The Fallacies of Work-as-Imagined (Aviation Version)

In this talk, I outline seven fallacies of work-as-imagined, concerning outcomes happen, how people work, how we design and implement, and how we think. A number of examples are given from aviation. The talk was given at the Joint African Symposium on Human Factors and Aviation Safety & Ergonomics Society of South Africa conference, Durban, South Africa, 28 Aug 2019.

Transcript

1. Steven Shorrock Chartered Psychologist | Chartered Human Factors & Ergonomics Specialist 28 Aug 2019 | African Symposium on Human Factors and Aviation Safety | Ergonomics Society of South Africa conference | Durban, South Africa @stevenshorrock | speakerdeck.com/stevenshorrock
2. “I feel there is an ever increasing disconnect again between what nationally is sometimes said to be going on and what people on the ground feel or see is going on.” Sir Robert Francis QC, 2017, HSJ The fallacies of work as imagined | @stevenshorrock
3. Image: Steven Shorrock CC BY-NC-SA 2.0 https://flic.kr/p/25wGrGQ
4. Image: Steven Shorrock CC BY-NC-SA 2.0 https://flic.kr/p/MYAVK4
5. Regulation Media & Public Comms Legal Academia Planning Design & Eng Management Front-line Staff The fallacies of work as imagined | @stevenshorrock Government Training Safety HR
6. Work-as-Measured Work-as-Judged Work-as-Analysed Work-as-Observed Work-as-Simulated Work-as-Prescribed Work-as-Imagined Work-as-Disclosed Work-as-Done The fallacies of work as imagined | @stevenshorrock
7. Work-as-Prescribed Work-as-Imagined Work-as-Done Work-as-Simulated The Prescription and Simulation of Human Work The fallacies of work as imagined | @stevenshorrock
8. enter your presentation title 8 SETTING STANDARD PRESSURE
9. Work-as-Analysed Work-as-Observed Work-as-Imagined Work-as-Disclosed Work-as-Done The Observation and Analysis of Human Work The fallacies of work as imagined | @stevenshorrock
10. THE NEW Photo: NATS UK Air Traffic Control CC BY-NC-ND 2.0 https://flic.kr/p/ouoeYr TOWER
11. Work-as-Judged Work-as-Prescribed Work-as-Imagined Work-as-Disclosed Work-as-Done The Judgement of Human Work The fallacies of work as imagined | @stevenshorrock
12. USE OF RADAR Image: © EUROCONTROL WITHOUT A LICENCE
13. Work-as-Measured Work-as-Done The Measurement of Human Work Work-as-Imagined The fallacies of work as imagined | @stevenshorrock
14. How we work How we design & implement How we think What happens Influence Influence The fallacies of work as imagined | @stevenshorrock
15. How we work How we design & implement How we think What happens Influence Influence The fallacies of work as imagined | @stevenshorrock
16. The fallacies of work as imagined | @stevenshorrock
17. How we work How we design & implement How we think What happens Influence Influence The fallacies of work as imagined | @stevenshorrock
18. FALLACIES ABOUT OUTCOMES § The fallacy of difference § The fallacy of the first story (human error-as-cause) The fallacies of work as imagined | @stevenshorrock
19. We explain the unusual event by invoking the usual and proclaiming it to be different, when of course it is not. Instead, it is the obscure, accidental, and even random concatenation of normal disorders that produces a great event that we assume must have had great causes. Perrow (1984) Normal Accidents “ The fallacies of work as imagined | @stevenshorrock
20. The fallacies of work as imagined | @stevenshorrock Success and failure are derived from the same sources … bad events are not separate phenomena that can be eliminated by the use of some managerial or technological tool. Cook, Woods & Miller (1998) A Tale of Two Stories: Contrasting Views of Patient Safety “
21. The fallacies of work as imagined | @stevenshorrock Safety…is an emergent property of the ways in which the technical, individual, organizational, regulatory, and economic factors … join together to create the settings in which events—the best ones and the worst ones—occur. Cook, Woods & Miller (1998) A Tale of Two Stories: Contrasting Views of Patient Safety “
22. Failure is rich in learning opportunities for a simple reason: in many of its guises, it represents a violation of expectation. It is showing us that the world is in some sense different from the way we imagined it to be. What makes your ANSP safe? “
23. PLAY CHAMPIONSHIP GOLF by Learning the Secrets of the Worst 20 Players in the World By J. Cleese The fallacies of work as imagined | @stevenshorrock
24. ‘FIRST STORY’ § Appears quickly after an event § High personalisation (sharp-end actors) § Low context § Low complexity § High newsworthiness § Appears easily preventable and fixable (with hindsight) The fallacies of work as imagined | @stevenshorrock
25. ‘SECOND STORY’ § Emerges slowly after long delay § Lower personalisation § Higher context § Higher complexity § Lower newsworthiness § No easy prevention or remediation The fallacies of work as imagined | @stevenshorrock
26. The fallacies of work as imagined | @stevenshorrock
27. How we work How we design & implement How we think What happens Influence Influence The fallacies of work as imagined | @stevenshorrock
28. FALLACIES ABOUT WORK § The mind projection fallacy (the ultimate WAI fallacy) § The fallacy of the system-as-designed § The fallacy of technical rationality The fallacies of work as imagined | @stevenshorrock
29. USE OF MODE S DURING LOSS OF FLIGHT DATA Image: © EUROCONTROL
30. SAFETY AND EMERGENCY PROCEDURES Photo: Darren CC BY-NC-ND 2.0 https://flic.kr/p/f26Qci
31. SECTOR CAPACITY Image: Caren Mack CC BY-ND 2.0 https://flic.kr/p/63FSJX THUNDERSTORM …DEVIATION
32. SIDS AN D STARS Image: Brennan Raj CC BY-SA 2.0 https://flic.kr/p/dpaHaK
33. 1. Goal conflicts 2. Production pressures 3. Systems not-as-planned 4. Clumsy technologies 5. Procedural complexity 6. