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On August 20, 1969, two Penn Central commuter trains collided head-on near Darien, Connecticut, killing four and injuring 43. That tragedy 45 years ago began the NTSB's call for development and implementation of Positive Train Control (PTC) systems. Since then, the NTSB has issued almost 50 PTC-related safety recommendations and has included PTC on its Most Wanted List every year from its inception in 1990 until enactment of the RSIA. Unfortunately, despite some progress in the four decades since that original recommendation, PTC preventable train collisions still occur. In this paper, we identify human and organizational factors that affect a successful PTC implementation and evaluate the application of High Reliability Organizing (HRO) characteristics in the implementation of this safety system.

March 5, 2020Disclaimer: Editor's note: This article was originally published in the National Academy of Medicine Perspectives on March 5, 2020. It was is the 5th most read NAM Perspective pape...

The National Research Council’s Healthcare Comes Home Report encourages system engineering involvement in homecare research and development to provide medical device designers information on demands associated with homecare and the capabilities needed for non-clinical caregivers to perform successfully The objective of this study was to develop invasive therapy evaluation techniques with human factors considerations for pediatric medical devices, specifically home parenteral nutrition and home mechanical ventilation, to minimize undesirable outcomes in non-clinical settings. The method used was the case study approach to qualitative research through expert interviews, environmental observations and document review data collection methods as well as cross-case themes analysis. This discussion reviews the rated impact of human factors consideration on the safety and effectiveness outcomes of invasive therapy devices use on pediatric patients in non-clinical environment.

High-risk organizations are inherently complex and depend on the latest technologies to survive and function properly. Therefore, introducing new technology to such an organization is inevitable. Studies show that the installation of new technology always involves some changes to the organization and its members. The railroad industry, as an example of a high-risk and safety-critical organization, strives to avoid catastrophic events, while performing dynamic tasks under strict time constraints, operating technology posing large-scale physical hazards. High Reliability Organizations (HROs) are a subset of high-risk organizations designed and managed to avoid such accidents. This paper discusses the adaptation of HRO principals as part of the implementation process for the Positive Train Control (PTC) technology in a safety-sensitive railroad organization.

This study applies the AcciMap methodology, which was originally proposed by Professor Jens Rasmussen (1997), to the analysis of the tragic Sewol Ferry accident in South Korea on April 16, 2014, which killed 304 mostly young people and is considered as a national disaster in that country. This graphical representation, by incorporating associated socio-technical factors into an integrated framework, provides a big-picture to illustrate the context in which an accident occurred as well as the interactions between different levels of the studied system that resulted in that event. In general, analysis of past accidents within the stated framework can define the patterns of hazards within an industrial sector. Such analysis can lead to the definition of preconditions for safe operations, which is a main focus of proactive risk management systems. In the case of the Sewol Ferry accident, a lot of the blame has been placed on the Sewol's captain and its crewmembers. However, according to this study, which relied on analyzing all available sources published in English and Korean, the disaster is the result of a series of lapses and disregards for safety across different levels of government and regulatory bodies, Chonghaejin Company, and the Sewol's crewmembers. The primary layers of the AcciMap framework, which include the political environment and non-proactive governmental body; inadequate regulations and their lax oversight and enforcement; poor safety culture; inconsideration of human factors issues; and lack of and/or outdated standard operating and emergency procedures were not only limited to the maritime industry in South Korea, and the Sewol Ferry accident, but they could also subject any safety-sensitive industry anywhere in the world.

The Persian/Arabian Gulf plays a critical role in the sustenance of its surrounding countries, home to over two-thirds of the world’s proven oil reserves. With minimal rainfall and natural water sources, these countries rely heavily on desalination of the Gulf for potable water. A new industry is now emerging in the region: nuclear power. This adds another layer of complexity to the preservation of the already stressed Gulf water.

Failures in complex technological systems could have multiple dire aftermaths, including many deaths and injuries. These events, such as nuclear accidents, pose serious threats and long-lasting health and environmental consequences to workers, the local public, and possibly the whole country and neighboring regions. Such failures, given interconnectivities and interdependencies, could also have spillover effects and threaten the integrity of other systems operating in the same area. There is an essential need for effective integration and interoperability among multiple emergency response agencies, possibly from different countries, in the case of an accident in a safety-sensitive industry that causes the release of hazardous materials or contaminants. This article proposes a generic integrated system-oriented model to address this urgent need. It has been applied to the Persian Gulf area and its waters as a case study because of the existence of multiple co-located, safety-sensitive industries such as nuclear power generation, offshore oil and gas drilling, seawater desalination, and seafood harvesting. The Persian Gulf region and its ecosystems are highly vulnerable, and the countries around the Gulf are tightly interdependent, with an urgent need for cooperative emergency response planning. The Black Sea and other semiclosed, water-based ecosystems can also benefit from this model.

