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This chapter focuses on one way to try to crack the envisioned world problem, in this case in air traffic control. Through various future incidents that mimicked the rules and roles of the envisioned system as closely as possible, supervisory controllers were able to generate one kind of empirical data about human performance in the future. In air traffic control there is much pressure to automate routine portions of the human task, putting controllers at a larger supervisory distance. This will allow higher system throughput and consequently allow air traffic centres to absorb ever-increasing traffic loads. The basic requirement is to minimise human control involvement in routine events, freeing controllers to concentrate on the key areas where human skills have most to offer: traffic management, system safety assurance, and dealing with the exceptional occurrence”. The idea of management by exception in human-machine systems was born out of the supervisory control paradigm in the mid-1970’s.

The resources for action idea suggests that procedures, although they appear to be constraints that control, direct and restrict actions, are in fact resources that support a wide range of actions. Whereas the notion has gained considerable traction in the academic discourse, few empirical studies investigated how procedures are used as resources or if they are the only resources deployed. This paper applies resources for action approach to describe how a cockpit manages emergencies and other non-normal situations and the role played by the Quick Reference Handbook (QRH). Data was collected through participant observation, interviews, and analysis of technical documents. The results indicate that some situations encountered by pilots are far more complicated than the procedure anticipates. In order to cope with these situations, pilots employed strategies that interleaved a range of resources, often consulting fragments of the QRH checklists rather than following them from start to finish. These findings suggest that emergency checklists should be divided into smaller units that can be followed independently, and that procedures should sometimes provide pilots with choices rather than mandatory instructions. The other resources deployed can also enhance the performance of pilots.

Objectives Checklists are being introduced to enhance patient safety, but the results have been mixed. The goal of this research is to understand why time-outs and checklists are sometimes not effective in preventing surgical adverse events and to identify additional measures needed to reduce these events. Methods A total of 380 consecutive patients underwent complex cardiac surgery over a 24-month period between November 2011 and November 2013 at an academic medical center, out of a total of 529 cardiac cases. Elective isolated aortic valve replacements, mitral valve repairs, and coronary artery bypass graft surgical procedures (N = 149) were excluded. A time-out was conducted in a standard fashion in all patients in accordance with the World Health Organization surgical checklist protocol. Adverse events were classified as anything that resulted in an operative delay, nonavailability of equipment, failure of drug administration, or unexpected adverse clinical outcome. These events and their details were collected every week and analyzed using a systemic causal analysis technique using a technique called CAST (causal analysis based on systems theory). This analytic technique evaluated the sociotechnical system to identify the set of causal factors involved in the adverse events and the causal factors explored to identify reasons. Recommendations were made for the improvement of checklists and the use of system design changes that could prevent such events in the future. Results Thirty events were identified. The causal analysis of these 30 adverse events was carried out and actionable events classified. There were important limitations in the use of standard checklists as a stand-alone patient safety measure in the operating room setting, because of multiple factors. Major categories included miscommunication between staff, medication errors, missing instrumentation, missing implants, and improper handling of equipment or instruments. An average of 3.9 recommendations were generated for each adverse event scenario. Conclusions Time-outs and checklists can prevent some types of adverse events, but they need to be carefully designed. Additional interventions aimed at improving safety controls in the system design are needed to augment the use of checklists. Customization of checklists for specialized surgical procedures may reduce adverse events.

A ‘just culture’ aims to respond to anxiety about blame-free approaches on the one hand, and a concern about people’s willingness to keep reporting safety-related issues on the other. A just culture sets out the conditions that legitimize managerial intervention in the sanction or restoration of individuals in the organization. In this paper we examine the manifestly important moral and safety issues that a just culture needs to consider. These include substantive justice which prescribes how regulations, rules and procedures themselves are fair and legitimate; procedural justice which sets down processes for determining rule-breaches, offers protections for the accused, and governs who should make such determinations; and restorative justice which aims to restore the status of the individual involved and heal relationships and injuries of victims and the wider community in the wake of an ethical breach. Just culture approaches need to provide such foundations for a genuinely just safety culture, to be conducive to reporting, engagement and safety improvement.

Current assessment practice and its models typically aspire to capture the considerable variety of airline pilots' performance across highly specific behavioural markers and highly unspecific categories. Yet research into one of the most advanced assessment models has shown large disagreement among assessors in terms of both their scoring and reasoning. Rather than further attempts to eliminate this variety in assessors' judgments, a deeper understanding is required of the source of disagreement. The aim of this study is to reflect on current assessment practice by considering opposing, yet complementary views of human error and safety. Considerable discrepancy is identified between the underlying assumptions of assessment practice and the precepts of advanced safety research. The shift that has occurred in safety thinking hardly seems to have penetrated assessment practice in aviation. This study challenges current assessment practice and sketches approaches that might be more congruent with insi...

