Systems
Systems approach to analysing suicide incidents in community-based mental health care
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Author Nye Canham, Gyuchan Thomas Jun, Satheesh Kumar & Fabida Noushad |
| Abstract Mental health services in the UK are now predominantly community-based, rather than inpatient-based. Managing patients with suicidal risk within the community setting is challenging and suicides from those currently using or having recently used these services do occur. More than half of the people who commit suicide have visited their doctor in the month before their death. In current practice within the UK health service, patient suicides are investigated as serious incidents and analysed using Root Cause Analysis (RCA) but this method has limitations in exploring deep system problems. This study reanalysed 41 of these RCA incident reports using Systems Theoretic Accident Modelling and Processes (STAMP). The analysis revealed the weaknesses within the system safety control structure and the themes around those control flaws. An inherent weakness in the control structure is the need to monitor the patient’s risk without constant observation and relying on the patient to report issues and adhere to their treatment plan. Patient engagement issues are a major theme with loss of control and feedback on the patient status due to their lack of willingness to engage with services and treatment options. In some cases, patients have presented at a time of crisis but then declined the crisis support or inpatient treatment offered to them. Patients new to services present a problem where decisions on their care have to be made with limited knowledge of the patient. Certain coordination and communication issues between the multidisciplinary teams and multiple services are also found. In this study, STAMP application enabled effective aggregation of multiple incident analysis and system-wide remedial action prioritisation. |
The Air Traffic Kludge
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Author Hugh DAVID |
| Abstract Air Traffic is a ‘Kludge’. Antiquated methods are linked to state-of-the-art devices, and ‘work-arounds’ devised to keep going. There has never been a systematic analysis of Air Traffic as a whole. Analysis shows that the archaic controller-aircrew link is the weakest link in the system. The answer, however, is not to introduce specific technical innovations, but to examine the system as a whole, and to use knowledge of human (and computer) capacities to provide a safe, humane and economic solution. |
The role of ergonomics in creating adaptive and resilient complex systems for sustainability
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Author Andrew THATCHER |
| Abstract Anthropogenic-led changes to our biosphere now threaten to disrupt human health and wellbeing and perhaps even our existence as a species. The principle aim of this paper is to demonstrate what human factors and ergonomics can learn from the study of how natural systems operate. This paper will demonstrate how a complex systems understanding is required to unpack problems, to identify solutions, and to select places in the system where interventions will have the greatest impact. |
Building risk matrices from interview transcripts utilising HCA and IPA
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Author Megan Field |
| Abstract This paper proposes a methodological guideline for analysing interview transcripts to aid in the construction of risk matrices. This is to allow for the tabulation of qualitative data in a suitable manner as to provide appropriate qualitatively informed recommendations. Using this methodology, a comprehensive and qualitatively supported table to register concerns, priority and/or urgency of themes is created that can address inter- and intra- actor factors in socio-technical systems. The analysis aims to communicate the in-depth, rich data of narrative inquiry in verbal protocols to more technical or quantitative domains. |
Human system integration in the design of a new high-speed rail system
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Author Arzoo Naghiyev, Anthony Coplestone, Kathryn Montgomery & Hussien Aied |
| Abstract High Speed 2 (HS2) will be a highly automated rail system, which adds greater complexity to a complex socio-technical system, with potential unanticipated consequences. The Human System Integration workstream is at an early stage and the proposed methodology will allow the identification and management of Human Factors risk profiles associated to each function of the HS2 railway throughout the HS2 design lifecycle, as well as for the identified HS2 Operational Scenarios. |
Revolution of Report Writing in Safety Investigations
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Author Jenny O’Donnell, Nic Steevenson & Paul Bowie |
| Abstract This paper highlights the presence of reductionism and consequent blame within safety investigation reports across multiple high-reliability industries. It discusses the use of an innovative Learning Response Review and Improvement Tool, (LRRIT, referred to as the ‘Tool’ in this paper) initially developed for healthcare safety improvement (HSSIB, 2023). This Tool helps to shift the focus from the person, at the sharp end, to drive impartiality and systemic learning in safety investigation reports. |
Understanding human behaviour and decision-making at level crossing
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Author Katherine L. Plant, Richard Bye, Katie J. Parnell, Craig K. Allison, Jade Melendez, Neville A. Stanton |
| Abstract This work presents a collaboration between [an academic] and [industry partner] to help improve safety at level crossings by developing a deeper understanding of how people behave at them. Using the theoretical foundations of the Perceptual Cycle Model (Neisser, 1976) to generate behavioural insights from workshops, interviews and field observations, the work aims to create decision support tools for level crossing managers, engineers, safety teams and investigators. The resulting human factors toolkit will inform hazard analysis, system design and behavioural interventions that will put level crossing users—and their needs, goals and behaviours—at the centre of activities to improve system safety. |
Systems Ergonomics within a Systems Architecture Framework: Future Issues
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Author Mike Tainsh |
| Abstract The need to develop the key concepts of systems ergonomics is examined. The benefits of introducing architectural concepts into the high level set for systems ergonomics are presented in terms of an improved capability to address ergonomics issues of major systems. A brief review of the key concepts associated with systems ergonomics and systems architectures is carried out and a framework developed. This is exemplified with the architecture of a User’s workstation. Issues for future consideration are presented. |
Using Cognitive Work Analysis to Evaluate Psychological Wellbeing in School-based Camps
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Author Michaela E. Schuler, Gemma J. M. Read, Clare Dallat and Paul M. Salmon |
| Abstract Every year, large numbers of school students attend residential camps in Australia and around the world. While it is assumed that these experiences promote psychological development and wellbeing through exposure to novel environments and challenges, little research has evaluated the extent to which camps facilitate psychological well-being (PWB). This study represents a novel application of Cognitive Work Analysis (CWA) to describe the current residential camp system, providing insight into how the current design of school-based residential camps support PWB. The Six-Factor Model of PWB was adopted, which proposes six dimensions of PWB: self-acceptance, positive relations with others, environmental mastery, purpose in life and personal growth. The first phase of CWA, Work Domain Analysis, was used, with an initial model developed by the researchers and validated through workshops with nine subject matter experts. The model indicates that some PWB dimensions are well supported in the current system (e.g., positive relations with others), while others (e.g. purpose in life and personal growth) are less well supported. Further, the model provides insight into which functions or activities support which PWB dimensions, enabling changes to be made to the design of camps to better support specific dimensions. |
Measuring Professional Wellbeing in Healthcare
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Author Giulia Miles, Eva-Maria Carman,Upasana Topiwala, Benjamin Warren, Sasha Blackwood & Steve Cantellow |
| Abstract Wellbeing of healthcare staff has been highlighted as a key issue across clinical professions and a focus on professional wellbeing allows us to identify and better understand the system performance shaping factors that affect individual clinicians and ultimately patient care. This paper describes the method of selecting and applying a validated wellbeing tool in a large acute NHS hospital trust as part of a wider project looking at system monitoring tools. |
