The Man – Technology – Organisation approach

1. The Man – Technology – Organisationapproach Jan Heimdal – Research scientist – Psychologist Institute for Energy Technology, Halden, Norway

2. Safety in complex systems Contents Human Error Human & Technologicalexplanation models System approach MTO model Technology Organisation

3. It is human to err… • The literature claims that human error is part of 60-80% (depending on domain) of all accident in safety related industry • Human errors are those actions that exceeds a norm or border for what was planned or intended (Kjellen) • Human error reported from a control room: • X did not see the alarm • X did not ask for the state of the process when he arrived • X misunderstood the available information • X turned switch A rather than B • X prioritized task Y rather than Z • Can human errors be removed?

4. Human explanation model • The need to find the guilty • The human are free to chose between safe and risky behaviour. • Errors are caused by: • forgetfulness, motivation, inconsideration • lack of commitment, knowledge or experience • failure to follow rules or procedures • the responsibility is placed on the person committing theerror • The event could have been avoided if the human was behaving correctly... • Remove the guilty – remove the problem...

5. Technological explanation model • Origin in reliability models • Error threes – dichotomous result • Error as • Technological failure Failure in technical equipment

6. Limited amount of cognitive resources To err is human – but why? • Human has a tendency to: • make as small effort as possible to achieve a goal • seek recognition from others • play with technology (when familiar) • do ”something” in all situations – even if the situation is not fully understood • let irregularities pass when tired • see only what one whish to see (confirmation bias)

7. Model of Cognition (Wickens, 1984)

8. What is needed for the individual worker to contribute towards safety? Competence: Education and training Motivation: Culture: Attitudes, norms, values Equipment: Necessary tools, procedures and technology - Support and adjustments Resources: Time Design: The workplace must support safety enhancing actions.

9. Disadvantages of the human explanation model • Cases are related to a person • The latent conditions are not identified • Only symptoms are considered • Similar or serious events are likely repeated • Reporting of other events may not occur • Fundamental management problems are not considered • Resources are spent on solutions that are not effective • The development of safer organisations is hampered

10. A ‘M-T’ perspective is not sufficient • Contextual influences • Bigger socio-technical production systems • Complexity • Three Mile Island, Bhopal, Tsjernobyl, Zeebrugge, King’s Cross, Piper Alpha, and Clapham Junction • These accidents had to a large extent their origin in leadership and organisational factors

11. Systemexplanation model • Human failure is unavoidable (Perrow) • Situations are affecting human performance • Failure as: • consequence rather than cause • symptoms revealing latent conditions in the system

12. Man - Technology - Organisation • Human, Technology, Organisation • System-oriented perspective • A MTOsystem = a set of components/units organised in order to fulfil a certain need • Safety = ’a dynamic non-event’ • An error will not lead to an accident if the consequences of the error is effectively compensated

13. Staff selection Staff selection Education Education Inspectorate Inspectorate and training and training Principles and Principles and procedures procedures First line First line actor(s) actor(s) Super Super - - Management’s Management’s visor(s) visor(s) specifications of specifications of Interface Interface Outcome Outcome Decision Decision Decision the goals, standards the goals, standards support support support and resources of and resources of Auto Auto Auto - - - the organisation the organisation mation mation mation Process Process system system Reporting Reporting Maintenance Maintenance Systemdesign System design Evaluation Evaluation The MTO model (Skjerve, 2005)

14. The dynamics of the MTO system • Current: • The condition of the individual components of the MTO system is changing during operation due to the changes of other components • Longer term: • The workers are changing: level of competence, age, new staff. • Technology is changing: new technology, removal of old technology, modifications. • The organisational structureis changing: reorganising procedures, rules, etc.

15. Local Factors Organisational Factors ReviewMethodology Laws, moral, social norms Risky actions “Sharp end” factors – active mistakes “Blunt end” factors -latent conditions The sharp and blunt end (Hollnagel)

16. Error – not intended actions • Latent errors: Errors latent in the system – increasing the risk of a non-intended action, increasing the consequence of an active error • Active errors: Errors having direct consequences for safety (Reason, 1992)

17. Barriers (Reason, 1990) Barriers Barriers: • Hurdles built into the (MTO) system to: • control the risk, and • limit the number of events, and/or • limit the consequences of the events • The motivation to use barriers: • The likelihood of errors is reduced Function: to stop entry

18. Summary • The humans’ behavior in complex systems are always affected by factors in the technologythey are using, and in the organizationthat is surrounding them (outside their immediate control) • The M, T and O must be seen in relation to each other • The MTO system: Dynamic, complex, dedicated • Latent errors vs. active errors • Safety: a dynamic non-event