Tools & techniques
Understanding the Human Factors Related to Unrecognised Oesophageal Intubation Using the SEIPS Framework
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Author Melody CheN, B. L. William Wong |
| Abstract Unrecognised oesophageal intubation (UOI) is a medical procedural error in which a breathing tube is mistakenly placed into the oesophagus and not promptly identified or addressed. A literature review on the human factors relating to UOI was performed and findings presented in the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Key themes relating to issues around intubation equipment factors were used to inform the design of a cognitive aid to improve human performance in this clinical context. A semantically meaningful tray consisting of images and uniquely sized slots was created and sought to address technical and non-technical human factors identified in adverse event reports and coronial cases of UOI. |
The risk of moving – using risk analysis to develop simulation centre policy
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Author Sally Scott, Caroline Martin, Sharon Donaghy, Julie Mcquade, Julia Fowler, Lisa McCarroll, Michelle Graham, Karen Higgins, Allan Duke, Ashley Black, Catherine Paton |
| Abstract A risk analysis tool was utilised to facilitate the development of a pragmatic and effective moving and handling Standard Operating Procedure (SOP) specific to the simulation centre environment. The tool that fits the purpose was a Failure Modes Effect Analysis (FMEA), which enabled a proactive and collaborative risk assessment process to occur, thereby fostering a safety culture. |
Tool for Estimating Rail Freight Yard Complexity and impact on human performance
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Author David Golightly , David Ethell & James Lonergan |
| Abstract Previous research has identified that the complexity of freight yards – layout, capacity, access and local physical context – is one factor that impacts the safe performance of freight yard tasks. We present the rationale, method and contents of a tool that makes explicit the definition of site complexity, and elements that comprise site complexity. Applications of the tool include site risk assessment, impact assessment of operational change, and potential to underpin a design standard. |
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. |
Equality, Diversity and Inclusion: The Forgotten Human Factors
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Author Ryan Gamble, Phoebe May Asquith1, David Greeno, Jessica Evans & Phil Morgan |
| Abstract This short paper presents a collection of scenario-based case studies, illustrating how matters of equality, diversity and inclusion (EDI) may operate as human factors. This paper aims to highlight that by placing EDI at the heart of human factors research and practice, future work can ensure a more informed and inclusive practice that avoids reinforcing systemic bias and injustice. |
EEG-based Mental Workload Level Estimation using Deep Learning Models
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Author Kunjira Kingphai & Yashar Moshfeghi |
| Abstract Deep learning-based approaches have recently received much attention and managed to accurately capture variance characteristics in the Electroencephalography (EEG) signals. In this paper, we aim to classify the subject’s mental workload (MWL) level from EEG signal by using deep learning models named Stacked Gated Recurrent Unit (GRU), Bidirectional GRU (BGRU), BGRU-GRU, Stacked Long-Short Term Memory (LSTM), Bidirectional LSTM (BLSTM), BLSTM-LSTM and Convolutional Neural Network (CNN). The classification was performed on a publicly available mental workload dataset, STEW. Our encouraging results show the potential of deep learning models for MWL level detection. |
Allocation of Function in the era of Artificial Intelligence: a 60-year old paradigm challenged
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Author Nick Gkikas |
| Abstract The Fathers of the discipline of Ergonomics and Human Factors used their scientific research and real-life experiences of technological development during WWII and the first years of peace that followed to propose a set of principles for Human-Machine Interaction (HMI). These principles stood the test of time and informed common applications of the discipline, such as allocation of function between human and machine for many years. It is only recently with the advancement and generalisation of certain underlying technologies that forms of Artificial Intelligence (AI), machines and systems with non-deterministic behavioural characteristics became operational. The underlying specification of those machines and systems appear to challenge some of the underlying assumptions made by the Fathers of the discipline. The present article revisits those principles of HMI, identifies the changes in the underlying assumptions and discusses the implications of the changes identified to the discipline of Ergonomics and Human Factors. |
Guidance on customising Bowtie Analysis for use in healthcare
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Author Ronald W. McLeod and Paul Bowie |
| Abstract Based on the CIEHF white paper ‘Human factors in barrier management’, NHS Education for Scotland (NES) has been exploring the potential application of Bowtie Analysis (BTA) in healthcare. Both an initial workshop-based study in a primary care context, as well as feedback from training and a series of case studies conducted across primary and secondary care and supporting health functions, suggested BTA has significant potential as an approach to identifying and managing risk in healthcare. It seems realistic to expect that existing healthcare professionals should be able to conduct BTAs to a reasonable quality standard making use of an NES Guide guidance document, together with a relatively small amount of training and support. |
