A systems approach to organizational error

Abstract

The past two decades have seen a significant number of large-scale disasters in a wide range of hazardous, well-defended technologies. Despite their differences, the root causes of these accidents have been traced to latent failures and organizational errors arising in the upper echelons of the system in question. A model of the aetiology of these organizational accidents is outlined. The model describes two interrelated causal sequences: (a) an active failure pathway that originates in top-level decisions and proceeds via error-producing and violation-promoting conditions in the various workplaces to unsafe acts committed by those at the immediate human-system interface and (b) a latent failure pathway that runs directly from the organizational processes to deficiencies in the system's defences. The paper goes on to identify two sets of dependencies associated with latent failures and violations. Organizational errors increase the likelihood of operator error through the active failure pathway and, at the same time, enhance the possibility of adverse outcomes through defensive weaknesses. Violations have a narrower range of consequences. Non-compliance with safe operating procedures increases the likelihood of error by taking perpetrators into regions of operation in which neither the physical regime nor the hazards are well understood. Violations, by definition, also take perpetrators ‘closer to the edge,’ and thus increase the chance that subsequent errors will have damaging outcomes. The paper concludes by indicating two ways in which the model has been applied in industrial settings: (a) through the development of proactive measures for diagnosing and remedying organizational processes known to be implicated in accident causation, and (b) an accident investigation technique that guides investigators and analysts to the organizational root causes of past accidents.     

Ergonomics and occupational safety and health: An ILO perspective

The ILO has a mandate to protect workers against sickness, diseases and injuries due to workplace hazards and risks including ergonomic and work organization risk factors. One of the main functions for the ILO is to develop international standards related to labour and work. ILO standards have exerted considerable influence on the laws and regulations of member States. The ILO standards take the form of international Conventions and Recommendations. ILO Conventions and Recommendations relevant to protection of workers against ergonomic risk factors at the workplace include Convention No. 127 and Recommendation No.128 which specify the international requirements concerning the manual transport of a load. To help member States in applying the ILO standards, the ILO produces practical guides and training manuals on ergonomics at work and collects and analyses national practices and laws on ergonomics at the workplace. The ILO also conducts technical cooperation activities in many countries on ergonomics to support and strengthen the capacities of its tripartite constituents in dealing with workplace ergonomic and work organization risks. The ILO’s technical cooperation activities give priorities on the promotion of voluntary, participatory and action-oriented actions to improve working conditions and work organizations of the small and medium sized enterprises. This paper reviews ILO’s policies and activities on ergonomics in relation to occupational safety and health and prescribes ILO’s considerations for its future work on ergonomics.     

Investigating slips, trips and falls in the New Zealand dairy farming sector

The paper presents findings from 39 detailed follow-up investigations of slips, trips and falls (STF) incurred by individuals working in New Zealand's dairy farming industry. The study sought to identify the key contributory risk factors for STF in this sector to provide evidence to support intervention design, and to determine the effectiveness of the investigative methodology used to achieve these objectives. Findings from the follow-up investigations included an analysis of factors related to the underfoot surface, underfoot hazard and footwear. Of note here was the propensity for STF-involved workers to not see or identify an underfoot hazard due to concurrent visual task distractions, and for workers to use footwear that both lacked effective tread and was unsuitable for the task and underfoot surface. Key latent risk factors and their interactions identified included problems associated with time pressure and related time-saving behaviours and the presence of design errors that, for example, required workers to climb onto equipment to view aspects of the task they were working on. The paper concludes that the potential resource and logistical problems associated with conducting detailed STF investigations are outweighed by the opportunity to collect rich data on key risk factors and their interactions in STF research.     

Using Reason’s Model of Organisational Accidents in Formalising Accident Reports

This paper proposes a method for analysing what are called organisational accidents. The first step of the method involves using Reason’s model of organisational failures. This provides heuristic guidance in identifying both the active and latent conditions that lead to major failures. The second step involves applying formal methods to support a detailed analysis of each latent and active condition. The method is demonstrated on a case study: the railway accident at Watford Junction in the United Kingdom. Analysis of the formal model helps to identify organisational factors that might have prevented the accident. It also helps to identify weaknesses in the report itself. In particular we argue that a signalling standard was misunderstood, the consequences of which could lead to another serious accident.     

