Safety Control: A Moving Target

1. Safety Control: A Moving Target Jens Rasmussen HURECON jensras@post4.tele.dk NOFS, Karlstad, June 03

2. Changing Research Focus

3. 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?

4. The Safety Control System

5. 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

6. 1 Horizontal versus Vertical Studies

7. 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

8. 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)

9. 2 Task versus Work Analysis

10. 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

11. 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

12. 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

13. 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

14. 3 System Design versus System Evaluation

15. Abstraction vs. Decomposition

16. 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)

17. 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

18. 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

19. 4. Performance-based versus Rule-based Legislation

20. 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?

21. 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?

22. 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?

23. Academic versus Problem-oriented Research

24. 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?

25. 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

26. 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?