Download - Safety Control: A Moving Target Jens Rasmussen HURECON [email protected] NOFS, Karlstad, June 03
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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
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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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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
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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
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1 Horizontal versus Vertical Studies
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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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2 Task versus Work Analysis
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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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• 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
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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
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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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3 System Design versus System Evaluation
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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
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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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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
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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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•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?
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5 Academic versus Problem-oriented Research
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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?