. They get joy from connecting people. You can probably identify people with these informal roles in your own workplace or organisations you’ve worked with. They are as important as ‘leaders’, but rarely recognised as such.

In The Abundant Community, McKnight and Block (2010) wrote of community connectors, “we want to elevate and make more visible people who have this connecting capacity. We also want to encourage each of us to discover the connecting possibility in our own selves … The operating question becomes, who are the proven and potential connectors of our acquaintance? Who sees the gifts of local people and figures out ways to share them? Whom do people turn to when something needs to be done on the block? Who are the people who take responsibility for civic events? Who are the leaders of our local associations?” The same questions could be asked in organisations. But do we?

In working with interdisciplinary Learning Teams, Cormac and I asked each person what they appreciated about the sessions. The responses of the 200 or so people were heart-warming, but also sometimes sad. We heard from many people who said that they work in the same corridor, or do work that affects each other, or passing one another daily for years or even decades, and had a conversation for the first time during these small group conversations. 

Lesson 4: Understand first what can be done BY teams

One parallel for Learning Teams in communities is ‘Listening Tables’ of neighbours and their representative associations, and institutions that want to become friendly with communities. McKnight and Block (2010) remarked that“these initiatives can create a dialogue that begins to redefine the powers and responsibilities of institutions and communities. This dialogue can be framed by three questions: First: What functions can neighborhood people perform by themselves? Second: What functions can neighbors achieve with some additional help from the institutions? Finally: What functions must institutions perform on their own?” 

They go on to say that “the order of these questions is very important. It shows that the basic productive force is the local community. What citizens can do for themselves is the primary question. What institutions can do is a secondary question. A neighborhood doesn’t know what it needs from outside until it is clear on what is has inside.” This message is echoed by Russell (2019), using the question of change done BY, WITH, FOR, and TO people.The question of agency and power in health and safety is important. If we start by asking what can be done TO or FOR people, rather than BY people, we end up disempowering them.

Just as systems and professionals cannot provide health and safety for communities, health and safety professionals cannot provide health and safety for workers. Safety is created at many levels of organisations, and by startingwith what health and safety professionals can do, we end up colonising health and safety, perhaps creating and even believing an illusion that only the professional has the capacity to create safety. As McKnight (1995) remarked, “As you are the problem, the assumption is that, I the professional service, am the answer. You are not the answer. Your peers are not the answer. The political, social and economic environment is not the answer. Nor is it possible that there is no answer. I, the professional, am the answer.”(p.46). 

McKnight went on to say that “the disabling function of unilateral professional help is the hidden assumption that ‘you will be better because I, the professional, know better’”.

He identifies a second disabling characteristic of professionalised remedial assumptions as the remedy defining the need. “As professionalised service systems create more elegant techniques and magnificent tools, they create an imperative demanding their use.” (McKnight, 1995, p.47). By making workers the subjects of systems, rather than co-creators, we disable their capacities – gifts that are essential to health and safety, and effectiveness more generally.

Health and safety professionals, and organisations, can help learning teams by creating space and time for them to convene, illuminate what’s going well, document their dilemmas, state what they want, and what they can offer.

Summing up

I find it hard to think of a more important aspect of organisational life when it comes to health and safety, and effectiveness more generally, than small group conversations and action. Learning Teams are nothing new in this regard (being similar to action learning) but there are some useful orienting insights to be had from fields such as community development. To sum up:

  • talk about everyday work
  • start with what’s strong, not what’s wrong
  • find ways to cross departmental boundaries and get multiple perspectives
  • understand first what can be done BY teams.

Our recent feedback from around 200 people, is that Learning Teams, integrating insights from Asset-Based Community Development, can: 

  • help better understand one’s own work
  • introduce new perspectives on problems and opportunities
  • illuminate the work of others, and how it interacts with one’s own
  • introduce colleagues to one another
  • foster a sense of inclusion, and 
  • give hope and optimism. 

These outcomes relate to health and safety, but go further still to help focus on what matters to those who do the work, to make work as effective as possible and worklife as fulling as possible.


EUROCONTROL (2013, September). From Safety-I to Safety-II. A White Paper. Brussels: EUROCONTROL Network Manager. Retrieved from https://www.skybrary.aero/bookshelf/books/2437.pdf

McKnight, J. (2008). The careless society: Community and its counterfeits. Basic Books. 

McKnight, J. and Block, P. (2010). The abundant community: awakening the power of families and neighborhoods. Berrett-Koehler Publishers.

Russell, C. (2017). Asset-based community development – 5 core principles. Retrieved from https://www.nurturedevelopment.org/blog/asset-based-community-development-5-core-principles/

Russell, C. (2018). Asset based community development (ABCD): Looking back to look forward. Cormac Russell.

Russell, C. (2019). Four modes of change: to, for, with, by. HindSight, Issue 28, Winter 2018-2019, EUROCONTROL: Brussels. Forthcoming at https://www.skybrary.aero/index.php/HindSight_-_EUROCONTROL

Shorrock, S. (2013). Déformation professionnelle: How profession distorts perspective. [Blog post]. Retrieved from https://humanisticsystems.com/2013/12/12/deformation-professionnelle-how-profession-distorts-perspective/

Shorrock, S. (2017). Editorial: Invitation, participation, connection. HindSight, Issue 25, Summer 2017, EUROCONTROL: Brussels. Retrieved from http://www.eurocontrol.int/publications/hindsight-25-summer-2017

Shorrock, S. and Russell, C. (2018). Learning from communities: a conversation with Cormac Russell. Retrieved from https://humanisticsystems.com/2018/01/11/learning-from-communities-a-conversation-with-cormac-russell/

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The Real Second Victims

In many professions, specific terms – both old and new – are often established and accepted unquestioningly, from the inside. In some cases, such terms may create and perpetuate inequity and injustice, even when introduced with good intentions. One example that has played on my mind over recent years is the term ‘second victim’.