Modelling User Contribution to Capability Within a Supervisory Control System
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Author Mike Tainsh |
| Abstract Supervisory control is a common category of system employed for many surveillance applications and is a continuing subject of interest to ergonomists. During their development, following an initial statement of system requirements, capability options need to be assessed to understand the contribution of design features to system effectiveness. One technique that can be employed is capability modelling which aims to generate predictions of outcomes dependent on initiating events. A novel capability modelling technique is proposed based on an integration of ergonomics research results and professional input. |
Using the decision ladder to reach a better design
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Author Daniel P. JENKINS, Malcolm BOYD, Chris LANGLEY |
| Abstract As with all safely critical interfaces, it is imperative that medical devices communicate the right information, to the right people, at the right time, in the right place, and in an optimal format. This paper describes an approach for eliciting information requirements based on Rasmussen’s decision ladder. A hypothetical example of radiography equipment is used to illustrate the process; however, the approach is also considered to be applicable to a wide range of domains. The approach is based on a semi-structured interview and creates an explicit link between the data collection activity and the final design interface. |
The Information Relevance Task Model of SAP System and Information Presentation
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Author Wu Xiaoli, Zhang Lan, Huang Xiaoli |
| Abstract SAP system, as a typical production management system, has great advantages in operation monitoring and production management, which has the characteristics of rapidly processing massive data and integrating information modules. However, in terms of human-computer interaction, the presentation of massive data is prone to an increase of cognitive load of users. The disorderly connection of information makes the user's misunderstanding of interface information, and it is also easy to add unnecessary operation steps. The SAP system information data of an enterprise was selected as the sample to optimize the information organization and presentation. It analyzed the production management task process for different types of users, and built an information association architecture for them based on the task domain model. The results show that the information association structure of purchasing engineer, planning engineer, quality engineer and manufacturing engineer established according to the task domain model can intuitively show the hierarchical relationship, importance and task flow of production data information under the real-time monitoring of SAP system, which is conducive to improving the work efficiency of users. |
Taking a ‘7 E’s’ approach to road safety in the UK and beyond
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Author Katherine L. Plant, Rich C. McIlroy & Neville A. Stanton |
| Abstract Road traffic accidents claim the lives of more than 1.25 million people each year, 90% of these deaths occur in Low-and Middle-Income countries (LMIC). The Socio Technical Approach to Road Safety (STARS) project brings together a consortium of four LMICs (Bangladesh, China, Kenya and Vietnam) and a leading Transport Research Group in the United Kingdom (UK) in order to tackle Road Safety. Traditional road safety research has been characterised by the ‘3 E’s’ of Engineering, Enforcement and Education. Although these have provided guidance to engineers and policy makers, they do not go far enough to providing a holistic and integrated approach to road safety and fail to consider fully the wider system factors that shape road user performance and outcomes. STARS intends to tackle road safety from a ‘7 E’s’ perspective, with the inclusion of Economics, Emergency response, Enablement, and the overarching ‘E’ of Ergonomics, i.e. applying contemporary socio-technical systems methods to develop systemic solutions to the seemingly intractable problem of road safety. This paper provides a status review of the ‘7 E’s’ of road safety from a UK perspective and the poster will contrast road safety across the five countries using the Actor Map component of the Risk Management Framework to model the road safety system. |
Analysing two serious incidents in clinical research from a systems theory perspective
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Author Anthony Vacher, Yannick Bardie, Monica Pollina, Myra Daridan and Brian Edwards, for the Safety Analysis Team |
| Abstract Effectively ensuring the safety of volunteers that participate in clinical trials involving healthcare products (drugs, medical devices) is a subject of debate in clinical research. This is especially so when healthy volunteers choose to enter Phase I (first-in-human) trials where any serious incident is unacceptable and undermines the confidence in the whole healthcare industry. As in other industries, safety management of clinical trials rely mainly on a traditional view that aims to avoid serious incidents by the identification of hazards, the development of safety barriers (technological barriers, procedures, regulation, laws) to prevent and mitigate risks, and the strict compliance of operators with these safety barriers. This traditional view of safety management is recognised as no longer sufficient to maintain safety in a dynamic, complex, and competitive environment where changes and perturbations are permanent, and the pace of technological innovations is high. In that respect, a group of individual pharmacology and clinical professionals have argued for the need to introduce the principles and methods from human factors and systems theory into the process of safety investigations following serious incidents occurring in clinical research. In this perspective, an international, interdisciplinary and multi-stakeholder collaboration was established to explore the feasibility to transpose human factors and systems theory methods to the specific context of investigation of serious incidents that occurred during phase I-trials. The Causal Analysis using System Theory method was applied to two emblematic serious incidents, one in London (United Kingdom) in 2006 and one in Rennes (France) in 2016. These two serious incidents have benefited from extensive investigations by both stakeholders and authorities afterwards to identify their root-causes and propose remedial actions to avoid their recurrence. |
Significant event analysis: a systems approach to exploring personal impact and improving the analytical process in primary care
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Author Paul BOWIE, Elaine MCNAUGHTON, Deirdre HOLLY, John MCKAY and David BRUCE |
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A Sociotechnical Systems Analysis Approach to Playground Design
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Author Leigh MISSEN a, Nicholas, J. STEVENS b, Paul, M. SALMON b |
| Abstract This paper describes an application of Work Domain Analysis (WDA) to support urban planning decisions regarding play. The study sought to determine whether WDA offers greater insight to the design requirements of playgrounds. A new understanding of the important interdependencies of objects and functional purposes of playgrounds is revealed. Constraints, complexity, and emergent behaviours are not necessarily concepts associated with urban design challenges; however this paper evidences that they have much to offer if considered within a sociotechnical systems framework. |
Do our complex systems meet requirements? An example from naval ergonomics
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Author Mike Tainsh |
| Abstract Throughout the produce or services lifecycle, the assessment of the ergonomics contribution to system development evolves to ensure that designs meet requirements. This is particularly important towards the final stages when assessment is against operational scenarios. Current assessment techniques are examined, and exemplified using experience from current work on naval systems, and User System Architectures (Tainsh, 2016). Assessment techniques for contributions to operational scenarios are proposed using risk-based metrics which include the criterion ‘Risks At Operationally Acceptable Levels (RAOAL)’. |
Getting cognitive requirements for system design right
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Author Shirley Brennen and Victoria Doherty |