How people are treated following their involvement in a workplace accident can have far reaching implications for both the individual and the organisation. In this paper, we examine the impact the use of retributive justice mechanisms within the accident analysis process have on both the individual and the organisation. We analyse the perceptions of those involved in five accidents where retributive justice mechanisms were used. Our study of these cases shows retributive justice mechanisms used as part of the accident analysis process negatively impacts three key areas; (1) the mental health of the individual; (2) organisational learning and; (3) organisational performance. Our study also illustrates that the language used as part of the accident analysis has a significant impact upon the perception of the process and the willingness to participate.

The present study reports on the transition of a critical incident investigator group within a University Medical Center to a Safety Differently paradigm. The most salient findings of this transition relate to the requirements that investigators themselves identify for the success of Safety Differently investigations in their institution. We conducted a FRAM (Functional Resonance Analysis Method) analysis of the requirements related to inputs, outputs, time, control, preconditions and resources for a successful Safety Differently investigation. The findings are applicable to Safety Differently investigations independent of the domain in which they might take place. The results show a critical need of training, coaching, time, human resources and commitment of institutional leaders for the transition to Safety Differently investigations.

Neoliberalism refers to the political, economic and social arrangements that have become globally dominant since the 1980s. It promotes privatization, free markets, and deregulation. Neoliberal governance can be linked to safety management by stifling rules developed by non-experts, bureaucratic overreach, imposition of discipline and accountability, and a hemming in of autonomy and discretion on the frontline. Using a variety of sources, this paper examines what safety and safety management can look like after neoliberalism. Centrally, it hinges on changing the belief that complex risks can be managed by rule-based uncertainty reduction, documentation-based liability management, or shrinking the bandwidth of allowable human performance. Safety after neoliberalism involves regulation on the basis of capacities to make things go right as opposed to compliance; de-bureaucratizing safety by putting safety expertise closer to the ‘messy details’ of actual practice, and instituting investigations and restorative incident responses that emphasize safe working conditions as a collective responsibility. In addition, safety after neoliberalism takes a fresh look at global supply chains, participatory equality, and workers’ compensation practices.

The safety management literature describes two distinct modes through which safety is achieved. These can be described as safety management through centralized control, or safety management through guided adaptability. Safety management through centralized control, labelled by Hollnagel as ‘Safety-I’, aims to align and control the organization and its people through the central determination of what is safe. Safety management through guided adaptability, or ‘Safety-II’, aims to enable the organization and its people to safely adapt to emergent situations and conditions. Safety-II has been presented as a paradigm shift in safety theory, but it has created practical difficulties for safety professional practice. In this paper, we define the two modes of safety management and explain the challenges in changing the role of a safety professional to support Safety-II. When should safety professionals re-enforce alignment, and when should they support frontline adaptations? We outline specific activities for safety professionals to adopt in their role to move towards a guided adaptability mode of safety management. This will move the safety professional further towards their fundamental responsibility – ‘to create foresight about the changing shape of risk, and facilitate action, before people are harmed.’

In providing reflections on 25 years of situation awareness (SA) research, particularly the ever-popular 1995 model of SA, our response is twofold. First, we ask whether the model’s grasp has exceeded its epistemological reach. By overlooking important insights from the second cognitive revolution as well as from other late-20th-century developments in (social) science, it might well do that. In fact, SA, in its 1995 model, is strongly committed to a 17th-century ontology that separates mind from matter and sees awareness as a correspondence or mirror of the world outside. This view seems to strongly reverberate today in a somewhat dogmatic stance of the 1995 model about the role that the world and cognitive artifacts play in constituting cognitive processes. Second, we suggest that after 25 years of SA, we might need to reflect on what SA as a scientific human factors object has brought us or the operators we once set out to support. This is not a trivial or academic question. We know of one operator who is in jail today because the prosecution was able to successfully argue for the dereliction of his duty to maintain SA. Without the human factors community supplying this object, he might still be in jail, but surely not under this charge.

This paper examines the bureaucratization of safety, and the increase in safety as measurable bureaucratic accountability. The bureaucratization of safety-which has accelerated since the 1970s-revolves around hierarchy, specialization and division of labor, and formalized rules. Bureaucratic accountability refers to the activities expected of organization members to account for the safety performance of those they are responsible for (e.g. unit, team, site). Bureaucratization of safety has brought benefits, including a reduction of harm, standardization, transparency and control. It has been driven by regulation, liability and insurance arrangements, outsourcing and contracting, and technologies for surveillance and data storage. However, bureaucratization generates secondary effects that run counter to its original goals. These include a reduced marginal yield of safety initiatives, bureaucratic entrepreneurism and pettiness, an inability to predict unexpected events, structural secrecy, "numbers games," the creation of new safety problems, and constraints on organization members' personal freedom, diversity and creativity, as well as a hampering of innovation. This paper concludes with possible ideas for addressing such problems.