Accident Analysis Models used in Practice: Comparison of MAIB and NSIA models
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Author Abigail Palmer, Gyuchan Thomas Jun & Will Tutton |
| Abstract The aim of this study is to compare two accident analysis models: Casualty Analysis Diagram (CAD) used by Marine Accident Investigation Branch (MAIB) and a model developed/used by Norwegian Safety Investigation Authority (NSIA). The study explored the similarities and differences between the two models when applied to a real marine accident involving a collision of two vessels. The views of investigators working at MAIB and NSIA were collected using a questionnaire and interviews. This paper discusses various issues on usability of these models and provides insights into effective use of accident analysis models in practice. |
The quest for the ring: Designing submarine control room work using ComTET
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Author Neville A. Stanton, Aaron P. J. Roberts, Daniel Fay and Kiome A. Pope |
| Abstract Research and development for new operational capability in submarines comprises research into human centred design of new capability (where the Command Team-work Experimental Testbed (ComTET) resides), procurement of new capability training capability, and operational evaluation of capability and lessons learnt. The research is given impetus from lessons learnt at sea as well as horizon scanning for technological capability by Defence Science and Technology Laboratory (Dstl). This is fed into the design challenge, which is presented to the ComTET Team, who undertake the research. The ComTET team work with submarine trainers to review current operations and new ways of working. Experiments conducted using the ComTET facilities with serving submariners are able to test and evaluate new technologies and new ways of working. The refined concepts may be taken into the simulators to further refine and test. Once the new operational capabilities have been shown to deliver benefit in ComTET facilities, and the simulators, then they may enter the procurement process. When the new capability enters service on operational platforms, then full evaluation in-service may begin. Any lessons learnt during service may then be fed back into the research cycle. The ComTET team have delivered a guidance document reviewing simulator fidelity, validity and transfer of training to underpin understanding of facility requirements across the different phases of testing. |
Measuring Field of Vision Using Digital Human Modelling Techniques
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Author John Lovegrove |
| Abstract This paper will provide the methodology used to evaluate the field of vision for an entire target population whilst only working in a digital environment using digital human modelling techniques. The context is an evaluation of a small, powered craft at sea, operating at different running trims. The maritime regulations stipulate that the pilot of the boat must be able to see the surface of the water at one boat length. The standard BS EN ISO 11591:2019 ‘Small craft – Field of Vision from the steering position’ provides the practitioner with the target conditions in the horizontal and vertical fields but very little information on the evaluation of the different boats that exist. This paper will take the reader through the entire process for measuring the Field of Vision for any small craft (i.e. less than 24 metres in length), at a range of running trims, using digital human modelling and computer aided drawing techniques. |
Applying FRAM to support service delivery changes in a regional cancer network
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Author Nicholas Seaton, Julie Crawford, Vanessa Mclelland, Helen Morris, Amanda Saunders, Rachel Dommett, John Moppett, Laura Pickup |
| Abstract This paper describes how Functional Resonance Analysis Method (FRAM) was used to produce a model to support a project team to deliver a planned service change in paediatric leukaemia care. With the anticipated wider use of the immunotherapy Blinatumomab, a regional initiative sought to introduce ambulatory shared care delivery of the medication across an operational delivery network of regional hospitals and family homes. The same team had previously used FRAM to analyse incidents, and the existing model was revisited and expanded to explore new system functions, dependencies, and sources of variability created by the change. By enabling multi professional staff to reason together across organisational boundaries, the model acted as a shared reference for understanding system resilience and guiding practical actions for a risk informed implementation of the proposed service delivery changes. Potential instantiations raised during this process were used to generate a Resilience Analysis Grid questionnaire intended to produce an early profile of the system’s potentials for resilient performance and to help focus attention on areas requiring further support as the pathway is introduced. |
Validating ergonomics methods
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Author Neville A Stanton |
| Abstract This paper revisits the challenge laid down over 15 years ago, that Ergonomics needs to report on the reliability and validity of its methods if it is to maintain its standing amongst the Engineering community. Unfortunately, a review of books reporting on Ergonomics methods since that time shows very little change. The theoretical constructs of reliability and validity are presented together with the rationale for conducting studies of training in Ergonomics methods. Revisiting the original study shows the way in which such validation work can be undertaken and data reported. It is hoped that this article provides the stimulus for more studies of this nature. |