| Abstract Recently, the Ministry of Defence (MOD) updated guidance on the application of human factors in system acquisition. During that process, a number of gaps were identified. The aim of this study was to address one of the gaps by providing the MOD with a generic process that would allow them to: determine the cognitive capabilities required for accurate system operation; and measure the current cognitive capabilities of a proposed user group to inform the design or selection of any military system. Building on an analysis of cognitive literature, and an understanding of military tasks, a framework was derived for the classification of cognitive abilities. By combining the framework with guidance and best practice, a simple process for deriving and incorporating cognitive requirements into military system development was created. This process extends the current standardised approach, providing a holistic approach to human factors in system design. |
Breaking bad systems: using work domain analysis to identify strategies for disrupting terrorist cells
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Author Paul M. Salmon, Tony Carden & Nicholas J. Stevens |
| Abstract Terrorism represents a major global issue. Despite decades of research, interventions designed to prevent or disrupt terrorist activities are failing to adequately control the problem. This paper argues that a human factors systems-thinking approach may support the identification of novel, holistic and impactful interventions. To demonstrate, a systems analysis of a generic Islamic State terrorist cell, created using the work domain analysis phase of cognitive work analysis, is presented. The analysis is subsequently used to identify opportunities for disrupting terrorist cells and their activities. In addition to well-known and already applied interventions, the analysis identified a series of other opportunities for disrupting terrorist cell activities. Examples discussed include strategies designed to disrupt propaganda activities and the planning of terrorist attacks. The analysis also showcases the potential use of systems ergonomics for disrupting, as well as optimising, sociotechnical systems. The implications for ergonomics generally as well as counter-terrorism activities are discussed. |
Net-HARMS, AcciNet and SafetyNet: A new safety management toolkit for complex systems
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Author Paul M Salmon, Neville A Stanton, Guy H Walker, Patrick Waterson & Adam Hulme |
| Abstract Risk assessment and accident analysis methods based on systems thinking are currently popular, but few can be used together in an integrated manner. This article describes and demonstrates the Systems Thinking Accident and Risk Toolkit (START) which comprises the Networked Hazard Analysis and Risk Management System (Net-HARMS) risk assessment method, the Accident Network (AcciNet) accident analysis method, and the Safety Network (SafetyNet) intervention evaluation method. The three methods were designed to be used in an integrated manner as part of organisational safety management activities. START is described and demonstrated via a case study focussed on autonomous vehicles. The findings highlight the benefits of integrating risk assessment and accident analysis activities, including how accident data can be used to strengthen risk assessment outputs, and how the efficacy of specific risk controls can be considered in accident analysis efforts. Practical guidance on using the methods is offered, as well as recommendations for future research and applications in practice. |
Passengers’ Requirements for developing a Passenger-Centred Infrastructure to Enhance Travel Experiences at Airports
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Author Genovefa KEFALIDOU1, Mirabelle D’CRUZ1, Sarah SHARPLES, Christine De LILLE, Nikos FRANGAKIS, Richard OTTENS, Ronald GROSMANN, Rui MARCELINO, Klaus LÜTJENS, Sonja LÖWA, Eddie SHAW, Antonello NARDINI, and Sicco SANTEMA |
| Abstract PASSME (Personalised Airport Systems for Seamless Mobility and Experience) is an EU-Horizon 2020-funded project focusing on enhancing passengers experience at airports while reducing air travel time, through optimising interiors, luggage flow and offering real-time personalised information. We identified current processes, interactions and needs passengers and airport services experience while travelling. We employed mobile diary surveys on-the-go followed by semi-structured interviews to unpack journey trails and contextual information that influence passengers’ experiences while at airport(s) and on board. Passenger experiences are multi-factorial while at airport(s) and during their journey demonstrating a strong need for trust, situation awareness and prompt information provision. |
Taking a systems approach to designing national safety policy
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Author Tracey A Herlihey, Lauren Mosley & Matthew Fogarty |
| Abstract Any policy developed in a siloed manner and presented for implementation in a straightforward way is limited in its application in complex systems such as healthcare. In this article we describe a process for developing new patient safety policy by taking a user-centred approach and applying a system-based framework. The Patient Safety Incident Response Framework published in 2022 (NHS England, 2022), represents a complete redesign of how the NHS responds to patient safety incidents for the purpose of learning and improvement. The Framework will replace the current Serious Incident Framework (NHS England, 2015). Testing and revision were a formal part of the development cycle. The final version incorporates findings from an early adopter programme and independent evaluation and used SEIPS as a framework specifying the structure of a patient safety incident response system. We found the framework to be a useful tool for informing the revision of PSIRF; however, translating this work into policy form proved difficult and some nuance and direct links to SEIPS may have been lost. |
The Process of Training ChatGPT Using HFACS to Analyse Aviation Accident Reports
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Author Declan Saunders, Kyle Hu & Wen-Chin Li |
| Abstract This study investigates the feasibility of a generative-pre-trained transformer (GPT) to analyse aviation accident reports related to decision error, based on the Human Factors Analysis and Classification System (HFACS) framework. The application of artificial intelligence (AI) combined with machine learning (ML) is expected to expand significantly in aviation. It will have an impact on safety management and accident classification and prevention based on the development of the large language model (LLM) and prompt engineering. The results have demonstrated that there are challenges to using AI to classify accidents related to pilots’ cognitive processes, which might have an impact on pilots’ decision-making, violation, and operational behaviours. Currently, AI tends to misclassify causal factors implicated by human behaviours and cognitive processes of decisionmaking. This research reveals the potential of AI's utility in initial quick analysis with unexpected and unpredictable hallucinations, which may require a domain expert’s validation. |
Using a systems thinking tool to identify work system interactions in healthcare
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Author Emma Smith & Stacey Sadler |
| Abstract This paper advances the use of Systems Engineering Initiative for Patient Safety (SEIPS) to provide a visual representation of how work system factors interact with each other to shape processes and outcomes. Healthcare professionals identified that deficiencies in work system factors surrounding the person, task, tools and technology, environmental factors, organisational factors and external factors shaped undesirable outcomes for the patient, professionals or organisation around the discharge process. Improving work system factors may decrease the likelihood of negative outcomes for the patient, professionals or organisation. |
Assumption-Based Leading Indicators to Monitor Healthcare System Drift Towards Failures
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Author Elizabeth Wilson-Lewis & Gyuchan Thomas Jun |
| Abstract This study explores how the assumption-based leading indicator approach can be applied to monitor organisational drift of healthcare systems towards failures based on the Mid Staffordshire NHS hospital failure case. |
Ergonomics in the informal work-systems of developing countries; need not luxury
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Author Adedoyin A. Adeleye |
| Abstract In most industrially developing countries, artisans/tradesmen in the Informal work-systems are significant drivers of the economic life. Some simple, intuitive participatory ergonomics interventions hold great potentials to make a big difference, even if sometimes subtle, in this work milieu. The application of such interventions would increase the practitioners’ productivity and income. |
Developing a systems-based professional wellbeing tool: What should we consider?