The term ‘second victim’ was coined by Albert W Wu in his paper ‘Medical error: the second victim’. Wu wrote the following:

“although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors: they are the second victims”.

As someone with a PhD in ‘human error’, the potential for trauma associated with one’s own actions and decisions is a phenomenon that I have come across in many interviews and discussions, albeit in a different context – air traffic control. In this context, professionals’ decisions and actions are almost never associated with death, but there are rare examples, and the prospect of hundreds of lives being lost at once can be devastating in the context of a near miss.

The term ‘second victim’ in healthcare was further popularised by Sidney Dekker in his 2013 book Second Victim: Error, Guilt, Trauma, and Resilience. There are tens of thousands of webpages on ‘second victims’. It is a term that is accepted by healthcare practitioners who see only too clearly the immediate consequences of mistakes and actions-not-as-planned.

While the term is accepted within the medical professions, important questions have been asked by those who have lost more than their confidence, profession or even – for however long – mental health. Sara Ryan – the mother of Connor Sparrowhawk (popularly known as LB, or Laughing Boy), is one of several families who have questioned the use of the term in healthcare. Sara remarked on twitter:

The thread continued:

She later clarified:

Surely families are the second victim? It was one of those questions that could perhaps only come from the profound truth of pain. LB was “a fit and healthy young man, who loved buses, London, Eddie Stobart and speaking his mind” (see the #JusticeforLB website). As described on #JusticeforLB:

LB’s mood changed as he approached adulthood and on 19 March 2013 he was admitted to hospital, the STATT (Short Term Assessment and Treatment Team) inpatient unit run by Southern Health NHS Foundation Trust). LB drowned in the bath on 4 July 2013. An entirely preventable death.

Sara and her family were not only victims following the death of Connor. They were further victimised by organisations responsible for Connor’s death. The process of getting justice has involved an inhumane ordeal, including a good deal of ‘mother blame’, detailed in Sara’s book ‘Justice for Laughing Boy’. This is a book that should be standard reading on a wide range of courses, from medicine to law. But in a paragraph, from the website #JusticeforLB:

How are you all doing?

Mmm. Good question. Not sure really. I can probably only speak for myself [Sara]. Not brilliant really. The death of a child is an unimaginable happening. That it could have been so simply and easily avoided, in a space in which no one would have thought he was at risk of harm, is almost impossible to make sense of. The actions of Oxfordshire County Council and Southern Health NHS Foundation Trust since his death have been relentlessly battering.

So perhaps it takes an experience of being a real second victim, and of being victimised, to see that the the term ‘second victim’ is one that only applies to loved ones.

Then again, it’s obvious. Of course family are the second victims. How could they not be?

But it is not obvious to tens of thousands, perhaps hundreds of thousands or more, of healthcare workers who find personal meaning in the term ‘second victim’, as applied to themselves – actually or potentially.

I asked my partner – an experienced practising psychotherapist and trainee counselling psychologist – what came to mind with the term ‘second victim’. Without hesitation, she said “family“. She had never heard the term ‘second victim’ before and did not know why I was asking.

She said, “If you’d have said ‘secondary trauma’, I’d have said the professional“. That is because, in this sense, the primary trauma is with the family who survive a person who has died. She also mentioned the difference in choice and control between clinicians and family, in that a clinician for instance, while unable to control the environment and resources, has control over whether she or he is a clinician. While my partner has no control over clients, she has control over her choice to remain a psychotherapist.

Some have tried to combine those who have died and their families as first victims (e.g., https://www.youtube.com/watch?v=YeSvCEpg6ew). But this casual combination of the dead and their loved ones is unconvincing, and seems like a fudge. My own mother died at 45 years old (following delays in treatment and lack of communication between a private and public hospital, which I won’t go into here). I remember my father at the time saying, “People tell me they feel sorry for me. I say they should feel sorry for her. She died at 45!”

There is a very real difference between a someone who has died, and a loved one who is grieving for that person, and someone who is suffering having witnessed or somehow been involved as a healthcare professional before the person died. Sara writes more about that here. She notes that “I’m not ignoring or denying that healthcare staff may/must be devastated by the death or serious harm of a patient here. It simply ain’t comparable to the experiences of families.”

Questions about first and second victims inevitably imply a ranking. So if loved ones are the real second victims, different in a very real sense to the deceased, then where does this leave professionals, who are different in a very real sense to bereaved families? Logically, however unsavoury the ranking exercise, professionals are third victims. The conversation in the third tweet above continued on this line of inquiry:

While ranking victimhood may seem like a troubling exercise, professionals in healthcare have, in effect, already created a ranking by establishing – quite uncritically it seems – the term ‘second victim’. ‘Second victim’ indicates a first victim, and implies a third victim.

During bereavement, families are sometimes victimised further still by organisations during the natural quest for justice. Justice, in this context, includes apology, truth, genuine involvement, learning, and change. For LB and his loved ones, it included this and this. In effect, justice involves the proper meeting of needs. There are millions more like LB, and millions of families like his, who feel forgotten and discounted by the professionals, organisations, and society, who morally and ethically should be involved in meeting these needs.