Investigating risk factors for slips,trips and falls in New Zealand residential construction using incident-centred and incident-independent methods

Slip, trip and fall (STF) incidents, particularly falls from a height, are a leading cause of injury in the New Zealand residential construction industry. The most common origins of falls from a height in this sector are ladders, scaffolding and roofs, while slipping is the most frequent fall initiating event category. The study aimed to provide detailed information on construction industry STF risk factors for high-risk tasks, work equipment and environments, as identified from an earlier analysis of STF claims data, together with information to be used in the development of interventions to reduce STF risk in New Zealand residential construction. The study involved the use of both incident-centred and incident-independent methods of investigation, including detailed follow-up investigations of incidents and observations and interviews with workers on construction sites, to provide data on a wide range of risk factors. A large number of risk factors for residential construction STFs were identified, including factors related to the work environment, tasks and the use and availability of appropriate height work equipment. The different methods of investigation produced complementary information on factors related to equipment design and work organization, which underlie some of the site conditions and work practices identified as key risk factors for residential construction STFs. A conceptual systems model of residential construction STF risk is presented.     

Translating concepts of complexity to the field of ergonomics

Since 1958 more than 80 journal papers from the mainstream ergonomics literature have used either the words ‘complex’ or ‘complexity’ in their titles. Of those, more than 90% have been published in only the past 20 years. This observation communicates something interesting about the way in which contemporary ergonomics problems are being understood. The study of complexity itself derives from non-linear mathematics but many of its core concepts have found analogies in numerous non-mathematical domains. Set against this cross-disciplinary background, the current paper aims to provide a similar initial mapping to the field of ergonomics. In it, the ergonomics problem space, complexity metrics and powerful concepts such as emergence raise complexity to the status of an important contingency factor in achieving a match between ergonomics problems and ergonomics methods. The concept of relative predictive efficiency is used to illustrate how this match could be achieved in practice. What is clear overall is that a major source of, and solution to, complexity are the humans in systems. Understanding complexity on its own terms offers the potential to leverage disproportionate effects from ergonomics interventions and to tighten up the often loose usage of the term in the titles of ergonomics papers.

Statement of Relevance: This paper reviews and discusses concepts from the study of complexity and maps them to ergonomics problems and methods. It concludes that humans are a major source of and solution to complexity in systems and that complexity is a powerful contingency factor, which should be considered to ensure that ergonomics approaches match the true nature of ergonomics problems.     

Fundamentals of ergonomics in theory and practice

In this paper ergonomics is defined as a discipline in its own right, as the theoretical and fundamental understanding of human behaviour and performance in purposeful interacting socio-technical systems, and the application of that understanding to design of interactions in the context of real settings. This definition is justified in the financial, technicat, legal, organisational, social, political and professional contexts in which ergonomists work. On the basis of the history of ergonomics and contemporary contributions, it is proposed that it is one of the modern sciences, drawing as much from the field as from the laboratory, and including elements of an art and a craft as well. Justification for the new definition is provided by examining the interacting systems which are prevalent in the modern world and which are the domain best understood through the holistic approach of ergonomics. Finally a number of challenges for ergonomics are identified.     

Investigating risk factors for slips, trips and falls in New Zealand residential construction using incident-centred and incident-independent methods

Slip, trip and fall (STF) incidents, particularly falls from a height, are a leading cause of injury in the New Zealand residential construction industry. The most common origins of falls from a height in this sector are ladders, scaffolding and roofs, while slipping is the most frequent fall initiating event category. The study aimed to provide detailed information on construction industry STF risk factors for high-risk tasks, work equipment and environments, as identified from an earlier analysis of STF claims data, together with information to be used in the development of interventions to reduce STF risk in New Zealand residential construction. The study involved the use of both incident-centred and incident-independent methods of investigation, including detailed follow-up investigations of incidents and observations and interviews with workers on construction sites, to provide data on a wide range of risk factors. A large number of risk factors for residential construction STFs were identified, including factors related to the work environment, tasks and the use and availability of appropriate height work equipment. The different methods of investigation produced complementary information on factors related to equipment design and work organization, which underlie some of the site conditions and work practices identified as key risk factors for residential construction STFs. A conceptual systems model of residential construction STF risk is presented.     