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Author Eva-Maria Carman, Giulia Miles, Upasana Topiwala, Benjamin Warren , & Steve Cantellow |
| Abstract A key consideration to work systems are the people within it and the resource and resilience they bring to the system. As a result, professional wellbeing should be considered as a key element for systems monitoring. To work towards developing a professional wellbeing tool associated with work system elements to guide and inform improvement strategies and system redesign, an exploratory study was conducted to capture the relevant concepts. The aim of this phase of the project was to explored what staff thought were key elements of professional wellbeing that should be assessed, how work is organised and managed by staff, how this may be related to professional wellbeing and capture practical considerations for data capturing and tool outputs. A total of eight focus groups and seven interviews were conducted with staff within the Hospital 24 service between January and September 2023 with a total of 28 participants. The results from the focus groups and interviews assisted in addressing three key questions, namely: what should one measure for professional wellbeing, what is currently measured and how should one measure professional wellbeing? In addition to addressing these questions, key work system considerations emerged that are essential for understanding the context of the concepts identified and the potential implications for measurement and data interpretation. These qualitative results provided the building blocks for a conceptual framework that will guide the development of a systems-based professional wellbeing tool. |
Human and organisational factors in cybersecurity: applying STAMP to explore vulnerabilities
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Author Andrew Wright, Gyuchan Thomas Jun |
| Abstract The human and organisational factors contributing to information security are still poorly understood, primarily due to a lack of research and absence of suitable techniques to assess complex digital systems. This paper presents the application of the System-Theoretic Accident Models and Process (STAMP) technique to the 2013/2014 Target Corporation data breach. The aims of the study are to investigate the causal factors using a systemic approach, and to demonstrate the benefits of the technique to information security applications. A number of critical control flaws were identified through the STAMP analysis include: i) poor external and internal communication/co-ordination of new threats and vulnerabilities; ii) inadequate learning from past events, internally and externally; iii) a lack of proactive security management to understand and learn from system successes and good practices as well as system failures; iv) ineffective management and co-ordination with the supply chain. |
Cognitive decision-making strategies in patient flow management
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Author Matthew Woodward, Julie Gore, Fotios Petropoulus & Christos Vasilakis |
| Abstract Decision-making for hospital patient flow management is a time-constrained task for a dynamic problem, but little is known about the cognitive strategies required for this type of task. The SkillsRules-Knowledge model of cognition was used to study the decision-making strategies of clinical coordinators and patient flow managers in acute medical units in two hospitals. For timeconstrained decisions in an environment with a plethora of dynamic data, a rule-based feedforward strategy was predominant. Additionally, decision makers applied their tacit knowledge of bed demand profiles to project the future situation and to compensate for delays that were inherent in the patient transfer process. |
Responding to identity theft: a systems analysis of actors, responsibilities, and vulnerabilities
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Author Judy M. Watson, Gemma J. M. Read, Don Kerr & Paul M. Salmon |
| Abstract Responding to identity theft incidents is complex however our current understanding of the response system is limited. This study applied a systems analysis with the aim of identifying the actors that share the responsibility for victim outcomes following identity theft incidents in Australia. The findings identify a diverse set of 60 actor types involved in the response process and emphasise the lack of a single ‘one-stop-shop’ point of contact for victims. Recommendations for improvement are suggested. |
Capturing Changes in Healthcare during COVID-19 – A Physiotherapy Services Case Study
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Author Giulia Miles, Eva-Maria Burford & Laura Evans |
| Abstract During the UK’s initial response to the COVID-19 pandemic, the National Health Service witnessed drastic and rapid changes to the way work was done. Not only were changes implemented at an organisational level, but at a more local level, staff across the service adapted and developed methods of coping to keep the healthcare system functioning. As a result of this, ideas and innovations that emerged during the initial response may be helpful not only in the immediate future but also in the longer term. This study applied a systems approach to explore the changes and adaptations to work in the Physiotherapy department of a large acute trust in the UK during the initial response to COVID-19 (April 2020). Using online focus groups, the changes to the work structure, challenges and aspects that worked well were explored with 26 physiotherapy staff. The qualitative data was analysed using thematic analysis to determine the common themes across the focus groups. By utilising a systems approach, a better understanding of the effect of the changes and how they may be connected to challenges and aspects that worked well could be identified. The depiction of the work system also put into context some of the outcomes experienced at this time. Based on these results potential considerations for ‘wave 2’ were extracted and consisted of general work-system aspects and pandemic-specific aspects. |
Out-of-Hours Hospital Service: A Multi-Phased Approach to Applying a Systems Analysis
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Author Eva-Maria Carman, Giulia Miles, Steve Cantellow & Patrick Waterson |
| Abstract Healthcare needs to provide services 24 hours a day, seven days a week, 365 days a year. This includes out-of-hours from 17:00 to 09:00 weekdays, weekends and Bank Holidays. To provide this care, which has been estimated to be about 75% of the working week, dedicated out-of-hours teams have developed within the healthcare system. At one large NHS Hospital Trust, the focus of this study, the out-of-hours care is provided by the Hospital 24 service, a small team with limited resources covering a wide range of medical and surgical specialities across two large and complex hospital sites. In light of the increasing demand on this service, changes in available technology and with the numerous changes as a result of the COVID-19 pandemic, the Out-of-Hours Review aims to capture the current state of this service to determine the potential requirements for the future. This component of the Out-of-Hours Review aims to provide a high-level description of the system elements of the Hospital 24 Service. The systems analysis was compiled from three different data sources, namely a survey, data from the task management system and observation sessions. Using the SEIPS 2.0 model, high-level descriptions of the different work system components and a preliminary list of the barriers staff encounter, and facilitators staff use in this work system were generated. This analysis also identified the perspectives, system components and interactions that need to be explored in more detail in the next phase of this review. |
Human Factors Guidance for Robotic and Autonomous Systems (RAS)
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Author Claire Hillyer, Hannah State-Davey, Nicole Hooker, Richard Farry, Russell Bond, James Campbell, Phillip Morgan, Dylan Jones, Juan D. Hernández Vega & Philip Butler |
| Abstract This paper outlines recent (2021/2022) work to produce Human Factors (HF) guidance to support the design, development, evaluation, and acquisition of Robotic and Autonomous Systems. |
Lessons learnt from introducing a Fatigue Risk Management System