Sadly, the established ‘second victim’ concept, in effect, further victimises the forgotten. Acknowledging and helping to meet the needs of loved ones as the real second victims, as well as healthcare professionals as third victims, would be a truly restorative act of justice.


Wu, A.W. (2000). Medical error: the second victim. The doctor who makes the mistake needs help too. British Medical Journal, 320, 726–727.

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The Commercialisation and Commodification of Competency


Image: https://www.gapingvoid.com CC BY-NC-ND 3.0

Two or three years ago, I undertook a course involving UX ‘certification’. I had already undertaken courses in HCI and design as part of an MSc(Eng) in Work Design and Ergonomics some years (ahem…21) earlier. And I had already been involved in most aspects of the design and evaluation of interactive systems. So I was interested in what was new. In fact, the course was an overview of an ergonomics standard (and a good one: ISO 9241-210, 2010), which was not new to me but was enjoyable nonetheless. The course lasted two days, with a half day revision session, and a multiple choice exam. The course was well delivered, and the exam was properly invigilated.

But the test, in my view, was primarily a memory test that tested recall or recognition of specific vocabulary. Aspects of the test seemed to focus on dubious and debateable semantic differences, using very similar options that seemed to be designed to confuse. The certification arrangement seemed to encourage teaching to the test, and ironically felt like UX (and accessibility) had been ignored in the certification process, which required a high level of English to wade through the semantic quagmire.

Those who undertook the test came out feeling deflated, doubtful, discouraged and demoralised. Their passion for the subject as newcomers was gone, while existing practitioners were now skeptical of certification, at least of this sort. I know this because I spoke to many immediately after the course. After a while, we either learned that we had passed, or not, the test. Some of the questions were so vague and convoluted that complaints were made. People waited to hear whether their money – or moreover that of their employer – had been well spent and whether they were now certified. I am quite sure though that a ‘pass’ would give most a feeling of relief and pride. We humans, indeed mammals generally, like to be members of clubs, and we like ranks. We see this natural preference throughout organisational life.

There are many other such courses, often a day or a few days in duration, relating to all aspects of work (e.g., safety management, crew resource management [sometimes sold as ‘human factors‘], safety culture, just culture, error management, etc). In my experience, at their best, they offer a starting point for further exploration, but usually little more than that. That is enough. But they are often sold as much more. Importantly, rather than acting as a springboard for reflection, exploration and divergent learning, they act as a dragnet for further convergent indoctrination and up-selling of a defined set of ideas and tools. More worrying still is when they infer membership of an ‘exclusive’ club (which may benefit the owner of the club much more than the members).

Such training is often associated with ‘tools’ (almost always trademarked) that are licensed for profit, often combined with mandatory commercial training, refresher training, and ongoing subscription by the tool developer. Trade-marking and licensing is often a legitimate and necessary way to protect intellectual property (especially for small businesses). But it does not infer quality. Some of these tools lack innovation, have been overtaken by fundamental changes in theory, or are available in similar form elsewhere freely or at reduced cost, and yet subscription and licensing services can lock users into hard or soft dependency.

So here are a five things to look out for, and associated questions to consider, when considering products and services of this nature. They are not in any way definitive. There will be other criteria and questions, and some of these may not indicate a problem, but they may be useful things to think about.

  1. Dependency: Does it lock you into dependency? Is it hard to move to something more suitable, with a different supplier or service provider, for hard reasons (e.g., contracts; subscription) or soft reasons (e.g., feelings of commitment; sunk cost)?
  2. Manufactured exclusivity: Does it create ‘exclusivity’, and the sense of being an ‘insider’, or ‘part of something’ (a club, scheme, network, community, user group, benchmarking group)? Does your feeling about it, and evaluation of it, depend on your membership status, or whether you pass a test? Does it involve ranks (belts, ‘Master’ status, bronze/silver/gold) or other appeals to pride?
  3. Dubious value: Can your need realistically be met by reading along with online/in person discussion groups, supervised practice, etc? Is something comparable available elsewhere that provides much of the value, at much reduced cost? Is the product or service outside of a respected, independent not-for-profit regulation or certification body?
  4. Closed: Does it remain fixed, and not updated in light of scientific developments and changes in theory and method? Is independent evaluation precluded? Does it ignore fundamental challenges to its assumptions, theory, method, etc? Is critical reflection and inquiry discouraged? Is exploration of alternative approaches discouraged, without good reason?
  5. Control: Is control (over ideas, information, method, theory, means of interaction and exchange) highly centralised into one person or private commercial entity?

If you can answer ‘Yes’ to a few of these questions, this may not be a problem. The product or service may provide sufficient value, or the questions answered ‘Yes’ may not be significant. But increasing ‘Yes’ responses may indicate a problem, and in this case you might want to consider whether the product or service is what you need, or what someone else wants you to need.

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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 https://goo.gl/XJyXNB. The evidence transcription is at https://bit.ly/2NnItlY. The report is available at https://bit.ly/2wJ1DbD

Autonomous vehicles: The evidence transcription is at https://bit.ly/2wZKTOi. Supplementary written evidence is at https://bit.ly/2MfuBWv. The report is available at https://bit.ly/2NBbon2

The Williams Review report is available at https://bit.ly/2sN7ADw

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The Real Focus of Safety-II

Safety-II has become a talking point. It is discussed not only among safety professionals, but – perhaps more importantly – among front line practitioners, managers, board members and regulators in a wide array of industries. Its practical and inclusive focus on everyday work seems to strike a chord, acknowledging the reality of work for those who actually do the work.