Safety culture is part of a larger discursive practice shared by scholars and practitioners in the field of accident prevention. It appears in various institutional documents, such as scientific and accident reports, industry-related statistics, manuals, and legislation. We examine the constitution of safety culture and its effects as a form of knowledge based on a Foucauldian archae-genealogical approach. Our analysis lays out the historical conditions for the emergence of the object, the scientific approaches for its delimitation, and its regular characteristics. We also describe four effects of the object in the discourse: a focused aspect of organisational culture that implies a normative homogeneity of values, beliefs, and behaviours; a disciplinary enforcement of workers' safety behaviours; a biopolitical control of organisations; and a form of governmentality that connects the conduct of individuals with organisational norms.

Resilience engineering wants to differ from safety practices that have evolved differently in various industries. The nuclear industry, for example, relies to a large extent on barriers and defences in depth. Aviation system safety thus seems to run relatively open-loop and represents a partially reactive control of risk. Military systems, having to deal with active adversaries, emphasise hazards, hazard analysis and hazard control, relying in large part on top-down approaches to making safer systems. In contrast with aviation, this represents a more proactive control of risk. The role of a safety organization in fanning discussion about risk alive, by the way, is problematic. But a safety department has to reconcile competing demands for being involved as an insider, while being independent as an outsider. In addition, a strong safety department could send the message to the rest of an organization that safety is something that can and should be delegated to experts; to a dedicated group.

A broad issue in cognitive systems engineering is at stake here. If we want to learn from practitioners’ interactions with each other and technology, we need to study their practice. Process tracing methods are part of a larger family of cognitive task analysis but aim specifically to analyze how people’s understanding evolved in parallel with the situation unfolding around them during a particular problem-solving episode. Process tracing methods are extremely useful, if not indispensable, in the investigation of incidents and accidents.

In 1960, shortly after his election, President Kennedy asked Robert McNamara to become secretary of defense in his new cabinet. McNamara, known as a star and a whiz-kid, had been president of the Ford Motor Company for all of five weeks, so it took a bit of cajoling. But he eventually joined the administration in 1961, taking with him the high modernism of Ford’s production lines – with traces of Taylor’s measurement and scientific management still starkly present. A few years into his tenure, with Vietnam taking up ever more resources and political space, he wanted to know from his top generals how to measure progress in the war. He told General Westmoreland that he wanted to see a graph that would tell the defense secretary whether they were winning or losing (McMaster, 1997). Westmoreland did as he was asked, although he produced two graphs: One graph showed the enemy body count. Under pressure to show progress (and knowing that political fortunes of their masters, promotions for themselves and their comrades, decorations, rest and recreation decisions and resourcing all depended on it), those who did the accounting made sure that not a single dead enemy body was missed. Soon, the lines between soldiers and civilians had blurred completely: all dead bodies became enemy personnel. Implausibly, the total number of enemy dead soon exceeded the known strength of the Viet Cong and the North Vietnamese Army combined. Civilian casualties mounted, the frustrations and incentives even leading to some massacres. In the field, of course, the ‘enemy’ was nowhere near all dead, and certainly not defeated. The other graph showed a measure of civilian sympathies for the United States and against communism. It tracked the effects of the so-called Winning Hearts and Minds campaign (or WHAM), which had divvied up Vietnam into 12,000 hamlets, each of which was categorized into ‘pacified,’ ‘contested’ or ‘hostile.’ Pressure to show McNamara progress here was relentless too. Militias on the side of the Americans were invented on paper. Incidents of insurgent activity or hostile takeovers of hamlets were ignored. In an ambiguous, messy and protracted war, it wasn’t difficult to skew numbers in favor of making the graph look good. It soon seemed that the entire countryside had become pacified. 76The progress charts demanded by McNamara produced a monstrous auditing system (Scott, 2012). It was an example of the synoptic legibility of authoritarian high modernism, callously erasing all meaningful difference and distinction: a dead body was a dead body. It could be counted, and that was all that counted. And a pacified hamlet was a pacified hamlet – with all the cross-currents, fluidities and complexities of a shredded social order collapsed into a single number on a chart. McNamara’s system may well have played its own small part in contributing to the continuation of war and the stifling of meaningful, rational discourse about its merits and demerits. The political back tapestry, for instance as painted by McMaster in Dereliction of Duty (1997), was one of civilian leaders who were obsessed with domestic reputation and who had leaned further into military operational matters than turned out to be healthy. It took authority from those who would have had the knowledge and experience to adapt to local circumstances, instead sending them on missions to supply a desirable number up the chain – whatever it took.