Objective: The aim of this study is to identify the interdependencies of human and organizational subsystems of multiple complex, safety-sensitive technological systems and their interoperability in the context of sustainability and resilience of an ecosystem. Background: Recent technological disasters with severe environmental impact are attributed to human factors and safety culture causes. One of the most populous and environmentally sensitive regions in the world, the (Persian) Gulf, is on the confluence of an exponentially growing number of two industries—nuclear power and seawater desalination plants—that is changing its land- and seascape. Method: Building upon Rasmussen’s model, a macrosystem integrative framework, based on the broader context of human factors, is developed, which can be considered in this context as a “meta-ergonomics” paradigm, for the analysis of interactions, design of interoperability, and integration of decisions of major actors whose actions can affect safety and sustainability of the focused industries during routine and nonroutine (emergency) operations. Conclusion: Based on the emerging realities in the Gulf region, it is concluded that without such systematic approach toward addressing the interdependencies of water and energy sources, sustainability will be only a short-lived dream and prosperity will be a disappearing mirage for millions of people in the region. Application: This multilayered framework for the integration of people, technology, and ecosystem—which has been applied to the (Persian) Gulf—offers a viable and vital approach to the design and operation of large-scale complex systems wherever the nexus of water, energy, and food sources are concerned, such as the Black Sea.

In 2010 ~12 million Americans received home health care or care in a non-clinical environment due to the growing cost and capacity constraints of hospital health care. The purpose of this research study is to initiate an effort to understand the socio-technological risk factors associated with invasive medical therapies in non-clinical environments and develop mitigation strategies for non-clinical caregivers. Participatory Ergonomics is utilized to facilitate the discovery of cognitive, physical and macro-ergonomic risk factors associated with invasive medical technology in non-clinical environments to address the socio- psychological, technological and organizational perspectives of this study. This research study will result in a patient safely template and quality of care model for health systems engineering that involves invasive medical technologies in non-clinical environments, which can be applied to pediatric and adult populations globally.

Healthcare services provided in U.S. is offered through a fragmented system that in majority of cases cannot provide patient population with access to care, high quality of care, or coordinated care, and cannot guarantee the safety of patients. To overcome these shortcomings there is a need to create a new model of care. This study suggests a systematic approach to implement an innovative package of system elements including patient safety interventions, high reliability principles, and care coordination which illustrates the role of human factors in improving health outcomes of our population, enhance their health status, and enrich their overall well-being. Human health in full spectrum is a balance between medical, oral, physical, and mental/behavioral health. In this study all four elements of health services are provided to patients and their health outcomes have been studied in conjunction with the health status of their family members. This research aims to assess and analyze the impact of the addition of the aforementioned system elements in relation with human factors on population's overall health status.

Complex safety-critical technological systems breakdowns, which are often characterized as ‘low probability, high consequence’, could pose serious threats for workers, the local public, and possibly neighboring regions and the whole country. System designers can neither anticipate all possible scenarios nor foresee all aspects of unfolding emergency. Front-line operators’ improvisation via dynamic problem solving and reconfiguration of available recourses provide the last resort for preventing a total system failure. Despite advances in automation, operators should remain in charge of controlling and monitoring of safety-critical systems. Furthermore, at the time of a major emergency, operators will always constitute the society's both the first and last layer of defense; and it is eventually their improvisation and ingenuity that could save the day.

According to the US Energy Information Administration [1], the natural gas industry supports 33% of electricity generation in the US. Despite this critical role, the importance of safety and safety culture in the natural gas industry has not been adequately highlighted. The absence of strict regulations and lack of attention towards precautionary measures have allowed the industry to persevere with insufficient urgency for implementing innovative technologies and safety-first protocols. On October 23, 2015, the Aliso Canyon natural gas accident highlighted how the lack of regulatory oversight in a low probability, high consequence industry could have such impactful and unpredictable repercussions. This paper analyzes the concatenation of events that led to the Aliso Canyon gas leak. It adopts the AcciMap methodology, which was originally introduced by Rasmussen in 1997 as an accident investigation framework, to conduct a systematic root-cause analysis and capture different involved socio-technical factors that contributed to the leak.