There are, however, a few myths and misconceptions about Safety-II, some of which I highlighted in What Safety-II Isn’t. One is that Safety-II is about exceptional performance – excellence. This is perhaps associated with the use of the term ‘success’ and the phrase ‘go well’ in the literature on Safety-II (e.g., the EUROCONTROL [2013] White Paper). ‘Success’ is used here in a rather general sense, that work achieves its goals, in line with one definition of the term: The success of something is the fact that it works in a satisfactory way or has the result that is intended. (Collins). The word is also commonly used to refer to exceptional attainment (i.e., that someone is. ‘successful’). This is not what is meant from the viewpoint of Safety-II, though the scope of Safety-II is inclusive of excellence, or especially desirable sociotechnical system performance.

Safety-II should be seen as focusing on all forms of work and all outcomes, routine and (perceived as) ‘unremarkable’ work, incidents and accidents, and exceptional performance. It is not about how things go well, so much as how thing go, but with the aim of course that things do go well. This is clearly depicted in the graph from the EUROCONTROL White Paper in Safety-I and Safety-II.

The focus of Safety-I and Safety-II. From EUROCONTROL (2013). From Safety-I to Safety-II: A White Paper. Brussels, p. 25. https://www.skybrary.aero/bookshelf/books/2437.pdf

What this shows is that the focus of Safety-II in terms of work and outcomes includes the focus of Safety-I. But Safety-II does not include Safety-I in terms of its precepts and concepts, which are quite different. (Importantly, both approaches can and should be practised – see Mind your Mindset: Safety-I and Safety-II – though some adjustments and compromises are naturally to be expected.) Both Safety- I and Safety-II include a focus on accidents, actual and potential. (In reality, accidents are a typically fraction of the 0.1%, in the graph above, though potential accident scenarios are a much greater, albeit unquantifiable, proportion.) The difference is that this is the whole focus of Safety-I, which reacts to events and risks primarily via an analytical approach, considering the human role in terms of contributions to accidents (causal or mitigating).

For Safety-II, the major focus is on less remarked-upon work and outcomes, as well as work and outcomes that are especially wanted (and might be seen as goals) or especially unwanted (anti-goals). But Safety-II does not focus specifically on ‘excellence’, and does not ignore accidents and other unwanted events (And ‘best practice’ really makes no sense, since what is best in one context – place or time – will not be best in another. Practice is always contextual.)

A key reason for this focus on everyday work is that work-as-done is the reason why sociotechnical systems are effective, including safe operations, and also the reason why they fail. By ignoring work-as-done, whether it is more or less congruent with work-as-prescribed or work-as-imagined, or whether it is quite different (see the messy reality), we don’t know how the system is functioning and whether it is drifting into an unwanted state, or shifting toward an especially wanted state (see Work and how to survive it: Lesson 2. Understand variation inside your organisation).

Focusing on normal work also makes sense from a Safety-I point of view, with its focus on accidents, actual or potential. This was highlighted in 1984 by sociologist Charles Perrow in his book Normal Accidents. Perrow was making the point that unusual events such as accidents are not fundamentally different to normal, everyday system functioning. They are, in some important senses, equivalent. Big accidents don’t have big causes. It’s just that ‘normal disorders’ combine in unexpected, often emergent, ways. ‘Normal disorders’ might be seen as degraded aspects of the system and context (e.g., technology used beyond design intent, degraded tools, excessive and overly complex procedures, stretched shift systems, competency gaps) along with differences between work-as-imagined and work-as-done. An important point is that it is normally the context of work that is disordered, while work-as-done tends to adapt, adjust and stretch to make things work, in locally rational ways. Work-as-done strives to create order in a system that is fundamentally disordered and not as-imagined from afar.

Adapted from EUROCONTROL (2013). From Safety-I to Safety-II: A White Paper. Brussels. https://www.skybrary.aero/bookshelf/books/2437.pdf

So while we want to ensure that work goes well, aiming for excellence, the focus of Safety-II is on the whole picture, but especially work that we might consider routine, everyday, and even unremarkable. This is the work that may end up in incident reports, or excellence reports, or simply keep the organisation running effectively. If we don’t look, we’ll never know.

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The problem with professional appropriation: The case of ‘human factors’ and ‘ergonomics’

In a recent article in the Sydney Morning Herald newspaper by journalist Liam Mannix (A difficult position: Experts question whether ergonomics holds up), a Sydney University Professor calls out physical ‘ergonomics’ as bad science and practice:

Every year, companies around the world spend hundreds of millions of dollars on ergonomic chairs, keyboards and consultants, believing they are taking science-backed steps to care for their workers.

Ergonomists are regularly called as expert witnesses in court, where their findings can decide workplace injury claims worth hundreds of thousands of dollars. Ergonomics is promoted by work safety organisations around the country.

Yet “ergonomics does not have a firm basis in science”, says Sydney University professor Chris Maher, a leading authority on back pain.

But it seems that some who operate under the label of ‘ergonomics’ and ‘ergonomist’ are neither qualified nor experienced. The article notes that there are only 82 certified professional ergonomists in Australia, according to the Human Factors & Ergonomics Society of Australia, plus another 250 or so full members qualified to practice. (There would be many more, however, who are full members of other professional Human Factors and Ergonomics [HF/E] societies.)