People and computers--some recent highlights

This paper aims to review selectively a fair proportion of the literature on human-computer interaction (HCI) over the three years since Shackel (J. Am. Soc. Inform. Sci. 48 (11) (1997) 970-986). After a brief note of history I discuss traditional input, output and workplace aspects, the web and 'E-topics', web-related aspects, virtual reality, safety-critical systems, and the need to move from HCI to human-system integration (HSI). Finally I suggest, and consider briefly, some future possibilities and issues including web consequences, embedded ubiquitous computing, and 'back to systems ergonomics?'.     

A manufacturing-oriented model for evaluating the satisfaction of workers – Evidence from Turkey

Job satisfaction, in terms of worker's satisfaction, is one of the intensively studied areas in human resource and management. However, there is little information available on how ergonomics and the manufacturing environment affect job satisfaction. This study analyzes the extent of the relationship between job satisfaction and work and workplace related conditions. A conceptual model is proposed to evaluate job satisfaction that considers 34 elements in four categories: manufacturing systems, facility design, safety and ergonomics, and human resources and management. A survey of 169 blue-collar workers working in the automotive industry was conducted to investigate the applicability of the model. A comprehensive exploratory factor analysis was used to determine inter-related elements, their underlying factors and their effects on job satisfaction. The analysis revealed 6 factors with 18 related elements. From a multi linear regression analysis, we develop a job satisfaction model built on factors of human resource policies, safety, ergonomics, air quality, thermal comfort and disturbing equipment. The results reveal that ergonomics plays the most important role in workers' satisfaction for the respondent Turkish automotive workers. In contrast, human resource policies seem not play a critical role in job satisfaction because of higher standards in automotive industry compared to other industries in Turkey.     

Understanding workplace violence: The value of a systems perspective

Workplace violence is a leading form of occupational injury and fatality, but has received little attention from the ergonomics research community. The paper reports findings from the 2012 New Zealand Workplace Violence Survey, and examines the workplace violence experience of 86 New Zealand organisations and the perceptions of occupational health and safety professionals from a systems perspective. Over 50% of respondents reported violence cases in their organisation, with perpetrators evenly split between co-workers and external sources such as patients. Highest reported levels of violence were observed for agriculture, forestry and construction sectors. Highest risk factor ratings were reported for interpersonal and organisational factors, notably interpersonal communication, time pressure and workloads, with lowest ratings for environmental factors. A range of violence prevention measures were reported, although most organisations relied on single control measures, suggesting unmanaged violence risks were common among the sample.     

A framework for performing workplace hazard and risk analysis: a participative ergonomics approach

Despite the unanimity among researchers about the centrality of workplace analysis based on participatory ergonomics (PE) as a basis for preventive interventions, there is still little agreement about the necessary of a theoretical framework for providing practical guidance. In an effort to develop a conceptual PE framework, the authors, focusing on 20 studies, found five primary dimensions for characterising an analytical structure: (1) extent of workforce involvement; (2) analysis duration; (3) diversity of reporter role types; (4) scope of analysis and (5) supportive information system for analysis management. An ergonomics analysis carried out in a chemical manufacturing plant serves as a case study for evaluating the proposed framework. The study simultaneously demonstrates the five dimensions and evaluates their feasibility. The study showed that managerial leadership was fundamental to the successful implementation of the analysis; that all job holders should participate in analysing their own workplace and simplified reporting methods contributed to a desirable outcome.