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Author Nicola Legg |
| Abstract Fatigue has long been known as a risk to safe human performance across many industries, in the UK. However, in 2019, it had not been considered as a risk factor within the gas distribution network industry. This paper summarises some of the work that has taken place so far to implement a Fatigue Risk Management System into an organisation and begins to reflect on what worked well and what needed reflecting upon and revising. |
Task Switching – Managing Workload within Digital AFV Systems
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Author Trevor Dobbins, Ryan Meeks, Dan Evans, Stuart Howe & Stephen Barrett |
| Abstract The Armoured Fighting Vehicle Commander’s role is characterised by having multiple mission critical tasks. They are required to rapidly redirect their attention at short notice as events change. This paper describes how this task-switching is modelled and analysed, within the system model, to manage workload and develop/deliver a useable system |
Task Analysis Within The System Model – The Single Source Of Truth
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Author Trevor Dobbins, Ryan Meeks, Michael Hespley, Stuart Howe & Kerri Garland |
| Abstract Contemporary military platforms are designed within a Systems Engineering environment. This paper describes how the use of the System Model and HCI wire-framing are being utilised to replace the traditional tabular task analysis as the Single Source of Truth of vehicle’s design. |
The Ageing Workforce in the United Kingdom and the Design of the Work System
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Author Peter BUCKLE |
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Scoping ergonomics information with User System Architectures to meet HSE’s COMAH requirements
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Author Mike TAINSH |
| Abstract The Health and Safety Executive (UK) apply the COntrol of Major Accident Hazards (COMAH) regulations during inspections of designated sites. They pay attention to the ergonomics issues associated with the organisation, the jobs and individual characteristics including competency. The organisation needs to scope the ergonomic information, and integrate it appropriately prior to assessment. A User System Architecture (USA) was used to scope and contain all ergonomics information. This supported an integrated understanding of the ergonomics issues, and traceability. |
From systems ergonomics to global ergonomics: the world as a socio-ecological-technical system
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Author Paul M. Salmon, Neville A. Stanton, Gemma J. M. Read, Guy H. Walker, Nicholas J. Stevens & Peter A. Hancock |
| Abstract Our future existence on earth is under threat. Immediate and significant action is required, however, the issues that we face are complex, interrelated, and difficult to solve. The potential role of ergonomics in managing existential threats has been discussed; however, few studies have used ergonomics methods to analyse major global challenges. This article presents the findings from a study that explored the use of a systems ergonomics tool, the abstraction hierarchy from Cognitive Work Analysis, to develop a complex sociotechnical systems model of the world. The aim was to determine whether the method was able to cope with such a large and complex problem space, and to explore what insights the analysis would give on how society can respond to current and future global challenges. The findings demonstrate that the abstraction hierarchy is capable of modelling the world as one large-scale problem space. In particular, the model was able to encapsulate the major global challenges recently outlined by the World Economic Forum. A contribution of the analysis is to show the interrelatedness of the issues underlying these challenges, which in turn demonstrates the difficulties faced when attempting to respond to them. The implications of the model are discussed, along with further work that is required to embed ergonomics in wider multi-disciplinary efforts aiming to tackle current and future global challenges. |
Practicing What We Preach: The Performance Shaping Factors of Human Factors Practitioners
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Author Darren Doyle, & James Blundell |
| Abstract The severity of performance shaping factors on human factors (HF) practitioners from safety critical industries in the United Kingdom (UK) is examined. Based on a Human Factors Analysis and Classification System (HFACS) survey, 32 HF practitioners reported that organisational influences were the most disruptive encountered PSF with the vocation (p < 0.01), compared with supervisory and workplace pre-condition factors. Follow-up semi-structured interviews with 5 participants highlighted these organisational PSFs could be attributed to the misperception of the HF role and value within organisational structures, contributing to the perception of HF receiving insufficient budgetary and organisational priority. Furthermore, participants viewed these PSFs to be significantly detrimental to their own well-being and to both the current and prospective health of discipline. Recommendations to address these issues are discussed. |
The Adaptive Organisation: Progress in understanding adaptation in safety management
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Author Craig Foster, Katherine Plant & Rich McIlroy |
| Abstract In the last 20 years, new theories, ideas, and disciplines of safety have emerged to address the evolving nature of safety management in complex sociotechnical systems. The literature increasingly recognises the importance of adaptation; whereby the people in the system use their skills and experiences to make continuous, real-time demand compensations to ensure safety through trade-offs, self-organisation, informal practices and strategies. This paper presents the results of an investigation into the nature of adaptation and the emerging understanding of the role it plays with reference to the safety of UK air traffic control. |
Human Factors and Procurement: Lessons Learnt from a High-Value Procurement Exercise
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Author Eva-Maria Carman, Michael Johnson & Giulia Miles |
| Abstract Human Factors can inform and enhance traditional procurement processes by capturing the users’ input and considering the wider system into which the products will be implemented. Despite this, traditional procurement processes do not typically consider integrating HFE into the process in a systematic way. This paper describes the role of Human Factors in the different phases of a large procurement project and the lessons learnt for the procurement of hospital beds within one large NHS Hospital Trust. The aim of the procurement project was to determine the best solution that includes a variety of products and service contract from one supplier. A total of six different bedframes and two different types of mattress needed to be considered. The role of the HFE team was to provide advice at strategic project meetings, support the specification design, conduct an HFE evaluation of the products and ensuring a system’s perspective was considered throughout the process. Across all the product types, the HFE evaluation included 27 simulation testing sessions followed by feedback from staff on in-situ use on 23 different wards. Key lessons learnt included the value of qualitative data can add to support the decision-making process in procurement projects, the need to understand clinical needs as in this context there is no one perfect product due to the wide range of applications, and the need for HFE specialists to have a better understanding of the procurement process and their involvement across all phases of this type of project. |
Applying systems thinking to telephone triage
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Author Jill Poots, Jim Morgan, Matteo Curcuruto, Stephen Elliott & MaryAnn Ferreux |
| Abstract The NHS 111 telephone triage service is a complex sociotechnical system that likely carries specific safety risks not present in traditional face to face care. Despite apparent system safety risks, there is a paucity of research in telephone triage. This paper outlines the use of a macroergonomics approach to identify system components, their interactions and risks in telephone triage |