Abstraction Hierarchy Tool: A Software for Developing Abstraction Hierarchies as Network Graphs
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Author Joshua Duvnjak, Luciana Blaha, Theodore Lim, Guy Walker, David Flynn, Phillip Greening |
| Abstract The Abstraction Hierarchy (AH) is a Human Factors (E/HF) method used to model the functional structure of complex systems. Although developments have combined the AH with network statistics, this approach is cumbersome to perform. We aim to resolve this issue with our development of a python-based software tool to enable easy access to quantitative statistics within the AH and visualise it as a network graph. |
Paediatric Homecare Risk Management: A Functional Resonance Analysis Method Study of Incident and Risk Assessment Management
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Author Kevin Michael Hoy, Enda Fallon & Martina Kelly |
| Abstract Paediatric homecare is an advancing field of healthcare and risk management is an integral component of these services. This study is part of a larger study into integrated risk management in paediatric homecare risk management. Through interviews with nursing staff using Grounded Theory methodology, analysis of the risk management components was undertaken using Function Resonance Analysis Method (FRAM). The results indicated a clear mapping of the functionality of the process for incident reporting and the assessment of risks. Resonance was evident in several key functions allowing system changes for organisational improvements to enhance quality of care. KEYWORDS |
Applying the ‘many models’ approach to the successful introduction of advanced automated vehicles
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Author Gemma J. M. Read, Paul M. Salmon, Alison O’Brien and Neville A. Stanton |
| Abstract There have been previous calls for a ‘many model’ approach to solving complex challenges in ergonomics (Salmon and Read, 2018). In this work, we demonstrate how the combination of three systems ergonomics methods can provide different, yet compatible insights into the emerging challenge of the successful (safe and effective) introduction of advanced automated vehicles. Specifically, we applied ActorMap, Hierarchical Task Analysis, and the abstraction hierarchy from the Cognitive Work Analysis framework. Each model provides detailed descriptions of the road transport system that can be used as a basis to explore the issues surrounding the introduction of automated vehicles. Importantly, they provide a series of compatible insights from different perspectives regarding the future road transport system that can inform policy response and other initiatives to support the successful introduction of advanced automated vehicles. It is concluded that the application of multiple methods is beneficial to gain more insight than would be available from a single method used in isolation. |
Design of human-machine teams using a modified CoActive Design Method
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Author Professor Chris Baber, Chris Vance |
| Abstract Designing Human-Machine Teams not only requires an appreciation of which functions might be appropriately allocated to human or machine, but also how each team member can make sense of the functions performed by it and its team-mates. The aim of this paper is to present an approach to Allocation of Function within Human-Machine Teams (HuMaT) that can be applied across different Levels of Automation and which can explore information management issues in such teams. To do this, we present a modification of the CoActive Design method. A key aspect of the modification lies in the focus on information exchange and issues relating to common ground in HuMaT. In this paper, Cognitive Work Analysis is used as the basis for the CoActive Design Method to explore how different Levels of Automation can be conceptualised. The benefit of such an approach is that is provides a decomposition of functions such that it is possible to see how, even in systems that have high-levels of autonomy, there remains a role for human operators. Taking the example of an in-car navigation system, we illustrate how each member uses information to support the functions allocated to them, and how common ground develops in the team. |
Putting the Focus on Drivers: Exploring Public Understanding of Driver Monitoring Systems
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Author David Large, Catherine Harvey, Hannah Parr, Iris Jestin, Elizabeth Box |
| Abstract Driver monitoring systems (DMS) are increasingly embedded in modern vehicles and safety assessment frameworks, yet little is known about how drivers themselves understand these systems and how their beliefs shape usage, trust and acceptance. Ten focus groups (n = 30 UK drivers, aged 20–79) were conducted in which pictorial storyboards depicting five generic driver monitoring scenarios (fatigue, distraction, cognitive decline, intoxication and data privacy) were shown to participants, who were then asked to discuss what they thought was happening, how they thought it was happening, and why they thought it was happening. Findings suggest that drivers perceived DMS as socio-technical systems shaped by behaviour, context, interface design and data governance, with acceptance driven more by trust, autonomy and expectations than detection accuracy. Drivers highlighted fluctuating states and subjective self-assessment, indicating binary “fit/unfit” judgements poorly reflect real-world driving. Transparent, advisory and explainable systems were favoured, while opaque inferences, intrusive monitoring and unclear data use reduced trust. Findings will be used to inform the design of a large-scale survey to measure acceptance. |
