safety control: a moving target jens rasmussen hurecon [email protected] nofs, karlstad, june 03
TRANSCRIPT
Changing Research Focus
Government
Company
Staff
Work
Judg-ment
Laws
Regulations
Judg-ment
Judg-ment
Plans
Judg-ment
Judg-ment
Management
Action
Hazardous process
Observations,data
Operatios Reviews
Regulators,Associations
CompanyPolicy
PublicOpinion
Safety reviews,AccidentAnalyses
IncidentReports
Logs &Work Reports
Mechanical, Chemical,and Electrical Engineering
Psychology; Human factors;Human-Machine Interaction
Industrial Engineering;Management & Organization
Economics; Decision Theory;Organizational Sociology
Political Science; Law;Economics; Sociology
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?
The Safety Control System
Government
Company
Staff
Work
Judg-ment
Laws
Regulations
Judg-ment
Judg-ment
Plans
Judg-ment
Judg-ment
Management
Action
Hazardous process
Observations,data
Operatios Reviews
Regulators,Associations
CompanyPolicy
PublicOpinion
Safety reviews,AccidentAnalyses
IncidentReports
Logs &Work Reports
Fast pace of technologicalchange
Changing political climateand public awareness
De-regulation
Changing market conditionsand financial pressure
Changing competencyand levels of education
Basic Research Planning Issues
1 Horizontal versus Vertical System Studies
2 Task versus Work Analysis
3 System Design versus System Evaluation
4 Performance-based versus Rule-based Legislation
5 Academic versus Problem-oriented Research
1 Horizontal versus Vertical Studies
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
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)
2 Task versus Work Analysis
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
• Separate representation of work domain and of actors
Focus of Work Analysis
• 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
Human Factors Phases
1. Phase:
- Normative, prescriptive theories & models
- control by 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
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
3 System Design versus System Evaluation
Up-datestored
patterns
Location and speedin topopgrahy
Target
Compare
Headingcontrol Speed
control
Perception- action loopsAdaptive
learning loop
Perception
Engine
Car
Brakes
Wheel
Throttle
Actioncontrol
Cause-effectrelations
CognitionMentalmodels
Vision
Speed,Locationintopography
Abstraction andfunctional separation
Decom-position
andisolation
Car driving
Abstraction vs. Decomposition
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)
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
Continued:
• 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
4. Performance-based versus Rule-based Legislation
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?
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?
•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?
A Paradox?
5 Academic versus Problem-oriented Research
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?
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
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?