Twitter as part of operational practice and passenger experience on the railways
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Author David GOLIGHTLY, Jason DURK |
| Abstract The paper examines social media in the management of rail operations. Using data collected through interviews and workshops with 14 rail stakeholders, a number of themes tie rail social media to human factors. These include (1) processes and organisation of functions for successful embedding of social media (2) HCI considerations for both staff and passengers (3) competency factors for staff (4) the importance of a system control perspective, to make explicit the flows of feedback and action that social media can mediate in operational rail processes. |
The 2017/18 Cape Town drought: A sociotechnical systems analysis
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Author Andrew Thatcher and Patrick Waterson |
| Abstract Our world has become increasingly interconnected and complex. In human factors and ergonomics (human factors) this complexity has been recognised by a growing number of researchers and practitioners as humans face a number of global crises that seriously threaten human wellbeing (and possibly our own existence as a species). Globally-challenging issues such as energy supply, urbanisation, health provision, violence and terrorism, food supply, and water scarcity have now been investigated and interventions implemented by people working in the human factors field. While most of this work has been at a relatively small scale, several human factors authors (including the authors) have suggested that there are now a variety of human factors systems analysis tools that can be used to analyse and find solutions to incidents and unfolding situations at a much larger scale including the analysis of trading on the darknet and an international food scandal. In 2018 the city of Cape Town was literally days away from shutting off the municipal water supply to four million residents. Persistent drought, exacerbated by climate change, had led the city to announce ‘day zero’ – the day when the potable water supplies would be shut off and water would only be available from water tankers at designated safe zones. This didn’t happen. The rains started falling and the water supplies were replenished. In safety science analysis this would be referred to as a near miss. Was this luck or the result of concerted efforts by city officials and the associated human systems (such as residents, engineers, scientists, local government, and national government)? This is the question that we investigated in this paper by examining the human-systems interactions as they unfolded over time from a sociotechnical systems perspective using a series of four STAMP analyses. |
Understanding and Improving System Safety Through System Dynamics Modelling – Systematic Literature Review
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Author Mohammed IBRAHIM SHIRE, Gyuchan Thomas JUN and Stewart ROBINSON |
| Abstract System Dynamics (SD) has been widely used in modelling across a range of applications but its potential has not yet been fully realised as a tool for understanding system safety and supporting relevant strategic decision making. We conducted a literature review of SD applications in safety-critical environments, employing a safety taxonomy framework. The result of our literature review provides an overview of SD modelling application in safety-critical environments, highlighting the existing gap and generating future research questions in this area. |
Setting the standard: a systems approach to the design and evaluation of safety standards
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Author Tony Carden, Paul M. Salmon and Natassia Goode |
| Abstract In 2003, adventure activity providers in Victoria, Australia, began to develop a set of common operating standards. The resulting Victorian Adventure Activity Standards became a model for similar standards in other Australian states. However, the development process lacked systematic rigour. This article argues that sociotechnical systems theory methods are suited to safety standard design and evaluation. A Work Domain Analysis revealed system weaknesses along with potential avenues for modifying and optimising the standards. Potential improvements and broader implications are discussed. |
Allocation of Function Method to support future nuclear reactor plant design
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Author Dr Arzoo Naghiyev, Mr John Mount, Mr Anthony Rice and Mrs Caroline Sayce |
| Abstract Current Allocation of Function methods require significant levels of judgement and interpretation and there is an opportunity to develop an improved capability for Allocation of Function for the context of the Nuclear Reactor Plant. This paper presents the development and application of an Allocation of Function method that provides a flexible and configurable set of tools which can be selected in accordance to the design stage and project requirements. The Allocation of Function method has been designed to be used in an iterative manner throughout the different stages of design development and used to engage with different engineering teams. The method draws upon existing and well-established HF methods to investigate and capture human-system interactions associated with function delivery. It also focuses on cognitive tasks to ensure introduction of automation continues to provide support to the operator. Particular emphasis is placed on mapping and understanding the cognitive processes employed in function delivery to ensure that all functionality and information requirements are captured in future automation design. The method also informs assigning and selecting a Level of Automation to a function. The Allocation of Function method enables integration with Systems Engineering to trade HF requirements against the engineering requirements for provision of automation. |
Point Merge: Increasing Human-System Integration in Air Traffic Management
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Author Shane Kenny & Wen-Chin Li |
| Abstract Through consideration of human-system integration (HSI) during airspace design, ATCOs who operate in a Point Merge environment can benefit from increased situational awareness, reduced workload and increased performance levels (Eurocontrol, 2021). This short paper outlines the advantages of implementing Point Merge operations to increase ATM safety, by considering the role of the ATCO and the importance of HSI when implementing air traffic control procedures. |
Systems Human Factors and Ergonomics methods: applications, outcomes, and future directions
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Author Samantha L. Jackson, Gemma J. M. Read, Adam Hulme, & Paul M. Salmon |
| Abstract This systematic literature review identified peer-reviewed applications of systems HFE methods to determine the range of problems examined and how the methods have been applied. The review revealed a growth in applications of systems HFE methods over time. The review suggests that as problem and system complexity continue to intensify, continual evaluation and potential adaption of methods may be required, including using more than one method. |
A model of Human Factors for frontline healthcare staff: Translation to clinical practice
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Author Nick WOODIER, Jonathan FOX and Bryn BAXENDALE |
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A Human Factors approach for analysing highly automated systems
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Author Ronald W. McLeod & Nora Balfe |
| Abstract Automation rarely if ever removes people from a system: rather, it changes their role in ways that can sometimes be difficult to predict. Learning from innumerable incidents has shown that organisations involved in developing and introducing highly automated systems must give sufficient attention during the design, development and deployment of automation to the role of people in the system. This paper suggests a structured analysis method that could be used early in the development of potentially any automated system to identify where a focused effort on Human Factors issues is likely to be needed. |
Multimodal detection of an electric aircraft propulsion system failure