“But there are thousands of people calling themselves ergonomists who aren’t,” says Associate Professor Jodi Oakman, head of the Centre for Ergonomics and Human Factors at La Trobe University.

“People will go out doing ergonomic work station assessments, they’ll call themselves an ergonomist – and they have no training whatsoever. It’s not a protected title,” she says.

Leon Straker, a Distinguished Professor at Curtin University added:

I don’t like a product being given the title ‘ergonomic’ – it’s not correct. If you don’t know who I am, what my job is, you cannot know my ergonomic requirements.”

Stephen Hehir, chair of the Human Factors & Ergonomics Society of Australia’s professional affairs board, remarked to Liam Mannix that many of the studies weren’t published in leading ergonomics journals, and most of the interventions they tested weren’t done by qualified ergonomists. 

“Imagine if they were reviewing surgical outcomes and including those operating without a medical licence rather than only qualified surgeons,” he said.

So it seems that the primary problem may not be with the evidence-based discipline and profession, so much as what I will call ‘professional appropriation’.


“There are thousands of people calling themselves ergonomists who aren’t,” says Associate Professor Jodi Oakman, head of the Centre for Ergonomics and Human Factors at La Trobe University. Photo: Jisc infoNet C BY-NC-ND 2.0 https://flic.kr/p/8N9izX

Professional appropriation

If we accept that HF/E is a profession, with registration schemes, codes of conduct, etc, then the next question is whether it is ethically acceptable to appropriate a professional title. Here, I define professional appropriation as taking as one’s own professional identity the label of a recognised profession, without undertaking the requirements to practise the profession, as accepted by professional bodies. The requirements to join a profession typically involve the following:

  • extended study, resulting in an appropriate qualification (for HF/E, these can include human factors /ergonomics or allied disciplines such as HCI, psychology, industrial engineering, biological sciences)
  • supervised experience
  • registration with a recognised regulator or professional body (professional society, association, or government body)
  • adherence to the Code of Professional Conduct of a professional society
  • other requirements, such as continuing professional development.

Professional appropriation seems to happen when individuals with limited exposure to a discipline appropriate an associated title based on this limited exposure. With limited exposure and experience, it may not be clear that professional appropriation is problematic.

The title ‘human factors specialist’ is sometimes appropriated, and this has happened historically with the title with ‘psychologist’, a term that is now legally protected in some countries. Despite being a discipline (with academic courses, journals, text books, professors, etc) and a profession (with certification, chartership, Codes of Professional Conduct, etc), HF/E professional titles are widely appropriated. Some describe themselves as ‘human factors experts’ without qualifications in human factors and without professional accreditation by a professional body. In most cases, this is probably done quite innocently, without understanding the unintended consequences.

Professional appropriation has occurred with a number of professions. The world of user experience/UX (an emerging profession) is apparently experiencing a growth in the use of terms such as ‘UX Psychologist’ by individuals who are not suitably qualified and experienced in psychology (e.g., Chartered or Registered Psychologists, in the UK). While some titles are legally protected (such as ‘Psychologist’ in Australia), other titles are only protected in their variant forms (e.g. ‘Psychologist’ is not legally protected in the UK, but ‘Counselling Psychologist’ and ‘Occupational Psychologist’ are legally protected). Other than legal protection of titles, we are left with legal protection of services, and associated laws (e.g., advertising laws, health and safety laws).


One could argue that professional titles are archaic, and that anyone should be able to choose whatever title one chooses. This argument seems to fall down quickly once one considers just a few professions, for instance physicians and surgeons, nurses and pharmacists, architects and structural engineers, accountants and solicitors, social workers and psychologists.

If one accepts that appropriate qualifications and experience are necessary to work as a professional (by definition), then the next question is whether Human Factors/Ergonomics should be included in this list of professions. Is HF/E a profession that requires suitably qualified and experienced people?

Whatever our view on this, HF/E is already a profession that requires appropriate qualifications and experience. This is evidenced by professional registration in many countries (including Chartership in the UK, as per Chartered Accountants, Chartered Psychologists and Chartered Architects). If one still rejects the idea that one needs to be suitably qualified and experienced, then one risks saying that professional standards in Human Factors/Ergonomics are unimportant and that the quality of Human Factors/Ergonomics professional services, including ethical considerations, is unimportant. This devalues HF/E to such an extent that to offer professional services becomes illogical. One cannot offer professional services (e.g., consultancy, training, expert witness) in something that one does not consider to be a profession. QED.


NATS employs 25-30 Qualified Human Factors/Ergonomics Specialists. Photo: NATS.- UK Air Traffic Control CC BY-NC-ND 2.0 https://flic.kr/p/gmWeLo


From the client’s point of view, the above may not seen terribly relevant. What matters more to clients is risk management. What is the risk of professional appropriation? The ‘risk’ concerns problems or opportunities that may not be properly recognised or managed. The risks could be risks to process safety, occupational safety, health, wellbeing, productivity, efficiency, quality, morale, etc,  By hiring someone who is not suitably qualified and experienced, you are hiring someone who is lacks the required competency to help recognise, understand and manage problems and opportunities relating to system performance and human wellbeing. And someone who is not suitably qualified and experienced may be unaware of this. The Dunning-Kruger effect shields us from the limits of our knowledge and skills.

The risks of professional appropriation are quite obvious and immediate for some professions (e.g., surgery, dentistry, anaesthesia), while for others the risks are obvious to some but usually emerge after some time as a project develops (e.g., civil and structural engineering, safety engineering). For still others, the risks are less obvious and may take longer to come to light. HF/E tends to fall into the latter two categories.