Integration of Human and Organisational Factors in Railway Systems Lifecycle Processes
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Author Nora Balfe, Virginie Papillault & Anna Windischer-Unterkircher |
| Abstract Integration of human factors in railway change management and systems engineering is an increasingly important topic, not least because of emerging regulatory requirements in the area. This paper will describe one model developed collaboratively in the International Union of Railways (UIC) Human and Organisational Factors Working Group (HOFWG) which maps 12 human and organisational factors steps to the 12 steps in the V-cycle model described in the railway Reliability, Availability, Maintainability and Safety (RAMS) standard (EN50126). The aim is to provide a framework, aligned with existing engineering approaches, to communicate how human and organisational factors can be integrated into a railway change project. |
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. |
Using the COM-B Model to Improve Safety Reporting by Railway Track Workers
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Author Jana Mihulkova, Sam Waters, Anita Weltz |
| Abstract This study used the COM-B model to investigate the barriers and enablers that influence safety reporting behaviour among track workers within the GB rail industry. Using a qualitative design, semi-structured interviews and focus groups were conducted with sixty track workers and seven safety managers to explore experiences and perceptions of reporting practices. Findings revealed fragmented and complex reporting systems that require significant knowledge and experience to navigate, inconsistent expectations, and negative influences of fear of repercussions as key barriers to effective reporting. Additional themes included the importance of feedback, trust, and recognition, alongside limited training and target-driven reporting. |
Beyond user-centred design. Crowdsourcing with Serious Games for Design.
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Author Edward Oates |
| Abstract Designers rely on direct access to ‘users’ (those who will use the product) to assist in their design process. User-centred design strongly emphasises the full involvement of users in the design process; but what happens when they aren’t available? This study investigates the extent to which Serious Games may offer an asynchronous remote alternative to ‘face-to-face’ design processes through Crowdsourcing. A design process completes with summative usability testing of the product. Again, a lack of access to users is a serious limitation and one that may be ameliorated by remote unmoderated usability testing. The extent to which Serious Games may be the vehicle for remote usability testing is also explored in this research. Results from the Crowdsourcing activity show, from contributed design ideas, that a Serious Game may provide a credible tool for Crowdsourced Design. Remote unmoderated testing has known limitations and the use of Serious Games provides some mitigation, with careful implementation being required. This is a mid-study report on UK Ministry of Defence sponsored research under the Royal Navy ‘DARE Innovation’ initiative. |
Allocation of Function: Yes, no, maybe?
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Author Adrian Wheatley, George Charalambous |
| Abstract This paper summarises the work undertaken to produce an Allocation of Function method in support of a number of client projects in the nuclear sector. This led to the development of an interactive Excel based tool to support the client in Allocation of Function decision making. |
Human-robot interaction: Assessing the ergonomics of tool handover
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Author George V. Papadopoulos & Michail Maniadakis |
| Abstract This work focuses on human-robot collaboration for assembly tasks, examining the position of robot-to-human handover of objects. A simulation environment is implemented to ergonomically evaluate the expected posture of the human arm in hypothetical delivery positions in the 3D space. |
Benefits of Using Visual Engineering to Support Human Factors Assessments
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Author Laura Poad, Samantha Hilton, Ben Gafner |
| Abstract This case study presents how modern Visual Engineering (VE) tools, such as Virtual Reality (VR), digital human modelling and interactive simulation, have been used to support traditional Human Factors (HF) assessments within the Nuclear Decommissioning Industry. The case study demonstrates a real-world example of how Visual Engineering tools have been integrated into existing HF processes and aims to provide practical, evidence-based insights and transferable lessons to HF practitioners interested how Visual Engineering technologies can benefit HF practice. |
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. |
Automation and Cyber Security Risks on the Railways – the Human Factors implications
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Author Eylem Thron & Shamal Faily |
| Abstract Automation improves rail passenger experience but may reduce cyber resilience because it fails to adequately account for human factors. Preliminary results from a study on signallers and automation confirms this, but judicious use of modelling tools may ensure design for automation considers this. |
Beyond SHELL: Integrating Self-Consciousness into Human Factors Systems (The SSHELL Framework)
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Author Astha Gill |