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Author Lamyea Ahmed, Michael A. Bromfield |
| Abstract The need for sustainable aviation has accelerated the development of electric aircraft and propulsion systems. These systems generate less noise compared to conventional piston engines (Moshov & Toropylina, 2022) and provide limited cues to the pilot in the event of a propulsion system’s failure. Not recognising powerplant failure and taking prompt recovery actions in a timely manner may lead to aerodynamic stall and loss of control in flight (Smith & Bromfield, 2022). This research aims to explore how multimodal presentation of electric propulsion system information affects pilot response times during propulsion system failure. A human-centred design approach was employed to develop multimodal presentations of data, incorporating visual, auditory and visual/auditory feedback in combination. Simulated flights were conducted in a fixed-base flight simulator, using control and experimental groups consisting of student pilots (n=eight). Preliminary results indicate that pilot response times are reduced when using a combination of visual/auditory information. |
The Combat Helmet as a System: Development of a Systems Model to Manage Complexity in Ergonomic Assessments
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Author Sheena E. DAVIS, Dr. Steve MILANESE, Alistair FURNELL, Prof. Karen GRIMMER |
| Abstract A systems approach was taken to identify the ergonomic attributes that affect the performance of a combat helmet system. The information was developed into a system model that comprehensively details the attributes, their influencing factors, and the outcome effects. Development of the model enabled the complexity of multi-disciplinary attributes to be managed and communicated. This model provides the basis for an assessment framework and provides a useful tool to inform design, development, and trade-off decisions. |
Developing an Explainable AI Recommender System
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Author Prabjot Kandola & Chris Baber |
| Abstract We used a theoretical framework of human-centred explainable artificial intelligence (XAI) as the basis for design of a recommender system. We evaluated the recommender through a user trial. Our primary measures were the degree to which users agreed with the recommendations and the degree to which user decisions changed following the interaction. We demonstrate that, interacting with the recommender system, resulted in users having a clearer understanding of the features that contribute to their decision (even if they did not always agree with the recommender system’s decision or change the decision). We argue that the design illustrates the XAI framework and supports the proposal that explanation involves a two-stage dialogue. |
70 years of sociotechnical systems (STS) principles for systems design: A review and reassessment of their relevance for the 21st century
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Author Amangul A. Imanghaliy, Guy Walker, Patrick Waterson, Pauline Thompson, Paul Salmon, Neville A. Stanton and Ken Eason |
| Abstract In the last couple of years two separate groups of researchers (Waterson and Eason, 2018; Imanghaliy et al., 2019) have worked on reviewing and reassessing a variety of principles for sociotechnical systems (STS) principles which have been developed for systems design. The principles date back to work carried out in the 1950s by a group of researchers at the London Tavistock Institute of Human Relations. The work of Eric Trist and Fred Emery for example, initially focused on understanding the role of human skill and methods of working (for example team working) on productivity within coal mines (Trist and Bamforth, 1951). One of the primary motivations for the STS principles was to underscore the role of choice and organisational design in the interaction between people (the social system) and tools, technologies and techniques (the technical system; Weisbord, 2012; Eason, 2014). A core value embodied in the principles is that, given the right choices, social and technical systems could be harmonised and balanced such that productivity, worker satisfaction and safety could be optimised in parallel (Cherns, 1976, 1987; Clegg, 2000). It is perhaps fair to say that the fortunes of sociotechnical theory have ebbed and flowed over the past seventy years, but the value of sociotechnical principles has remained. In our paper we argue that they are increasingly relevant to a host of distinctly 21st century problems (for example, automation and robotics, globalisation, climate change), all of which share a common imperative to effectively integrate people, technology and complex systems. |
Human Factors Integration in Digital Railway Transformation: A Call for Collaboration
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Author Niamh Tyson & Emily Thorne |
| Abstract A systematic literature review was conducted to synthesise research into Human Factors Integration and holistic risk management in the implementation of ETCS across Europe. The review highlights a lack of accessible literature in this field and makes several recommendations to bridge the gaps in knowledge and inform best practices in the UK. The importance of fostering collaboration within our discipline and developing new avenues for sharing lessons learned beyond traditional channels is highlighted throughout. |
Harnessing A Human Factors Approach to Improve Patient Safety
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Author Jenny Sutcliffe, Suzi Lomax & Jennifer Macallan |
| Abstract The interest in employing Human Factors (HF) in healthcare is increasing. The SCReaM HF and Team Resource Management (TRM) programme is aimed at raising the awareness, understanding and application of the science of HF within healthcare to help staff improve their safety and wellbeing and that of their patients. The programme is divided into three strands: rolling training, HF Projects and HF Engineering. The programme has been successfully embedded into an NHS Trust and provides a good model for how HF can be introduced and utilised within healthcare. |
Translating complex system analysis into a story-based film for participatory design: Dilemmas in suicide prevention
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Author Gyuchan Thomas Jun and I. Cecilia Landa-Avila |
| Abstract It has been widely recognised that whole systems approaches are required, but underexplored in the design and development of complex healthcare systems. Human factors and ergonomics (human factors) has adopted and developed various conceptual models and frameworks in order to support the application of systems approaches such as Cognitive Work Analysis (CWA), Systems Engineering Intitiative for Patient Safety (SEIPS), STAMP and FRAM to name but a few. Application of these systems approaches benefit from the involvement of all relevant stakeholders and the inclusion of their input in system design. However, evidence also suggests that involving healthcare stakeholders is challenging mainly due to their lack of time and system expertise. Undertanding outputs of system analysis, usually in the form of complex system maps, tends to require time and certain level of visual learning capacity, which some people don’t have. The full potential of a participatory systems approach has been hardly realised, so there is a need for improving the way the outputs of systems approaches are communicated. This study, therefore, aims to translate the outputs of complex system analysis into a story-based film for participatory design. |
Knowing and not knowing as system design imperatives
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Author Robert J. Houghton & Karen Lancaster |
| Abstract We discuss the importance of “not knowing” as a design imperative in digital and automated systems with examples drawn from a range of different settings together with discussion of how this might be responsibly addressed based on analysis using E/HF methods. Reflection is also offered on situations where the temptation to ignorance should not be acted on in design terms - or simply ignored - but embraced as a sensitive heuristic tool for detecting wider system design challenges made salient by digitalisation. |
How does explainability affect perceived transparency, trust, acceptance and usefulness?