This article focuses on a major human factors–related issue that includes the undeniable role of cultural factors and cockpit automation and their serious impact on flight crew performance, communication, and aviation safety. The report concentrates on the flight crew performance of the Boeing 777–Asiana Airlines Flight 214 accident, by exploring issues concerning mode confusion and autothrottle systems. It also further reviews the vital role of cultural factors in aviation safety and provides a brief overview of past, related accidents. Automation progressions have been created in an attempt to design an error-free flight deck. However, to do that, the pilot must still thoroughly understand every component of the flight deck – most importantly, the automation. Otherwise, if pilots are not completely competent in terms of their automation, the slightest errors can lead to fatal accidents. As seen in the case of Asiana Flight 214, even though engineering designs and pilot training have greatly evolved over the years, there are many cultural, design, and communication factors that affect pilot performance. It is concluded that aviation systems designers, in cooperation with pilots and regulatory bodies, should lead the strategic effort of systematically addressing the serious issues of cockpit automation, human factors, and cultural issues, including their interactions, which will certainly lead to better solutions for safer flights.

The removal efficiency of heavy metals from offshore muds is enhanced in the presence of generated chlorine gas (Cl2). The tests showed a high removal efficiency of heavy metals at the anode end of cores after 24 hours of EK application. In the initial tests, high electrokinetic flow potential was achieved; however, high levels of chlorine gas were produced in the high-salinity environments. The process was improved by controlling and maintaining a certain fraction of the chlorine gas (Cl2) in place. The pH was controlled by the chlorine gas maintained in-situ and transported from the anode to cathode. The transports of four heavy metals were evaluated in this study. The chlorine gas can have two impacts on the transport of metals in the system. One is to oxidize the metal ions to a higher oxidation state and the second is to form chloride complexes, which have higher mobility in the system. Determination of oxidation state and the subsequent metal chloride complex are left for future research.

This panel will discuss what new directions are necessary to maximize the usefulness of HRA techniques across different areas of application. HRA has long been a part of Probabilistic Risk Assessment in the nuclear industry as it offers a superior standard for risk-based decision-making. These techniques are continuing to be adopted by other industries including oil & gas, cybersecurity, nuclear, and aviation. Each participant will present his or her ideas concerning industry needs followed by a discussion about what research is needed and the necessity to achieve cross industry collaboration.

The investigation of accidents in different complex technological and high-risk industries indicates inadequate management systems and more specifically, ineffective communication as a major contributing cause of those accidents. In the specific case of the BP Deepwater Horizon (DWH) blowout, as the 2011 Chief Counsel's Report of the National Commissions noted, “what the investigation makes clear, above all else, is that management failures, not mechanical failings, were the ultimate source of the disaster.” This paper adopts the powerful AcciMap methodology, which was originally proposed by Professor Jens Rasmussen in 1997 and used for the analysis of accidents in industries such as transportation, for the risk management of offshore drilling accidents by incorporating associated socio-technical factors into an integrated framework. This graphical representation provides a big-picture to illustrate the context in which an accident occurred as well as the interactions between different levels of a socio-technical system that resulted in that event. In general, analysis of past accidents within the stated framework can define the patterns of hazards within an industrial sector. Such analysis can lead to definition of preconditions for safe operations, which is a main focus of proactive risk management systems. As a case study in this paper, the AcciMap methodology has been applied to the BP DWH accident in order to analyze the main contributing causes of that major system failure and the interactions of key involved decision-makers and stakeholders, who were involved in that disaster. The analysis of our developed AcciMap framework depicts that aside from influencing external components, organizational factors, among internal elements, were the root contributing causes of the BP DWH blowout. It is noteworthy that investigating previous accidents in oil and gas drilling shows that organizational factors were the root causes of accumulated errors and questionable decisions made by personnel or management. Such statement is generalizable to accidents in the whole oil and gas industry as well as other safety-critical systems such as transportation sector, healthcare industry and nuclear power plants. Our review of the literature indicates that few studies have applied a robust risk management method to the scope of interactions outside the boundary of an organization, with even more limited applications to the oil and gas industry. It is also noteworthy that although the AcciMap framework has been applied to the BP DWH case study, it is a systematic methodology that can be generalized and applied to other major mishaps in the oil and gas industry, both in upstream and downstream.