One particular risk of hiring someone who is not suitably qualified and experienced is second order problems. With relatively little knowledge and skill in a profession, we tend to be more focused on first order problems – immediate issues. With more knowledge and skill, we are more focused also on second order problems – possible unintended consequences. This requires systems thinking, which happens to be the foundation of HF/E. For instance, focusing only on non-technical skills training and labelling this as ‘human factors training’, without addressing underlying system and design problems to an appropriate degree, can consume an organisation’s ‘Human Factors budget’ and leave people (usually a small and diminishing proportion of the total number of people) to cope with systemic and design problems using their non-technical skills: an ethical dilemma.

And there are very specific risks to professional appropriation. The SMH article recounts a case where a worker was awarded tribunal-ordered compensation – after she suffered an injury caused by a so-called ‘ergonomics intervention’. 

Cakir was working as a web publishing officer with the Department of Employment and Workplace Relations when she was given an “ergonomic assessment of [her] workstation” by an injury management consultant, according to tribunal papers.

The ‘ergonomics intervention’ was apparently not prescribed by a SQE ergonomist, but by an exercise physiologist (the article does not question the validity of exercise physiology).

The risks of professional appropriation are real but hard for clients to see. Clients can, however, ask if those who use the title ‘ergonomist’, ‘human factors expert’ are suitably qualified and experienced. (Note that ‘expert’ is a term that most bona fide experts seem to avoid. I’ve met a handful of people in HF/E who I would truly consider experts. I am not one of them. Though just to confuse matters, note that in some countries, especially in mainland Europe, the term ‘expert’ simply refers to a specialist or someone occupying a particular job role.)

Professional desertification

If anyone can simply adopt any professional title, then one particular system-wide risk is the illusion that the market for associated services is already well-served. For instance, if everyone with a few days of life coaching or NLP training (or even no training at all) adopts the title ‘psychotherapist’, and if employers and clients are none the wiser, then why the need for suitably qualified and experienced psychotherapists (e.g., meeting the standards laid down for full membership by BACP and UKCP, in the UK, requiring many years of formal study, and supervised [often unpaid] practice)? The same goes for any profession.

I wonder if this has become a hidden reality in some sectors when it comes to Human Factors and Ergonomics. As Associate Professor Jodi Oakman, head of the Centre for Ergonomics and Human Factors at La Trobe University, pointed out, “there are thousands of people calling themselves ergonomists who aren’t.” In the National Health Service (NHS) in England, there was, at the time of writing this post, just one Chartered Ergonomist and Human Factors Specialist formally practicing in the role of an HF/E specialist.


The National Health Service in the UK has a focus on Human Factors, but only a few qualified Human Factors and Ergonomics Specialists, out of 1.5 million staff. Photo: Lydia CC BY 2.0 https://flic.kr/p/9YP29k

And yet, ‘human factors’ is a huge buzzword in the NHS. There are many courses, and many external consultants (often from aviation) describe themselves as human factors specialists or ‘experts’. The training provided is typically in behavioural (non-technical skills). Non-technical skills are vitally important but NTS training is – I would estimate – somewhere between 1/100th or 1/1000th of the whole scope of discipline of HF/E, if one were to count the pages of text books or journal articles, or hours of teaching on HF/E degrees. In fact, NTS training is more properly aligned with Applied Psychology, because its principles are behavioural, not design-led. (HF/E is primarily about fitting the task to the person, not vice versa.)

This is not to de-emphasise the importance of this training. I have supported such training in healthcare and aviation, and strongly encourage it. But the effect of labeling this ‘Human Factors Training’ – something that has been inherited from airlines – seems to have had unintended consequences. The most obvious of these is the widespread lack of understanding (including at Board level) about

  • the true focus of HF/E (socio-technical systems)
  • its primary means of gaining insight (understanding system interactions, which we might call ‘work’ for our purposes), and
  • its primary means of intervention (design).

In Frank Hawkins’ 1987 book ‘Human Factors in Flight’, he remarked that “There seems to be little justification for any large organisation not employing, in house, one or more degree-qualified Human Factors specialists. In fact, without some level of in-house expertise, Human Factors problems are unlikely to be recognised adequately to generate a call for reference to an external consultant” (p. 328-329).

It may be the case that the professional appropriation of HF/E is somehow associated with the professional desertification of HF/E. The same would likely happen, to varying degrees, with dietetics, architecture, nursing. and psychology.

Involvement and inclusion

At this point, having described some of the problematic aspects of professional appropriation, I find myself dissatisfied and conflicted. On the one hand, professional services, including those done by people who identify themselves as ‘Human Factors Specialists’ and ‘Ergonomists’, should obviously abide by professional standards, including ethical standards. But there are a few problems (see also Human Factors and Ergonomics: Looking Back to Look Forward).

First, there are not sufficient numbers of SQE HF/E specialists (internal or external) to meet demand for HF/E, let alone get involved in solving problems that could benefit from a professional HF/E approach. (This is similar, however, to clinical and counselling psychology in the NHS, for which there are long waiting lists.)

Second, there are relatively few HF/E courses, and little funding, for those who wish to become suitably qualified in HF/E. This applies more, to degree-level courses, which are also a significant investment in time and money. Still, an increasing number of people, for instance front line professionals and other those coming from other allied professions, are signing up for diploma and degree level courses in order to apply HF/E theory and method to their work. (See here for a discussion of becoming an HF/E practitioner.)

