Procedures and the Varieties of Human Work

This talk outlines basic concepts in Safety-I and Safety-II, along with some of the Varieties and Archetypes of Human Work (https://humanisticsystems.com/2017/01/13/the-archetypes-of-human-work/). Examples from aviation are provided, along with tips for understanding and intervention, including 7 steps for designing for human work.

Transcript

1. Supporting European Aviation Procedures and Human Work The Varieties of Human Work Steven Shorrock Senior Specialist Safety & Human Factors Network Manager Safety Unit EUROCONTROL Safety Forum, 4-5 June, Brussels
2. Adapted from EUROCONTROL (2013). From Safety-I to Safety-II. A White Paper Accidents & incidents: obvious internally and externally, investigated in depth Normal, routine, day-to-day performance: not well understood, generally ignored Exceptional performance: obvious internally, hard to see externally, gratefully accepted
3. Adapted from EUROCONTROL (2013). From Safety-I to Safety-II. A White Paper <0.0001% Commercial Aviation Accidents & incidents: obvious internally and externally, investigated in depth Normal, routine, day-to-day performance: not well understood, generally ignored Exceptional performance: obvious internally, hard to see externally, gratefully accepted
4. Errors Unsafe Acts Failures Deviations Violations Non-compliance Carelessness Recklessness Accidents & incidents: obvious internally and externally, investigated in depth
5. ? Accidents & incidents: obvious internally and externally, investigated in depth Normal, routine, day-to-day performance: not well understood, generally ignored Exceptional performance: obvious internally, hard to see externally, gratefully accepted
6. Effective-as-designed? Effective-as-operated? Accidents & incidents: obvious internally and externally, investigated in depth Normal, routine, day-to-day performance: not well understood, generally ignored Exceptional performance: obvious internally, hard to see externally, gratefully accepted <0.0001% Commercial Aviation
7. 7 ATCOs Rank C15 We are sufficiently involved in changes to procedures. 3 B18 Changes to the organisation, systems and procedures are properly assessed for safety risk. 11 C08 I receive sufficient safety-related refresher training. 12 C07r We often have to deviate from procedures. 15 B27 Other people in this organization understand how my job contributes to safety. 16 C19 The procedures associated with my work are appropriate. 16 C14r I often have to take risks that make me feel uncomfortable about safety. 18 C11 Adequate training is provided when new systems and procedures are introduced. 20 C04 The procedures describe the way in which I actually do my job. 32 C20 I have sufficient training to understand the procedures associated with my work. 43
8. Photo: Naviair (All rights reserved) THE VARIETIES OF HUMAN WORK http://bit.ly/TVOHW www.humanisticsystems.com
9. Image: Steven Shorrock CC BY-NC-SA 2.0 https://flic.kr/p/25wGrGQ
10. Image: Steven Shorrock CC BY-NC-SA 2.0 https://flic.kr/p/28EShtU
11. Image: Steven Shorrock CC BY-NC-SA 2.0 https://flic.kr/p/MYAVK4
12. Work-as-Measured Work-as-Judged Work-as-Analysed Work-as-Observed Work-as-Simulated Work-as-Disclosed Work-as-Imagined Work-as-Prescribed Work-as-Done
13. http://bit.ly/TAOHW1 HUMAN WORK THE ARCHETYPES OF www.humanisticsystems.com Photo: NATS - UK air traffic control CC BY-NC-ND 2.0
14. Work-as-Imagined Work-as-Prescribed Work-as-Done The Messy Reality http://bit.ly/TAOHW1 Tell me about a situation where work-as-done is not as-prescribed and usually not as-imagined by others ” “
15. USE OF MODE S DURING LOSS OF FLIGHT DATA Image: © EUROCONTROL
16. USE OF RADAR WITHOUT A LICENCE Image: © EUROCONTROL
17. http://bit.ly/TAOHW2 Tell me about a situation where work-as-done is as-prescribed and as-imagined by others. ” “ Congruence (as-imagined) Work-as-Imagined Work-as-Prescribed Work-as-Done
18. PROCEDURES STANDARD OPERATING Image: Randomwire CC BY-NC-SA 2.0 http://flic.kr/p/7u6jhM
19. http://bit.ly/TAOHW2 Congruence (not-as-imagined) Tell me about a situation where work-as-done is as-prescribed but not as-imagined by others. “ ” Work-as-Imagined Work-as-Prescribed Work-as-Done
20. enter your presentation title 20 SETTING STANDARD PRESSURE
21. DOUBLE Image: ©Steven Shorrock All Rights Reserved SHIFTING
22. Ignorance and Fantasy http://bit.ly/TAOHW4 www.humanisticsystems.com Tell me about a situation where current work-as-imagined is not as-done “ ” Work-as-Imagined Work-as-Prescribed Work-as-Done
23. enter your presentation title 23 THE LIGHTING CIRCUIT Photo: LRD615 CC BY-SA 2.0 https://flic.kr/p/2kNCax
24. Projection http://bit.ly/TAOHW5 www.humanisticsystems.com Tell me about a situation where work-as-imagined was projected into the future. It may or may not be as-done ” “ Work-as-Imagined Work-as-Prescribed Work-as-Done
25. AFTER Photo: ResoluteSupportMedia CC BY 2.0 https://flic.kr/p/922V3P THE RUNWAY INCURSION
26. http://bit.ly/TAOHW7 www.humanisticsystems.com Tell me about a situation where work-as-prescribed is not as-done “ ” Work-as-Imagined Work-as-Prescribed Work-as-Done Defunct
27. 4/2 ENGINE PROCEDURES Photo: William Warby CC BY 2.0 https://flic.kr/p/8hDHDf
28. Image: Steven Shorrock CC BY-NC-SA 2.0 https://flic.kr/p/2bkA8HS
29. 29 1. Psychological safety must be cultivated to really understand work-as-done 2. Work must be understood in terms of local rationality - why the things we do make sense at the time 3. Protection is required for the goodwill use of creative expertise – policy, principles and philosophy UNDERSTANDING
30. 30 1. Procedural solutions to systemic or isolated problems can make matters worse 2. Tightening procedural requirements can reduce necessary degrees of freedom 3. Human-centred design and systems methods are needed for procedure design INTERVENTION
31. 1.Understand work-as-done (WAD) 2.Collaborate on work-as-imagined (WAI) 3.Co-design prototype work-as-prescribed (WAP) 4.Implement in work-as-done 5.Test WAI and WAP against WAD 6.Repeat above until WAI-WAP-WAD gap acceptable 7.Monitor WAI-WAP-WAD gap Image: Steven Shorrock CC BY-NC-SA 2.0 https://flic.kr/p/2ajEAFt DESIGNING FOR WORK-AS-DONE
32. or www.bit.ly/HindSightMagazine steven.shorrock@eurocontrol.int Download Free at SKYbrary.aero