| Abstract The classical SHELL model has served as a foundational tool in Human Factors analysis, structuring the interactions among software, hardware, environment, and liveware. However, in modern high-stake systems, many performance variations arise from intrapersonal dynamics that the traditional model does not capture. This paper introduces The SSHELL Framework, a theoretical evolution that embeds Self-consciousness (S) as a core regulatory dimension within Human Factors systems. By addressing the role of internal self-regulation- awareness, emotional control, and reflective judgement- SSHELL redefines how human reliability and safety are understood. The framework bridges cognitive psychology, neuroscience, and ergonomics to propose a more conscious systems approach. Its relevance spans Aviation, Healthcare, and Defence, and points to future adaptability in Education as Human Factors principles extend into emerging domains. SSHELL thereby offers a conceptual bridge between human awareness and system resilience. |
Understanding work-as-planned and work-as-done in biomedical laboratories
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Author Viji Vijayan |
| Abstract An important concept in Safety II is distinction between Work-as-Imagined (WAI) and Work-as-Done (WAD). As in all industries, there are gaps between WAI and WAD in the biomedical laboratories, these concepts are poorly studied and understood. This study interviewed 15 biomedical lab workers to understand the gaps between WAI and WAD and how they were addressed. |
Critical Assessment of the usability of a New Modular Ward
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Author Jonathan M McCloud & Lauren Morgan |
| Abstract An acute District General Trust commissioned a new modular building to house a surgical ward. The process of commissioning and design of the building was in accordance with standard trust practice and established building regulations for hospital buildings. The purpose of this project was to assess the ward layout in terms of safety and efficiency and offer mitigations for any problems found. Observation of the ward layout demonstrated significant problems with sight lines in to bays, layout and design of toileting facilities, and layout and positioning of key ward areas including kitchen facilities, office space, drug and fluids stores, and nursing stations. To further examine the ward layout, Hierarchical Task Analysis and link analysis were performed to review two tasks: one an emergency task (treatment of a deteriorating patient) and a routine common task (serving meals). We also considered the Systems Engineering Initiative in Patient Safety (SEIPS) framework to ensure that our analysis was as thorough as possible. This work demonstrated significant problems with the ward layout, in terms of sight lines, workspace, communication, and contributed to significant extra time doing both emergency and routine duties. This led to a series of recommendations to mitigate on the ward, as well as a recommendation that appropriate staff involvement is included at appropriate times in planning future new build and refurbishment projects. |
Day in the Life Of: Applying the Process to the Nuclear Industry
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Author Lisa Kelly, Rachel Selfe & Suzy Sharpe |
| Abstract Day In The Life Of (DITLO) methodologies have been utilised in the rail industry to elicit user experiences and drive a greater shared understanding of how systems or designs will operate in a variety of scenarios. This paper describes the application of this approach to the nuclear industry, in order to improve the integration of design, engineering and safety disciplines, and to achieve a holistic understanding of the user’s environment to enhance operability and human performance. |
Using digital games to boost HF learning
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Author Johnny Mitchell & Lorraine Braben |
| Abstract This paper describes how an online game (‘Control Panel’) was used as part of Human Factors (HF) training to effectively introduce key concepts and engage participants. The game process will be explained and the results compared with available research. Finally, there will be some reflections from a practitioner on the impact the game has made in delivering HF training events. |
Applying barrier analysis to overspeed events in rail operations
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Author Nora Balfe, Ken Byrne & Ron McLeod |
| Abstract Irish Rail has applied the Bowtie Analysis method and followed the CIEHF White Paper guidance on Barrier Management to analyse the risk from overspeed events on the national rail network. The analysis was performed in the early days of the COVID19 restrictions, requiring a virtual approach to the analysis, rather than the normal face-to-face workshop format. This paper briefly describes the process followed and the results obtained, focusing on the learnings and potential improvements to the process, rather than the technical details of the analysis. These include: at what point in the bowtie development process to include frontline expertise; prioritising threats and consequences identified so that most effort can be focussed on the most important controls; the complexity of degradation factors relating to human performance; and ensuring presentation of the results matches the expectations of the stakeholder community. |
The Human Component of Safety in Defence
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Author Katie Parnell, Georgina Mason, Oliver Malpass, Isabel Holtby, Nicola Turner, Andrew Leggatt |