Increasing number of hydraulic fracturing operations necessitates paying more attention to the safety and environmental considerations of this technology. In-depth understanding of the complex nature and root-causes of incidents related to the hydraulic fracturing operation is a prerequisite for any proactive risk mitigation strategy. Many of the safety and environmental incidents during the development of shale resources are widely regarded by public as results of hydraulic fracturing operation. Differentiation among multiple steps of developing oil and gas resources allows an independent root cause analysis. In this approach incidents that are not directly caused by underground injection of fracturing fluid can be highlighted. These incidents can be treated in the same manner as common incidents in conventional production. In this research the hydraulic fracturing operation is broken down into its components and potential risks are investigated. Also, leading safety and environmental indicators for this industry are defined and case-studies are investigated to find the connections between the incidents and the proposed indicators.

According to a most recent (June 2014) report by the US Chemical Safety Board (CSB) that investigated the BP Deepwater Horizon (DWH) blowout, inadequate management systems and poor safety culture were major underlying causes of that blowout. This analysis has been corroborated by many other seminal reports on the DWH accident. In fact, lack of safety culture has been identified as a common contributing cause of many accidents in the oil and gas industry.In response to the above serious fact, there are strong recommendations that the Bureau of Safety and Environmental Enforcement (BSEE) of the U.S. Department of the Interior, as the responsible regulatory agency for offshore operations in the Outer Continental Shelf, has to promote safety culture. In addition, the BSEE director, in his speech for the fourth anniversary of the DWH accident in April 2014, emphasized the importance of fostering a culture of safety among all involved in offshore operations so that it becomes part of the way business is conducted.Safety culture can be defined through its five primary composing elements/pillars, characteristics or sub-cultures, which include an informed culture, a reporting culture, a learning culture, a just culture, and a flexible culture. Reporting culture, as one of the five pillars of safety culture, creates organizations in which people are prepared to report their errors and near-misses. In this regard, interoperation and interaction of multiple organizations play a critical role.This paper, by focusing on the foregoing reporting pillar, introduces a risk assessment framework to analyze multi-organizational interactions with the focus on ineffective communication. This framework models the interactions of involved organizations and key players in four different layers: the level of meta-system interactions, bi-lateral organizational interactions level, bi-lateral work interactions level, and the level of work site operations interactions.Our extensive literature review indicates that few studies have applied risk analysis to interactions among multiple organizations, with even more limited application to the oil and gas industry, particularly offshore operations. We further show the viability of our framework by using it to develop a risk assessment model based on the investigation of the DWH accident and to analyze the interactions of key players in that case.

All oil and gas pipeline systems are run by human operators (called controllers) who use computer-based workstations in control rooms to "control" pipelines. Several human factor elements could contribute to the lack of controller success in preventing or mitigating pipeline accidents/incidents. These elements exist in both the work environment and also in the computer system design/operation (such as data presentation and alarm configuration). Some work environment examples include shift hours, shift length, circadian rhythms, shift change-over processes, fatigue countermeasures, ergonomics factors, workplace distractions, and physical interaction with control system computers. The major objective of this paper is to demonstrate the critical effects of human and organizational factors and also to highlight the role of their interactions with automation (and automated devices) in the safe operation of complex, large-scale pipeline systems. A case study to demonstrate the critical role of human organizational factors in the control room of an oil and gas pipeline system is also presented.

To investigate NASA's process for culture change, we conducted research and analysis of the data in the NASA Lessons Learned Information System (LLIS) from a cultural perspective, and conducted extensive collaborative discussions with NASA personnel and a Technical Advisory Board (TAB) convened for this project. The results of this study indicate that culture change in order to implement lessons learned processes and achieve their benefits has been evolutionary and variable across NASA centers. Our interactions with and analysis of the JPL Lessons Learned Committee indicate that JPL has successfully implemented a comprehensive lessons learned process addressing technical and cultural change challenges. The process should be of interest to the project management community at large. Based on the results of this effort, we conclude that lessons-learned culture change is possible and underway at NASA. Executive-level, systems-based lessons learned guidance and support is critical for NASA-wide implem...