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Author Yifan Ding, Setia Hermawati |
| Abstract The effects of explainability on perceived trust, transparency, acceptance and usefulness were explored in a within subjects’ study (n=15) using an online shopping recommender system as a context. The study investigated three levels of explainability (low, medium, high) and perceived transparency, trust, acceptance and usefulness were obtained using standardised questionnaires. |
Identifying work system components and constraints of cancer multidisciplinary team meetings
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Author Eva-Maria Carman, Giulia Miles, Sarah Gregory, Gemma Bristow, Eleanor Robinson, James Catton, Alastair Ross and Bryn Baxendale |
| Abstract Multidisciplinary teams have been introduced into cancer care to improve quality of care and are now considered the gold standard for the management of cancer patients in the UK. Meetings of these teams provide an opportunity for experts to discuss the best possible treatment options for the patient. Trends show that referral numbers to these meetings are increasing, placing strain on the capacity of meetings to function optimally. This in turn has cognitive and workload implications for staff involved. Promoting MDT Excellence is a project that aims to examine the variation in practice of these meetings across one NHS Trust and to understand the challenges they are currently facing. In the first phase of this project, a systems analysis of cancer multidisciplinary teams was conducted for the purpose of identifying system constraints and resource issues. A total of twelve meetings were observed, and 42 staff from four specialties were interviewed. Using the SEIPS 2.0 model, key work system components and constraints for multidisciplinary team meetings were identified for the people involved, the tasks, tools and technology, organisation of work, internal environment and external environment. Furthermore, aspects that promoted efficient ways of working and positive outcomes were captured. Examples identified included adopting a more structured agenda, real time digital notetaking and different work organisation techniques, such as distribution of responsibilities and the scheduling of patient groups to be discussed during the meeting. These results provide the basis for a multifaceted approach for system improvement for this work process. |
Preventative solutions from a systems perspective: Outcomes of a co-creating process among executives and researchers
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Author Christine Ipsen and Signe Bergmann |
| Abstract Stress is still one of the biggest challenges when it comes to people’s mental health and workplace opportunities to create growth and wellbeing puts new demands on managers to solve the problem. There is also a stronger focus on top executives and managers, who play a key role in preventing and managing stress, but without a clear picture of what that role implies. There are plenty of international tools and methods available to support interventions to prevent stress, but managers still search for ways to deal with the increasing and costly problem. This search also includes two Danish companies, the Danish Association of Managers and Executives (DAME) and the Danish Pension and Insurance Company, (PFA) which experience an increase in the request for concrete knowledge and tools from their members and customers to solve this problem. Besides applying their vast in-house consultants’ experience to serve their members, the two companies also wish to provide their customers and members with current, relevant and research-based knowledge on how to prevent stress in practice. Acknowledging the experience and knowledge among executives, managers and researchers, the aim of this project was to allow these actors inspired by Mode 2 knowledge production to co-create new knowledge on preventative strategies. The idea is that the joint knowledge production in combination with a systems perspective on prevention and stress management can qualify the ongoing stress and management debate and provide ideas for new solutions, enhancing the implementability of stress preventive changes that can ensure both business relevance and improved mental health. |
Using social media for sociotechnical analysis: Examining the Fyre Festival
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Author Catherine Primrose and Matthew C. Davis |
| Abstract We present a sociotechnical analysis of the 2017 Fyre Festival. The Fyre Festival was marketed as a luxury festival in the Bahamas, promoted heavily through social media, attracting over 4000 attendees. The event was cancelled one day into its inaugural weekend amid chaos and acrimony, resulting in million-dollar losses for the organisers and subsequent law suits. We demonstrate the utility that social media presents for researchers undertaking sociotechnical analysis of business events and failures. Our sociotechnical analysis utilised archival materials, corporate websites, leaked internal documents and documentary accounts. These materials were supplemented with expert interviews with independent event organisers. Relevant twitter posts shared during the Fyre Festival were integrated into the analysis. 58467 tweets were collected in total. We discuss our key findings, drawing out sociotechnical factors and interdependencies that contributed to the failure. We reflect on the methodological challenges and opportunities of working with social media data, considering how this may be integrated within sociotechnical frameworks. We supplement our own interpretation with interviews with experts in the use of social media within social science research. We conclude by discussing the potential to apply sociotechnical frameworks to diverse business events, situations and problems. |
Holistic outcome-driven approach: How do patients and providers prioritise healthcare outcomes?
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Author I. Cecilia Landa-Avila, Gyuchan Thomas Jun, Carolina Escobar-Tello and Rebecca Cain |
| Abstract Healthcare systems are facing pressures to fulfil various needs from different stakeholders at different levels. Different stakeholders tend to prioritise different sets of healthcare outcomes. Consequently, how outcomes are valued or prioritised by different stakeholders needs to be understood in a holistic way to develop and improve new or existent systems. Human factors frameworks and approaches such as Systems Engineering Initiative for Patient Safety (SEIPS) and Cognitive Work Analysis (CWA) recognise the importance of outcomes, but fewer practical approaches for understanding and communicating outcomes as interrelated systems exist. This study applied network analysis as a practical approach to collect, aggregate and visualise interrelations among multiple outcomes. Also, this practical approach provides a mechanism for different stakeholders to communicate and negotiate priorities for holistic outcome-driven healthcare system development. We conducted graphic facilitation mapping interviews with ten patients with chronic conditions and eleven healthcare providers. Participants built outcome interrelationship maps following three steps: 1) Select and explain meaningful and ideal outcomes. 2) Make sense of outcomes by creating influence relationships and groups. 3) Select the most important outcome. Two outcome-based visualisations emerged from the network analysis respectively for patients and healthcare providers. Agreements, disagreements and critical outcomes between patients and providers were identified from those analyses. Wellbeing was equally acknowledged by both groups. However, patients prioritised outcomes such as personal resilience and self-monitoring, while providers prioritised integrated working, (re)admissions and hospitalisations. Overall, this practical approach contributes to a holistic outcomes integration for healthcare systems developing. The mapping process supports interrelated outcomes collection, while the network analysis offers a novel visual communication strategy to identify critical outcomes. This practical approach may complement frameworks such as SEIPS and CWA. A further study could be conducted to explore how multiple stakeholders use this approach for collectively discussing and negotiating their outcome prioritisation. |
The Impacts of Systematic False Alarms on Air Traffic Controllers’ Situation Awareness
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Author Ousmane Diack, James Blundell & Wen-Chin Li |
| Abstract The safety net, made of a set of alarms, is considered the final Air Traffic Management (ATM) protection to prevent an accident. The prevalence and causes of false Short-term Conflict Alerts (STCA), an alarm intended to represent one of the final safety barriers, was investigated based on the occurrence of 315 STCA events generated by a Western African Upper Airspace ATM system over an 11-month time period. Based on subject matter expert review, 313 STCA events (99.9%) were classified as false alarms. False STCA were caused by a combination of technical (aircraft position sensor fusion misalignment) and human attributes within the system. Furthermore, a survey with 26 ATCOs on the cognitive and behaviour effects elicited by the experience of false STCAs revealed that 73.08% of ATCOs experienced increased workload. Whilst 38.46% reported a reduction in situation awareness. Results of the analysis of the retrieved data on the STCA suggest that implementing efficient system integration of different sensors and reducing human error will reduce workload, and improve ATCO’s situation awareness and overall ATM system efficiency. |
Predicting how people will respond to a disruptive event: The human factors response framework
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Author Richard Farry |
| Abstract System disruptions can have far reaching negative consequences. The extent to which a system can anticipate, absorb and adapt to a disruption is a characteristic of its resilience. As people are often fundamental to system resilience, an improved understanding of the people-related factors that underpin system resilience helps in predicting system vulnerability and the response to a disruptive event. The Human Factors Response Framework was developed to provide this improved understanding. The framework supports analysts in identifying relevant people-related factors within a system, and the prediction of the system’s resilience and the likely dominant response from key personnel. This paper provides a high-level overview of the framework, its development, and future research direction. |