| Abstract Autonomous and Artificial Intelligence (AI) systems are being integrated into Defence at speed, with likely significant safety implications to the human component. This paper provides an overview of the human component of safety with respect to current Defence guidance and policy. Key areas of current UK Ministry of Defence (MOD) Human Factors (HF) guidance have been identified that need to keep pace with the rapid developments in Autonomous and AI systems. These areas will need to be addressed to tackle future safety challenges that impact human performance within safety critical systems. The practical implications for safety critical areas and ways to mitigate them through updates to government-based guidance will be presented. In addition, an exciting, novel and innovative Defence specific Human Reliability Assessment (HRA) tool is under development to capture and assess human performance in the context of risk in current Defence systems, to support the assessment of a broad range of military equipment and tasks. |
Information Chunk Similarity in Nuclear Power Monitoring: A Cognitive Bias Effect Paradigm
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Author Xiaoli Wu, Yiqun Li, Yuqi He, Zexi Fang |
| Abstract This study tackles the cognitive bias caused by high similarity among information chunks in nuclear power monitoring systems. A cognitive model was constructed to identify perceptual similarity as the key factor affecting operator cognition. Behavioral experiments using visual search and situational tasks were conducted to quantify chunk similarity and determine the optimal similarity range. Results show that perceptual similarity has a significantly greater impact than semantic similarity. An equation for calculating overall perceptual similarity based on color, layout, and complexity was developed. The optimal similarity value range (T0'' ∈ [4.624, 5.538]) was identified, enhancing interface recognizability and cognitive performance. This study proposes a similarity bias effect paradigm for visual tasks, providing a theoretical basis and empirical support for improving nuclear power monitoring interface design. |
Water Quality Investigations and Root Cause Analysis: A Human Factors approach
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Author Tracey Milne & Jodie Dix |
| Abstract This project aimed to integrate Human Factors (HF) into water quality investigations to enhance understanding of human behaviour in incidents, improve coordination, and ensure better system management. By developing an HF Root Cause Analysis tool, the client identified gaps in their investigation process, leading to a revised approach that fosters a learning-driven, human-focused culture for water quality events. |
Novel mental workload scale application using fuzzy sets theory
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Author Hanna J. Neroj & Jim Nixon |
| Abstract A new scale measuring pilot subjective mental workload was developed as part of the Horizon 2020, Future Sky Safety Project: The validity of new measures needs to be established for effective and reliable implementation. This article investigates the validity of this new scale through assessment of psychological distances between linguistic variables on the scale and subsequent transformation from discrete to continuous scale using fuzzy sets theory. Although the new scale has claimed ordinal properties for the items, no evidence exists to support the interval properties of the scale and any subsequent analysis using statistical methods. The results in this article show linear progression of the items on the scale, supporting the order of the items. To establish the interval properties of the scale, the distances between the ordered items were evaluated using fuzzy sets theory using the Fuzzy Logic Designer in MATLAB. Transformation to continuous scale using fuzzy sets may allow the capture of the dispersion of the data around specific points, showing the degree to which each score belongs to different linguistic category of mental workload. Finally, a proposal for incorporating the validated performance measure was presented. |
Evaluating Hazard Awareness in Virtual Reality Collaborative Robotics Using Eye Tracking
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Author Joshua Odeniran, Yee Goh |
| Abstract This study evaluates the use of VR as an effective training method of assessing operators’ hazard awareness when working with robots in collaborative tasks. The VR environment used in testing uses the UR_16e robot with three levels where a specific robot variable changes with the aim for the operators to notice. Findings indicate that participants recognised two of the hazards (force and speed changes) and were able to explain the adverse effects. Although directional changes were less frequently identified, this study contributed to their understanding of robotic behaviour. |
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. |
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. |
FRAM: A boundary object to understand management of paediatric leukaemia patients
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Author Nicholas Seaton, Julie Crawford, John Moppett, Laura Pickup |
| Abstract This paper describes the use of the Functional Resonance Analysis Method (FRAM) to understand the potential for variability in the delivery of chemotherapy across distributed care providers. The complexity of the system is considered and how the use of a FRAM model enabled cross disciplinary collaboration. This enabled consideration to common scenarios and incidents, where variability in the delivery of care is critical to adapt to a patient’s condition. The use of scenarios and incident-based analysis revealed how core functions within the system influenced the ability of teams and families to effectively monitor and communicate treatment regimes. In using the FRAM model to facilitate discussions, the team were able to challenge their beliefs on how knowledge of treatment regimens and a shared understanding across geographically distributed sites was achieved. This created new and shared knowledge on the potential variability in communication and transfer of information, essential to the reliability of the delivery of chemotherapy as intended. The paper considers the value and role of the FRAM model as a boundary object, an artefact that can support staff with different roles within the team to engage equally to solve a problem or safety concern. |