A novel technology (electrokinetics) is proposed to improve acidizing operations, i.e., increase the penetration distance. The acid dissolves the carbonates (limestones/dolomites), enlarging the pores and increasing the width of pre-existing fractures. This gives rise to an increase in permeability. The principal acid commonly used is hydrochloric (HCl), which is pumped through tubing. Aqueous solutions of hydrochloric acid (usually 15%) are pumped into the carbonate formations to enlarge the pores and pre-existing fractures. Without application of D.C. current, the penetration distance is usually very short, especially in tight rocks. However, the penetration distance of acid is very short. By applying D.C. current, one can drive the acid for long distances into the formation being acidized.

A technological system's overall performance, which is an aggregate of its safety, reliability, and efficiency indicators, is a function of its control room operators' performance. Operators' performance is also strongly determined and moderated by the design of the control room. Moreover, today's complex industrial facilities require operators to continually adapt to new and unforeseen changes in technological system and environmental demands. There is no clear-cut distinction between system design and operation since the operator will have to match system properties to changing demands and operating conditions. Thus, this continuous process needs a cohesive and integrated framework for information gathering from the interfaces, analysis according to operators' task demand, and decision making within the organizational and regulatory contexts of the technological system. Therefore, there is a need to approach human factors in a more global and systematic manner, which includes integration of display systems design, task demands, and with operators' information processing behavior. © 2003 Wiley Periodicals, Inc. Hum Factors Man 13: 269–277, 2003.

According to the Presidential National Commission report on the BP Deepwater Horizon (DWH) blowout, there is need to "integrate more sophisticated risk assessment and risk management practices" in the oil industry. Reviewing the literature of the offshore drilling industry indicates that most of the developed risk analysis methodologies do not fully and more importantly systematically address contribution of Human and Organizational Factors (HOFs) in accident causation. This is while results of a comprehensive study from 1988 to 2005, of more than 600 well-documented major failures in offshore structures show that approximately 80% of those failures are due to HOFs. This paper introduces a conceptual risk analysis framework to address the critical role of human and organizational factors in conducting and interpreting Negative Pressure Test (NPT), which according to many experts, is a critical step in ascertaining well integrity and quality of cementing during offshore drilling. The introduced framework in this study has been developed based on the analyses and lessons learned from the BP Deepwater Horizon accident and the conducted NPT by the DWH crew. However, the application of this framework is neither limited to the NPT nor to the DWH case. In fact, it can be generalized and be potentially useful for risk analysis of future oil and gas drillings as well. Along with a series of previous studies, analysis of the developed framework in this paper indicates that organizational factors are root causes of accumulated errors and questionable decisions made by personnel or management. Further analysis of this framework identifies personnel management, communication and processing uncertainties, and economic pressure as the most influencing organizational factors, which resulted in the misinterpretation of the negative pressure test. Investigative studies confirm that organizational factors such as personnel management and economic pressure are common contributing causes of other offshore drilling accidents as well. In summary, significance and contribution of this paper is based on three main factors: introducing a substantial risk assessment framework, analyzing HOFs as a main contributing cause of offshore drilling accidents, and concentrating on the NPT misinterpretation as a primary factor that affected the loss of well control and the subsequent blowout on the DWH.

Global security and sustainability are hostages to nuclear safety. Without nuclear safety, in this era of proliferating nuclear weapons, global security will be a dream; and in a world with 58 still operating Soviet-designed nuclear power reactors, sustainability will only be a mirage. According a Russian official, all the commercial nuclear reactors operating on Russian territory are nothing better than “bombs temporarily generating electricity.” The share of energy generation of these reactors in their respective countries is rather significant; and in the short run, their closure and replacement are neither realistic nor economically feasible. Human and organizational factors play a vital role in the safety of complex, large-scale technological systems. Fortunately, these days, this fact has been almost universally recognized, although not necessarily fully incorporated into the operation, by the nuclear industry around the world. In order to improve the safety problems of nuclear power, we need to improve the safety culture of this industry and proactively address human and organizational-related factors. To keep the nuclear Genie bottled around the world, we need genuine international cooperation and coordination among equipment manufacturers, operating companies, operators' unions, regulatory agencies, international organizations, scientific and research communities, and affected governments

Using the Liberty Mutual Insurance Group Data Base, 13 industrial machine-related accidents reported during 1990 with incurred losses over $200,000 each were analyzed for contributing human factors elements. The results indicate that machine-related high cost accidents in industrial operations have a multitude of human factors-related influences, both on the macro and micro-ergonomic levels.

