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Safety Control: A Moving Target. Jens Rasmussen HURECON [email protected] NOFS, Karlstad, June 03. Changing Research Focus. Accidents: The Side-effect of Efforts to Survive?.

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Safety control a moving target l.jpg

Safety Control: A Moving Target

Jens Rasmussen


[email protected]

NOFS, Karlstad, June 03

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Accidents: The Side-effect of Efforts to Survive?

  • Accidents are caused by the side effects of decisions made by several decision makers in different organizations at different points in time, all seeking to be locally effective

  • In an aggressive, competitive environment success is granted those who explore the limits of usual practice?

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Basic Research Planning Issues

  • Horizontal versus Vertical System Studies

  • Task versus Work Analysis

  • System Design versus System Evaluation

  • Performance-based versus Rule-based Legislation

  • Academic versus Problem-oriented Research

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Orientation of System Studies

  • Horizontal:- Teaching novices within a discipline - Design of tools for isolated tasks- Models of normative work organizations

  • Vertical:- Models of experts’ work practise - Support of expert performers- Evaluation of work system performance - Modelling behaviour of adaptive organizations

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Management Implications

  • From a horizontal perspective: being a manager is a profession independent of context (hospital, theater or company)

  • Consequences:

  • Safety: “Ships are no longer operated by shipping professionals, but banks and investors

  • Human costs of managerialism (Public health sector, Rees & Rodley)

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Analysis of Task Procedures is unreliable

  • Experts replace formal procedures by heuristics and practice

  • Behaviour shaping features may no longer be active and ”deep knowledge" is replaced by common sense “myths”

  • Work analysis requires "reverse engineering": It is necessary to identify the hidden behaviour shaping features and performance criteria

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Focus of Work Analysis

  • Separate representation of work domain and of actors

  • Models in terms of: - Behavior shaping features of work setting - Useful cognitive strategies - Actor's cognitive resources - Subjective preferences

Work Analysis requires domain expertise and competence in cognitive psychology

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Human Factors Phases

  • 1. Phase:

  • - Normative, prescriptive theories & models

  • - controlby normative instruction and punishment

  • - selection and training of 'first-class staff'

  • 2. Phase:

  • - Descriptive models in terms of deviations from norms

  • - control by removing causes of errors

  • - guidelines on human limitations

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Human Factors Phases, continued

  • 3 Phase:

  • - Descriptive models of actual behaviour

  • - control by supporting observed work practices

  • - match of interfaces to user's metal models & preferences

  • 4. Phase:

  • - Models of system constraints, opportunities & criteria

  • - control by shaping conditions of adaptation

  • - interface presents map of internal work structure

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Abstraction vs. Decomposition

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Design vs. Evaluation

  • Decomposition

    • - is useful for representation of elements

    • to be assembled into a new system (Watts’ design of steam engine by reconfiguring a mine draining pump and attaching a wind mill regulator)

  • Abstraction

    • - is necessary for analysis of the

    • functionality and behaviour of a working

    • system (Maxwell’s analysis of the instability of Watts’ regulator by differential equations)

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Dimensions of Evaluation Analysis

  • Communication network must be intact and active

  • All actors must have information about the actual state of the functions within their control domain

  • They need proper information about objectives corresponding to their options for action

  • The boundaries of acceptable performance must be known and observable

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  • Information must be presented for easy comparison of states and objectives

  • The decision-makers must be competent and capable of acting properly

  • Their priority ranking of cost-effectiveness and safety must be acceptable. Actors must be committed to safety also during crises

  • Their situation awareness must be supported

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4. Performance-based versus

Rule-based Legislation

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Control of Management Commitment

  • Management Incentives: - Problem of time horizons? - Conflicts between horizon of personal career, financial planning and safety management

  • Reinforcement of Management Incentives:- Rules, legislation and regulation? - Personal responsibility, use of criminal law? - Better coupling of higher levels based on a kind of ethical accounting?

  • Is the present level of safety, based on response to latest accident, actually financially acceptable?

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The Role of Errors and Accidents

  • Accepted frequency of errors determines the limit of adaptation and optimization at the operative level

  • Accepted frequency of incidents determines the limit of acceptable pressure toward cost effectiveness by resource management?

  • The debate in the media following accidents determine the political allocation of resources?

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A Paradox?

  • Basic national work environment acts are perfor- mance-based

  • To ensure that national interpretations of such general statements of objectives will not prevent the free movement of goods and machinery, the European Union issues very detailed pre- scriptive directives which become embodied in the detailed national legislation.

  • The interaction between trade and safety related regulation is a research issue?

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Academic research aimed at teaching

  • - Identify a phenomenon suited for study within paradigms of the discipline and

  • the time span of a Ph.D. program

  • - Involve students to teach them paradigms

    • and methods

  • - Design experiments or field studies to

    • compare competing hypothesis

  • - Validate by collegial contest; is test of

    • the hypothesis accepted by peers?

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Problem driven research for design

  • - Problem is given by an actual system;

    • it is typically cross-disciplinary

  • - Select paradigms from disciplines that are

  • relevant and mutually compatible

  • - Design of field studies and experiments to

    • understand and model actual phenomena

  • - Validate by introducing change (prototype)

    • in actual system; does it work?

  • - Time span and complexity do not generally

    • match Ph.D. programs or tenure tracks

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How to organize the cooperation between

the Rescue Services Agency and the Karlstad University in an effective, cross-disciplinary research for the design

of proactive safety control strategies?