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. |
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. |
Healthcare Investigation Fatigue Trigger Tool
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Author Laura Pickup, Saskia Fursland, Mairi Alexander, Suzy Broadbent, Paul Davis, Kathryn Whitehill & Sian Blanchard |
| Abstract Fatigue and the implications on human performance are well recognised in the literature and many safety critical industries. This is not currently the case in healthcare, where there are no formal approaches to monitor or investigate the impact of fatigue on clinical performance and patient safety. The Healthcare Safety Investigation Branch (HSIB) was set up in 2017 and its core function is to provide independent investigations of healthcare incidents. HSIB adopts a systems approach to investigations and this paper will describe the work in progress to develop a standardised approach to consider fatigue. |
Exploring the Critical Decision Method for Usability Evaluation
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Author Yiyao Li, Derin Borklu, Mojisolaoluwa Idowu, Setia Hermawati |
| Abstract Usability is central in the design and evaluation of interactive systems. There are different methods of usability studies, each offering some various advantages and challenges. The Critical Decision Method (CDM), widely used in cognitive task analysis, remains underexplored in usability contexts. This paper presents two empirical studies investigating CDM’s applicability. Study 1 (n=16) examined the use of recall aids (screen recordings) with an entertainment recommender system. Results showed that recall aids only significantly enhanced recall accuracy in one out of two tasks but there was no statistically significant difference in usability insights, indicating that CDM can mostly be effectively implemented without additional memory support tools. Study 2 (n=16) compared CDM and Think Aloud (TA) in evaluating search interfaces. Findings revealed that CDM and TA are similar in their effectiveness in identifying usability problem topics; however, CDM provides more comprehensive cognitive insights. Two studies suggest that CDM has the potential to be a complementary or alternative method in usability evaluation. |
Effects of safety gloves used by gardeners on perceived discomfort and performance
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Author Payam Khanlari, Fakhradin Ghasemi, Rashid HeidariMoghadam |
| Abstract A shovel is a common tool in agricultural activities. It is very popular among Iranian gardeners and they used it for a variety of purposes. To avoid such damages, some gardeners wear safety gloves. Some other gardeners do not use safety gloves because they maintain that the gloves negatively affect their performance. Accordingly, the aim of the present study was to investigate and compare several safety gloves used by gardeners in terms of comfort and performance. Ten gardeners with at least two years of experience were invited to participate in this study. The participants were asked to plow the ground with two commonly-used gloves and also bare hands for 30 minutes. After completing the task, they were given a hand and fingers map to express their discomfort level in each region. The performance of the participants was determined by measuring the surface area plowed by them. Area P was the one with the highest level of perceived discomfort, followed by TP, MM, and IM. In all areas, the lowest level of discomfort was perceived when the participants used the cotton glove. The average area plowed by participants with bare hands, cotton gloves, and Latex gloves were 1266cm2 (±112.7), 1230cm2 (±80.4), and 1186cm2 (±138.6), respectively. Therefore, wearing any type of safety gloves can negatively affect the performance of gardeners. Safety gloves used by gardeners were different in terms of the perceived discomfort and performance. |
Two Case Studies Demonstrating the ‘Psychological Imperative’ for Safety Critical Task Analysis
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Author Nick Taylor |
| Abstract Safety Critical Task Analysis (SCTA) is a structured activity, used to identify and mitigate risks associated with human actions / inactions for critical tasks on Major Accident Hazards (MAH). SCTA is widely accepted as part of a project in high-hazard industries (e.g. chemical processing and oil & gas) and is most often allocated to the Human Factors Engineering (HFE) scope of work. The common methods, now widely accepted (thanks to efforts from a generation of HFE evangelists) include references to human error / failures, Performance Influencing Factors (PIFs) and a range of psychological and socio-technical influences / drivers / responses. As HFE professionals we must very strongly focus and develop these human-centred areas of risk management because the designers, technicians and engineering disciplines involved in the assessments do not have the training, skills or focus to do so. The outcome of either sidelining or promoting solutions requiring psychological consideration, is compared in 2 case studies. |
Human factors: emergency department suspected heart attack process
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Author Frances Ives & Deborah Jackson |