Many serious large-scale technological systems' accidents, having grave conse quences, such as those of Three Mile Island, Bhopal and Chernobyl, have pri marily been attributed to "operator error." However, further investigation has revealed that a large majority of these incidents are caused by a combination of many factors whose roots can be found in the lack of human factors (micro- and macro-ergonomics) considerations. Relevant human factor considera tions, the causes of human error, and commonalities of human factor problems in major disasters are briefly reviewed. We concluded that system accidents are caused by the way the (system) parts — engineered and human — fit together and interact. Also, on many occasions, the error and the resultant failures are both the attribute and effect of such factors as complicated operational pro cesses, ineffective training, non-responsive managerial systems, non-adaptive organizational designs, haphazard response systems, and sudden environmen tal disturbances, rather than being their cause. Recommendations for preven tion of such accidents are provided.

The common causes of failures of complex technological systems (e.g., nuclear power and chemical processing plants; modern w weapon systems) are analyzed. It is demonstrated that in addition to independent and isolated problems at the individual subsystem levels — workstation (interface), job (task) and team (organizational) structure — there is a serious lack and need for a coherent framework to coordinate these subsystems' formation, as well as their integration, in the context of the total system design. It is proposed and demonstrated that the skill, rule, and knowledge (SRK) model, developed by Rasmussen (1983), is a high-potential and powerful conceptual framework that could be utilized for the integration of workstation, job, and team (organizational) design in the complex human-machine systems.

Human and organizational factors affecting safety and accident potential of large-scale technological systems (e.g., chemical processing or nuclear power plants) in the contexts of both developed and developing countries are investigated. It is concluded that the critical areas in need of serious attention (and further research) should include: Considering local user population's attributes, considering physical environmental conditions affecting operators' safety and performance, considering the effects of cultural and religious variables, employing more adaptive managerial and organizational systems, and determining the appropriated level of needed requisite variety and other organizational control mechanism. The yields and potential applications of this type of research are enumerated.

Whenever you fly an aircraft, either sitting in the cockpit or back in the passenger cabin, land at a “foreign” airport and your flight safety is likely to be at the mercy of macroergonomic considerations. These considerations include systematic incorporation of cultural factors in work system design and operation. The above succinct epigraph, which provides the first compelling reason, is also a testament to this contention. It may be anathema to many scholars and practitioners of “hard” sciences and other engineering-dominated fields, but recent rigorous research has proven that even scientific theories, facts, andpractices-that determine and govern aviation systems’ operations-are strongly culturally based.

Accidents in complex systems seldom arise from a single source, and are most often the result of multiple factors occurring at different levels of the system. Understanding the “systems” aspects of human performance (and performance error) in complex systems is a necessary part of any effort to avoid serious mishaps due to human error. This panel is intended to coincide with the development of a major research effort at the University of Wisconsin to address these issues. The Center for Human Performance in Complex Systems will apply the disciplines of systems engineering and ergonomics design to improve complex systems processes from the perspective of human performance. The purpose of this panel is to foster and demonstrate the Center's interest in bringing together a variety of perspectives and expertise bases to improve the overall quality and breadth of its activities. Each of the participants has a longstanding interest in improving the quality of human performance in complex and critical systems environments. Although they cannot represent the entire spectrum of relevant disciplines and perspectives of ergonomics and systems analysis, they provide a balance of insights, experience, and enthusiasm. This balance is essential to improving our understanding of factors affecting complex socio-technical systems, and implementing strategies to prevent and ameliorate the effects of system degradation and breakdown.

This paper explores the hypothesis that driver decision-making style influences highway-rail crossing accidents. To investigate this, the authors have designed an analysis of variance experiment with three independent variables: "driver decision style," "driver time pressure" and "intersection complexity." To simulate the driving conditions, the authors identified and videotaped a number of dangerous crossings in downtown Los Angeles. The tapes represented different environmental complexities and time pressures a driver experiences while crossing an intersection. The tapes were played back to the subject drivers. The subjects were classified according to their decision styles. Dependent measures were designed based on a driver's decision to cross the intersection. This paper presents the conceptual approach and the experimental design for this research.

