Designing work systems to reduce risks to safety is a major challenge for large organisations involved in high-risk or high-consequence operations, such as aviation, the military, the utilities and healthcare. The root of safety failures, such as BP’s Texas oil refinery explosion, or the cumulative sum of the UK’s NHS adverse events from infection, medication and surgical error, etc., often lies in the way in which those organisations have dealt with the human factor in their systems.
The causes of infrequent yet major accidents in industry or the more diffuse accidents in healthcare commonly trace back to management structures and policies for work, safety culture, poorly designed equipment and working environment, inadequate operating procedures and ineffective communications. It follows that there is an obvious demand for the Ergonomics and Human Factors (EHF) discipline for organisational safety.
EHF continues to grow in order to meet certain regulatory pressures in industry, and ad hoc requirements or research needs across domains. However, while EHF has an increasing presence in some organisations, it remains unclear where EHF ideally fits in organisational safety. We may not be surprised that some organisations do not have any defined strategy for their overall EHF application, as they might for other functions, such as human resources. A number of obstacles exist to clarifying where EHF fits, such as determining its value, its utility and the strategic framework used to apply it.
In healthcare, for instance, some hold the evidence-based view that EHF has little or no value to safety unless its application links to mortality. A focus on ultimate outcome is logical, but it ignores the fact that accidents usually have a complex network of causation and that the range of EHF interventions necessary for dealing with that network may be very difficult to model and link to outcome measures statistically. Accident frequency may be high enough to be very concerned with for its impact on people’s lives, but not high enough to relate statistically to EHF interventions.
Even if we were able to model a set of EHF interventions and measure their impact on safety outcome, this might not be so intuitively helpful. Consider that once an organisation achieves zero accidents that logic might dictate to the evidence based minded that the organisation would no longer need EHF. However, the general lessons of failure across domains indicate otherwise, in that past safety records will not guarantee future safety. The problem is that there are a great many factors influencing organisational safety and so the application of EHF may only be as effective as the strategic framework used to deal with those factors prospectively in their entirety.
An existing framework for safety, particularly the nuclear industry, derives from external regulation and the need to develop a case for safety in order to obtain the necessary license to operate. Essentially, this involves a detailed decomposition of a system and the identification of hazards. EHF assessments will provide the evidence for the adequacy of systems to support human performance with human error probabilities for the given tasks. The analyst may also identify contextual performance shaping factors and suggest alternative task designs. Some regulated industries have succeeded in becoming highly reliable and relatively safe through this regulatory framework.
However, while it is essential to eliminate, control and quantify human error from an engineering point of view, this cannot be the sole strategy for achieving and maintaining organisational safety from an EHF point of view. People working in complex systems do not operate in conveniently isolated units of linear work. They are less likely to learn, develop and refine their skill and performance from models of error than they would from models of performance observed in context. Moreover, their systems of work do not remain static; they may experience change and disturbance over time. For long-lived organisations, the loss of domain knowledge and expertise or rapid change in cultures through the succession of people may create further instability. The tendency of organisations to increase in size and diversity may exacerbate these problems. It follows that such disturbance to organisational systems, coupled with the complexity emerging from within them will inevitably lead to unpredictable consequences.
EHF practitioners must therefore help to organise safety and compose organisational systems in coherent meaningful ways to ensure people can operate them effectively and reliably. As teamwork rather than individual work is likely to make organisational systems cohere, focusing EHF on teams may be particularly useful for safety. Effective teamwork may provide the synergy that amounts to reliability and safety. Furthermore, by modelling teamwork, it may be possible to provide a common reference for both managing human error through the conventional decomposition of systems that serves safety cases and for prospective composition of future systems.
EHF holds considerable value for achieving and maintaining safety, if organisations realise the complexity of accident causation and the role of EHF in building safer systems. We can measure the direct value of EHF in terms of its effect on the conditions, interactions and processes of those systems, which will influence ultimate safety in subtle ways. We can readily measure the effect of EHF utility on improved product quality, ease of action and cognition, efficiency and job satisfaction. Collectively when modelled, these measures of process might relate to ultimate safety, but this will demand a sufficient sample size and a unifying reference model to integrate those measures.
Organisations should realise the limitations of applying EHF according to ultimate outcome measures and ideally seek to apply EHF strategically in light of the developing theory of organisational safety. For this, they might pursue a systems approach to safety and concentrate the applications of EHF on the teams who comprise and integrate their organisational systems. Measuring EHF value and clarifying its utility in terms of building high-reliability through teamwork might give some indication as to where EHF should fit in achieving and maintaining organisational safety, though research has some way to go in translating this theory into practice.
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