16
Sensemaking in Safety Critical and Complex Situations
looking back from the apparent violation might reveal a failure to integrate HF into
the systems engineering processes used to build the system in the first place. Thus,
to understand these issues, HF knowledge and competence should be a part of the
investigation teams.
Safety investigations are conducted as part of organisational learning in a ‘ just
culture’, the purpose of which is to generate safety recommendations and NOT to
apportion blame or to obtain evidence against individuals. The latter requires a different approach, is not part of HF and is usually carried out by other authorities
with different qualifications and training under a different system of governance.
Learning from incidents is a topic in its own right and further information can be
found in Drupsteen and Guldenmund ( 2014) and in the White Paper published by the
Chartered Institute of Ergonomics and Human Factors ( 2020).
MITIGATING SOURCES OF RISK IN SYSTEMS
THROUGH HUMAN FACTORS IN DESIGN
HF regards people as components of systems and not as separate entities. Technology
has become increasingly reliable and is normally low risk. Safety occurrences are
often traced to the actions of human operators who may even be blamed for the
occurrence, whereas it is at the interfaces between system components that much of
the risk normally lies. New components may be incompatible with older ones and
vice versa and some components may be incompatible with operators. Attributing
safety occurrences to ‘ human error’ may oversimplify a more complicated picture as
is summarised in Table 2.2. The contemporary view is that human error is a consequence of deeper issues with the system ( combination of issues such as poor design,
poor training, mental overload, fatigue ( Dekker 2004)).
Human error is u biquitous – people make mistakes all the time but normally nothing happens ( Bridger et al. 2013). Such errors often go unrecorded although many
high-risk industries have ‘ n ear-miss’ reporting systems in an attempt to improve the
resilience of the system by better understanding the kinds of errors and h igh-risk situations that do occur. The perspective of HF, then, is not to stop people from making
TABLE 2.2
Sources of Risk in Systems – Simplistic Interpretations
Safety Occurrence?
Human error?
Yes
No
Yes
A
B
No
C
D
Source: From Bridger, RS, Introduction to Human Factors and
Ergonomics, 4th Edition. CRC Press, Boca Raton, FL.
A, Blame the operator; B, An ‘unkno wn unknown’; C, blame
some thing else; and D, taken for granted.
Sensemaking in Safety Critical and Complex Situations
looking back from the apparent violation might reveal a failure to integrate HF into
the systems engineering processes used to build the system in the first place. Thus,
to understand these issues, HF knowledge and competence should be a part of the
investigation teams.
Safety investigations are conducted as part of organisational learning in a ‘ just
culture’, the purpose of which is to generate safety recommendations and NOT to
apportion blame or to obtain evidence against individuals. The latter requires a different approach, is not part of HF and is usually carried out by other authorities
with different qualifications and training under a different system of governance.
Learning from incidents is a topic in its own right and further information can be
found in Drupsteen and Guldenmund ( 2014) and in the White Paper published by the
Chartered Institute of Ergonomics and Human Factors ( 2020).
MITIGATING SOURCES OF RISK IN SYSTEMS
THROUGH HUMAN FACTORS IN DESIGN
HF regards people as components of systems and not as separate entities. Technology
has become increasingly reliable and is normally low risk. Safety occurrences are
often traced to the actions of human operators who may even be blamed for the
occurrence, whereas it is at the interfaces between system components that much of
the risk normally lies. New components may be incompatible with older ones and
vice versa and some components may be incompatible with operators. Attributing
safety occurrences to ‘ human error’ may oversimplify a more complicated picture as
is summarised in Table 2.2. The contemporary view is that human error is a consequence of deeper issues with the system ( combination of issues such as poor design,
poor training, mental overload, fatigue ( Dekker 2004)).
Human error is u biquitous – people make mistakes all the time but normally nothing happens ( Bridger et al. 2013). Such errors often go unrecorded although many
high-risk industries have ‘ n ear-miss’ reporting systems in an attempt to improve the
resilience of the system by better understanding the kinds of errors and h igh-risk situations that do occur. The perspective of HF, then, is not to stop people from making
TABLE 2.2
Sources of Risk in Systems – Simplistic Interpretations
Safety Occurrence?
Human error?
Yes
No
Yes
A
B
No
C
D
Source: From Bridger, RS, Introduction to Human Factors and
Ergonomics, 4th Edition. CRC Press, Boca Raton, FL.
A, Blame the operator; B, An ‘unkno wn unknown’; C, blame
some thing else; and D, taken for granted.