Human error has been recognized as the main contributor to the occurrence of incidents in large technological systems such as nuclear power plants. The traditional error prevention approach to human error has proved to be insufficient to solve this dilemma. Recent researches have concluded that human errors are unavoidable side effects of exploration of acceptable performance during adaptation to the unknown changes in the environment. This is particularly important under difficult unexpected situations where the operator’s deteriorated performance may lead to irreversible hazardous processes in the plant. Therefore, it is highly important that the operator’s job, which involves effortful and error-prone activities of solving and decision making at the workstation level, be facilitated by proper interface devices and be supported by the needed organizational structures. The innovative error tolerant approach to human error requires more cognitive-friendly designs for interface systems in the control room of large hazardous technological system.

Abstract Human error plays a significant role in oil and gas pipeline systems' incidents and accidents. According to one study, operator error was the "direct cause" and was responsible for 30.9% of 500 incidents involving pipework failure and subsequent chemical release. The material presented in this paper is based on findings of an investigation of control room operations of a U.S.-based oil and gas pipeline company. Notwithstanding, the utilized framework and its findings could be applied to the control rooms of other pipeline systems. Both the micro- and macro-ergonomic considerations are discussed; suggestions for the reduction of potential for human error through the elimination of human-task and human-machine mismatches are offered. INTRODUCTION TO MICRO- AND MACROERGONOMIC CONSIDERATIONS According to a study of of 500 incidents involving pipework failure and subsequent chemical release (in the U.K., U.S., Netherland and Finland) for the United Kingdom's Health and Safety Executive, "responsible in 30.9% of the incidents, operator error was the largest contributor to pipework failures among know direct causes" (Geyer, Bellamy, Astley, and Hurst, 1990, p. 68). This study has concluded and recommended "human factors reviews of maintenance and operations personnel and functions" (p. 69) as one of the four critical areas where management of oi1, gas and chemical companies should concentrate their efforts. Human factors, also called ergonomics, is a scientific field concerned with improving the productivity, health, safety, and comfort of people, as well as the effective interaction between people, the technology they are using, and the environment in which both must operate. Ergonomics specialists call these collective sets "human-machine-environment systems." Ergonomics at the micro level, microergonomics, is focused on the human-machine system level and is, for example, concerned with the design of individual workstations, work methods, tools, control panels, and displays. Microergonomics includes studies of human body sizes, known as anthropometrics, physical and psychological abilities and limitations, information processing, and human decision-making and error. It is noteworthy that in the context of the control room environment and according to studies of control room design of nuclear power plants: P. 685^

This Symposium describes the current work being performed on the Shelter (Sarcophagus) and a number of Human Factors/Ergonomic activities which should be conducted at the Chernobyl Nuclear Power Plant #4 in the Ukraine. The initial cause of the accident is discussed as well as the necessity of including Ergonomics and a Safety Culture in the process of designing and operating complex technical facilities.

The catastrophic accident at the Union Carbide Corporation's pesticide plant in Bhopal, India (1984) is investigated and its micro- and macroergonomic causes are identified. It is demonstrated that this accident was not prototypical, and there were numerous similarities with respect to the of lack of human factors considerations between the Bhopal plant and other industrial facilities which have had major accidents, including the Three Mile Island nuclear power plant (1979). This analysis can, by extrapolation, be applied as well to many other comparable plants around the world which because of sheer luck and/or coincidence, fortunately, have not had a major accident, yet. It is concluded that only through a proactive, systematic, and integrated micro- and macroergonomically-based policy can one control the safety and ensure the efficiency of the operations of industrial plants and facilities, both in industrialized and developing countries.

Technology transfer, its role in the economic development of developing countries, and factors affecting its success is studied. Numerous studies of appropriate technology indirectly and implicitly indicate that micro- and macroergonomic considerations play instrumental roles in the success of technology transfer projects. Major micro- and macroergonomic considerations of technology transfer are discussed, and it is concluded that only through a proactive and systematic incorporation of these considerations can one ensure the appropriateness, safety, and effective utilization of the transferred technology.

The Law of Requisite Variety states that “the system must possess as much regulatory variety as can be expected from the environment” (Ashby, 1957). This law may have some implications for culture. Specifically, the four cultural dimensions by which national cultures differ (as proposed by Hofstede, 1980a): Power Distance, Uncertainty Avoidance, Individualism-Collectivism, and Masculinity-Femininity influence Requisite Variety depending on the country to which the technology is transferred. Therefore, it is proposed in this study that Requisite Variety can be used as a concept to systematically investigate the influence of culture for technology transfer. This approach constitutes the incorporation of Human Factors considerations in technology transfer, as stated by Meshkati (1986 and 1989b) and Wisner (1985).