Practitioner summary: This paper seeks to clarify the scope of workplace ergonomics analysis by offering a theoretical and structured framework for providing practical advice and guidance. Essential to successfully implementing the analytical framework are managerial involvement, participation of all job holders and simplified reporting methods.     

Doing ‘organizational work’: Expanding the conception of professional practice in ergonomics

Literature on ergonomic practice contains many discussions of how ergonomists should work but far less attention has been paid to how they do work and the factors that influence their practice. In an effort to improve our understanding of ergonomic practice as it occurs and how it is conditioned by broader contexts, we conducted an interview study with 21 ergonomists in Canada. We were particularly interested to understand the different kinds of activities study participants engaged in during the course of their work, the challenges they faced and the strategies they employed for facing these challenges. Findings indicate that in the course of their professional practice ergonomists engage in a variety of types of activities. This includes consulting on risk factors as well as a proactive role of fostering the application of ergonomics in organizations. The process of advocating for ergonomics brought study participants into a variety of interactions and collaborations with workplace parties in a type of activity we have called “organizational work”. In the course of doing organizational work, ergonomists utilize different strategies, including “political manoeuvring”, tailoring data collection and report presentations to clients’ concerns and ‘goal hooking’ in order to make the case for implementing ergonomics in workplaces. The article concludes with a list of “tips” for practicing ergonomists that are suggested by the analysis.     

Evaluating the effectiveness of a participatory ergonomics approach in reducing the risk and severity of injuries from manual handling

Manual handling is the greatest contributor to non-fatal injury and disease in the workplace, commonly accounting for one-third of national injury counts. Interventional strategies that have focused on selecting or modifying the worker have been ineffective in reducing injury risk. In recent times, participatory ergonomics has been widely adopted as a process to reduce the risk of injury from manual handling but it is not well validated as an intervention. This study evaluated the effectiveness of a participatory ergonomics risk assessment approach in reducing the rate and severity of injuries from manual and non-manual handling sustained by a cohort of 137 cleaners within a hospital setting. The date of injury and the workers' compensation claim cost and hours lost from work were obtained for each injury incurred during the 4-year pre-intervention and 3-year intervention period. The age, gender and hours worked were ascertained for every cleaner whether injured or not. Using generalized linear mixed modelling analysis, reductions of rate of injury by two-thirds, workers' compensation claim costs by 62% and hours lost by 35% for manual handling injuries were found to be associated with the intervention period. Although the cleaners experienced a significant intervention period reduction in non-manual handling injury rate, the corresponding changes in severity of injury were not significant. The success of the intervention supports the adoption of a participatory ergonomics approach in reducing the rate and consequence of injuries in the workplace.     

Developing national ergonomics standards for Thai industry

This paper reports activities initiated by the Thai Government and its Technical Committee on Ergonomics Standards (TC 887) to develop national ergonomics standards for Thai industry. The main objective is to promote ergonomics practice by disseminating recommended ergonomics principles and applications to various industries so that employers and/or management become aware of essential design concepts and work methods that help to improve workplace conditions and enhance workers’ safety. Initially, the paper discusses the history of ergonomics in Thailand and its progress during the past 30 years. Ergonomics research activities and industrial projects that have been conducted are also summarized. Government activities to develop national ergonomics standards are then described in detail. Steps already taken to achieve such goals include participating as a P-member of the ISO/TC 159, conducting national surveys on ergonomics education and ergonomics specialists, and drafting ergonomics standards.

Relevance to industry

It has been well recognized in developed countries that ergonomics principles help to increase workers’ productivity and enhance workplace safety. For industrially developing countries such as Thailand in which ergonomics is not well known, it is essential that national ergonomics standards be developed and disseminated to employers and/or management. Furthermore, national standards need to be compatible with international standards to allow Thai manufacturing companies to be competitive in international markets.     