Third, it is crucial that HF/E is not merely a discipline and profession, but a broader endeavour aimed at improving system performance and human wellbeing. This is similar to psychology and psychotherapy (regarding mind, behaviour and mental health) and dietetics (regarding diet). This seems to apply various disciplines and professions that centre on human needs. HF/E theory and methods can be applied by many professions with various qualifications and experience as part of their professional work, given appropriate competency. It is not necessary that everyone undertakes a degree in HF/E, but neither is it sufficient to undertake a one- or two-day training course alone to be considered a specialist of any aspect of HF/E. There are, however, training courses in aspects of HF/E that are recognised by professional bodies affiliated with the International Ergonomics Association. There are also specific membership grades such as CIEHF’s ‘Technical Membership’ that apply to specific aspects of HF/E, as relevant to one’s own professional work. Ultimately, I consider HF/E expertise as emergent, from interaction between those with expertise in theory, findings and methods, and those with expertise in work and the context of work.

We can take some practical steps. It is helpful, for instance, when offering HF/E-related training courses or services, to indicate the scope of HF/E covered, relative to the scope of the discipline as a whole. This can be made more obvious in the title of the course, For example, a course entitled ‘Human Factors in <Operating Theatres>’ might cover human factors issues in operating theatres, including the interactions between people, activities, context and tools, and methods for improving these by design (of artefacts, tools, work, etc). Alternatively, a course could be titled, ‘Human Factors for <Surgeons/Pilots/etc>’. Such a course would be more adapted to the needs of a particular stakeholder group. This night be a blend of NTS training and training related to the design of various aspects of work (routines, checklists, equipment, etc), with an aim to help improve work design or at least compensate or mitigate unwanted effects.

And of course, in providing consultancy and training we must be clear about our own qualifications and experience. I ultimately consider my practice cross-disciplinary, and dip into several other disciplines that I find especially helpful in helping to improve system performance and human wellbeing (e.g., philosophy, anthropology, practice theory, community organising, counselling and psychotherapy, graphic design). My approach is to integrate aspects of these into an eclectic, cross-discplinary practice, but of course I stop short of describing myself as a professional or specialist in any of them. I know that my interpretation and implementation of these disciplines is narrow, often shallow, and selective. So I simply indicate the cross-disciplinary influences on my practice. Even within a discipline, our competency soon reaches its limits, and understanding these is a critical aspect of ethical practice. Physical ergonomics, for instance (the topic of the SMH news report) is not an area of competency for me. My last experience was part of my ergonomics post-graduate degree and I have not practised this, outside of basic anthropometry, for 21 years. I am simply not competent to practise it.

Summing up

As with may human-centred professions, there is a balance between professional standards and inclusion. The way to address this balance is by total honesty and clarity, abiding by ethical standards of professional practice, collaborating between different areas of knowledge and practice, carefully drawing from useful theory and applicable methods, but avoiding appropriating professional titles, which can have significant unintended consequences for professional standards, system performance and human wellbeing.


From my previous post on this topic (Suitably Qualified and Experienced? Five Questions to ask before buying Human Factors training or consultancy), here are the five criteria and questions that apply to paid-for human factors and ergonomics (HF/E) consultancy and training support and employment, that may help with reflection and discussion.

1. Qualification – Do they have a recognised qualification in HF/E?

2. Accreditation – Do they have an appropriate level of membership of an HF/E related professional organisation?

3. Code of Ethics – Do they abide by a code of ethical conduct from an HF/E related society or association?

4. Experience – Do they have experience in the HF/E work and the domain of interest?

5. Social recognition – Is the person recognised as an HF/E specialist by other qualified HF/E specialists?

The aim of these criteria and questions is to ensure that professional standards – including ethical standards – are met. The criteria and questions are framed above in the context of HF/E, but in fact they apply to any professions, such as psychology, dietetics, or physiotherapy. Proper consideration of the criteria and questions should help to protect organisations, individuals, and the integrity of the profession.

Related posts:

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Work and how to survive it: Lesson 2. Understand variation inside your organisation

Much of my practice is informed by counselling and psychotherapy as well as humanistic psychology more generally. One of my problems with these fields, however, is that insights and discussions are largely kept within the world of psychotherapy. What a waste! The vast majority of people are not engaged in psychotherapy and for the most part, psychotherapy pays little attention to applying itself to the mundane issues of everyday life, outside of counselling rooms. This is a second in a series reflecting [for now] on excerpts from Life and How To Survive It, by the psychotherapist Robin Skynner and the comedian John Cleese, with some reflections on work and organisations. 

Other posts in the series:

In Chapter 1, John Cleese and Robin Skynner are talking about people and families at different levels of mental health. Cleese asks about families that are unusually mentally healthy.

Robin …in trying to describe excellent mental health, and compare it with ill-health, and with the ‘average’ health in between that most of us enjoy most of the time … it’s difficult not to talk as if they are quite different from one another, and inhabited by different people. But, in fact, our level of health is changing all the time. We all feel more healthy in our better moments, when we are ‘in a good mood’, when things are going well, when we feel loved and valued, when we have done our best. And we can all feel less healthy under stress, when our usual sources of support are removed, when we have ‘let ourselves down’, when we ‘get out of bed on the wrong side’. Also, our level of health is not the same in all areas of our functioning. A person who is ‘average’ overall may be outstandingly healthy in some respects, even though functioning poorly in others.
John And obviously the overall level can change over time, too. Otherwise you’d be out of a job. I mean people can get more mentally healthy, can’t they?