| Abstract Early recognition of a heart attack is essential as delayed treatment can result in death. A Human Factors (HF) review of the process for treating suspected heart attack patients in a busy inner-city Emergency Department (ED) was completed to help decrease risk, improve patient safety, care and patient and staff experience. To provide timely treatment for a heart attack, a diagnostic electrocardiogram (ECG) must be performed within 15 minutes of arrival at ED. However, concerns had been raised by staff relating to patient experience and delayed ECG, due to the number of process steps the patient had to complete from arrival at ED reception to the ECG being taken. Observations of the process were carried out along with multidisciplinary staff focus groups to understand the patient journey. A Hierarchical Task Analysis (HTA) and Failure Modes Effects Analysis (FMEA) were also completed to identify process failures and impact. The FMEA and observations identified that the patient journey was complex due to: the distance they were required to walk; having to enter the department through the ambulance entrance; and the requirement to speak to a specific member of staff in the department to obtain further directions. The process was changed to: reduce the distance the patient had to walk; decrease the likelihood for them to get lost; improve patient visibility for staff; and to facilitate more timely ECGs. As result of the Human Factors review, ED staff felt empowered to make immediate, no-cost and sustainable improvements. |
Cognitive Work Analysis and Allocation of Responsibility in AI systems
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Author Chris Baber, Patrick Waterson, Paul Salmon |
| Abstract Often ‘responsible AI’ focuses attention on the design of AI systems. We propose that a more pressing need arises when such systems are deployed. There is a need to predict where to place responsibility for outcomes arising from the activity of AI systems. Responsibility cannot be given to the AI system, human oversight must be designed into the broader sociotechnical system in which the AI is deployed, and human oversight must be considered in terms of meaningful control of the AI system. We demonstrate how methods from the Cognitive Work Analysis (CWA) framework allow exploration of allocation of responsibility, AoR, in AI systems. Using a case study of a human-agent team, we show that the AI system does not operate at the level of physical form, i.e., it is not a tool that supports human activity, but operates at higher levels (e.g., physical and generalized functions) in ways that influence abstract functions (i.e., system values). Introducing AI involves redesign of the system to reflect the need for human oversight. As a result, we need to define new tasks for humans in this system and these could involve either changes to existing roles (e.g., the road traffic management role might extend to cover maintenance scheduling) or the introduction of additional roles (e.g., the highway engineers might need a role to work with the AI system and confirm its schedule), and the new roles could have additional requirements for coordination across the other roles in the system. |
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. |
Can thinking with personas improve policy discussions?
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Author Phuong Anh Nguyen, Robert Houghton, Sarah Sharples, Amanda Crompton |
| Abstract This research addresses the limited empirical evidence about the efficacy of using personas in public sector decision-making. Despite the increasing interest in using personas in policymaking, policymakers frequently express scepticism over the application of this relatively novel tool for complex social challenges. To fill this gap, the study employs a qualitative, scenario-based experiment in the context of transport disruption. The research findings indicate that personas enhance human-centred system thinking and encourage decision-makers to adopt a more inclusive context-sensitive approach. |
Social network analysis in submarine command and control
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Author Neville A. Stanton and Aaron P. J. Roberts |
| Abstract This is a world’s first-of-a-kind study that compares three operational scenarios in a simulated submarine control room: Returning to Periscope Depth (RTPD), Inshore Operations (INSO) and Dived Tracking of Contact (DT). The Event Analysis of Systematic Teamwork (EAST) method was used to model the social networks. 10 teams were recruited for the study. Results indicate that, across all scenarios, the Operations Officer (OPSO) and Sonar Controller (SOC) are particularly loaded, with communication between these operators being revealed as a potential bottleneck. The type of operation being performed affected the type of information used significantly, with a higher reliance on sonar information (and the sonar operators) during a RTPD and a higher reliance on visual information (and the periscope operator) during INSO. Implications are discussed alongside suggestions for future work. |
DOSE (Database of Occupation-Specific Exposures): Development and Case Example
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Author Marcus Yung, Amin Yazdani |
| Abstract Ergonomic, physical, psychosocial, and environmental conditions interact, and play a role in the risk of workplace injuries, including musculoskeletal disorders (MSD). There is a need for accurate and ecologically valid assessments of job exposures and demands to more effectively prevent MSD. This presentation describes the development of the multi-dimensional Database of Occupation-Specific Exposures (DOSE), a new initiative based on direct field measurement, that will support effective MSD prevention and open avenues of research in studying exposure-disease associations. |