Doing ‘organizational work’: Expanding the conception of professional practice in ergonomics

Literature on ergonomic practice contains many discussions of how ergonomists should work but far less attention has been paid to how they do work and the factors that influence their practice. In an effort to improve our understanding of ergonomic practice as it occurs and how it is conditioned by broader contexts, we conducted an interview study with 21 ergonomists in Canada. We were particularly interested to understand the different kinds of activities study participants engaged in during the course of their work, the challenges they faced and the strategies they employed for facing these challenges. Findings indicate that in the course of their professional practice ergonomists engage in a variety of types of activities. This includes consulting on risk factors as well as a proactive role of fostering the application of ergonomics in organizations. The process of advocating for ergonomics brought study participants into a variety of interactions and collaborations with workplace parties in a type of activity we have called “organizational work”. In the course of doing organizational work, ergonomists utilize different strategies, including “political manoeuvring”, tailoring data collection and report presentations to clients’ concerns and ‘goal hooking’ in order to make the case for implementing ergonomics in workplaces. The article concludes with a list of “tips” for practicing ergonomists that are suggested by the analysis.     

Fuzzy logic-based decision support system for automating ergonomics risk assessments

Workers in the modular construction industry are frequently exposed to ergonomic risks, which may lead to injuries and lower productivity. In light of this, researchers have proposed a number of ergonomics risk assessment methods to identify design flaws in work systems, thereby reducing ergonomic discomfort and boosting workplace productivity. However, organizations often disregard ergonomics risk assessments due to a lack of convenient tools and knowledge. Therefore, this study proposes a fuzzy logic-based decision support system to help practitioners to automatically and comprehensively assess the ergonomic performance of work systems. For comprehensive assessment of ergonomic risk, the proposed decision support system considers physical, environmental, and sensory factors. Specifically, the decision support system comprises eight fuzzy expert systems that output a composite risk score, called an “ergonomic risk indicator”, that indicates the overall level of ergonomic risk present in a given work system. The performance of the proposed decision support system is then evaluated using a real-world case study in a modular construction facility by comparing the results of the decision support system with the facility's occupational injury reports. The results prove the effectiveness of the decision support system. Overall, the decision support system is capable of generating a composite risk score, the ergonomic risk indicator, and the proposed high-level architecture and design represent significant contributions for the enhancement of health and safety in the modular construction industry.     

Computerized task risk assessment using digital human modeling based Job Risk Classification Model

Different from the classical ergonomics analysis, Virtual Interactive Design methodology relies on manikin movements in virtual environment. This platform has been implemented by researchers to accomplish static ergonomic analyses including Rapid Upper Limb Assessment, NIOSH lifting equation and Static Strength Prediction. However, considering only static posture information limits the capacity of ergonomics analysis. In this study, the methodology of performing dynamic ergonomics analysis based on this Virtual Interactive Design platform is proposed. This environment allows velocity and angular velocity of specified body segments/joints calculated for designed tasks to be used to assess the corresponding risk levels based on Job Risk Classification Model. The motion calculation is completed based on the captured interaction between human participants and virtual workplace/mockup. To evaluate the validity and reliability of this upgraded platform, potential errors are analyzed by comparing outputs from several designed experimental conditions.     

New methodological framework to improve productivity and ergonomics in assembly system design

This work analyses how ergonomics and assembly system design techniques are intimately related. It also develops a new theoretical framework to assess a concurrent engineering approach to assembly systems design problems, in conjunction with an ergonomics optimization of the workplace. Its purpose is to provide professionals with a new and detailed approach to assembly system design procedures that includes ergonomics issues.The methodological framework offered takes into account technological variables (related to work times and methods), environmental variables (i.e. absenteeism, staff turnover, work force motivation) and ergonomics evaluations (i.e. human diversity) to create a comprehensive analysis.At conclusion of the study, the work reports data and insights from two real industrial cases, where an advanced simulation software is used, to validate the procedure and support methodology applicability.

Relevance to industries

This work provides an extremely valuable methodological framework to companies who recognize the link between assembly and ergonomics. The methodology underlines the necessity to analyze and classify the assembly system layout configuration in relation to both technological and environmental parameters- as reported in the framework.