In my last post, I wrote about the everyday experience of work, which is often ignored in safety, for several reasons, sometimes beyond the control of safety practitioners. Within this great area of day-to-day activity, many things are happening that we can easily miss unless we pay attention to them. One is that performance changes over time. One aspect of this is what is sometimes called ‘practical drift’. In Friendly Fire,  Scott Snook defines practical drift as “the slow uncoupling of practice from procedure” (p. 24). It is one way how we end up in the work archetype of The Messy Reality.

This is very hard to see from the inside, as it tends to happen slowly and tends to help achieve a range of goals that are more positively reinforced within the organisation (e.g., cost efficiency and production). But without paying attention to normal, everyday work, we don’t see what is going on. Importantly, we don’t see changes in the normal operating point, and associated behaviours, especially when these changes happen slowly and are only exposed to those who are closely associated with the work, whether front-line staff, middle managers or the Board

Figure 1: Drift toward failure. Adapted from EUROCONTROL (2013).

It often takes an outsider to see this practical drift. As Edward Hall (1959) wrote in his book The Silent Language, “culture hides much more than it reveals, and strangely enough, what it hides, it hides most effectively from its own participants” (p.39). We are victims of our cultures – professional, organisational, and national – and insights often require an outside perspective. By ‘outsider’, I simply mean someone who is seen as an outsider by those in a particular in-group, or at least someone who is on the edge of the group.

Outsiders not only see this drift more clearly, but have ‘permission’ to ask about it. This can be associated with their relative innocence. Outsiders may be able to ask the sorts of questions that a child asks: Why do you do that? What do you do it like that? What is that for? The outsider will often, however, need a basic knowledge of the work, especially for less observable forms of work and work that is very complex.

‘Permission to question’ can also be because the questioner has been accepted into a particular role. One of these has been termed ‘barbarian’, by Steele (1975) in Consulting for Organizational Change. Steele characterises this role as “violating comfortable but limiting norms and taboos that are preventing the system from being as effective as it might be. (A counter measure against tunnel vision.)”.  This relates to the archetype Taboo. In-group members will find it difficult to raise taboo issues and will often need exceptional interpersonal skill to do so in a way that helps others gain insight.

An outsider may be a cultural insider, e.g., an air traffic control supervisor or anaesthetist from elsewhere. In this case, the person is an outsider in terms of workgroup and location, but an insider in terms of profession. Supervisors observing the work of other workgroups is one way to help people ‘see’ (and improve) their performance. They may be able to see things and ask questions that true insiders can’t.

Another kind of shift or change is where performance moves towards exceptionally good performance, where work is sustainably productive, innovative, healthy, joyful, etc.  Again, if normal, routine, day-to-day performance is unknown and generally ignored (not subject to anything like the same kind of attention as incidents), then we may just gratefully accept the marginally reduced number of incidents (on the left hand side of Figure 2), but not see the way that work is changing for the better, including the ‘good practice’ that contributes to it. In our Ignorance and Fantasy of this day-to-day work, we may well implement changes (rules, limits, targets, league tables, incentives, punishments, etc) that pull the operating point back, halting progress.

Postive drift
Figure 2: Shift toward exceptional performance. Adapted from EUROCONTROL (2013).

As well as changes over time, a second thing is happening that we can easily miss unless we pay attention: there are differences between different parts of an organisation. As Skynner reminds us, “our level of health is not the same in all areas of our functioning”. In travelling to over 50 air traffic control units and centres of various kinds, I have seen and heard about large variations in many aspects of practice and performance. In most cases, where units and facilities are isolated geographically or culturally (e.g., by profession), these differences are unknown or not appreciated beyond the facility, and often beyond the department, work group, or room. Therefore, good practice in one area of an organisation is not known in another that is similar in context and could benefit. For example, one particular air traffic control tower had developed its own refresher training arrangements. These innovative practices could have been of great help to other towers but, lacking day-to-day contact with the tower in question, were unknown. (See Issues 25 and 26 of HindSight Magazine, on ‘Work-as-Imagined and Work-as-Done’ and ‘Safety at the Interfaces: Collaboration at Work’.)

These differences may also be papered over by the way that we measure performance. For instance, if we average measures across the whole organisation, or if we measure things that do not reflect differences between different areas of an organisation, then again we will be less likely to see and pay attention to them. This means we must pay careful attention to the way that differences may express themselves in terms of department, location, profession, gender, age, experience, and on. In many cases, the differences within organisations are greater than the differences between them, but if we don’t pay attention to what’s going on, we’ll never really know.


EUROCONTROL (2013). From Safety-I to Safety-II. A White Paper. Brussels:  

EUROCONTROL Network Manager, September 2013. Authors: Hollnagel, E., Leonhardt, J., Shorrock. S., Licu, T. [pdf] (Contributor)

EUROCONTROL (2017) HindSight Magazine. Safety at the Interfaces: Collaboration at Work. Issue 26, Winter. Brussels: EUROCONTROL. [webpage] [pdf]

EUROCONTROL (2017) HindSight Magazine. Work-as-Imagined and Work-as-Done. Issue 25, Summer. Brussels: EUROCONTROL. [pdf]

Skynner, R. and Cleese, J. (1994). Life and How To Survive It. Mandarin.

Snook, S.A. (2000). Friendly fire. Princeton, NJ: Princeton University Press.

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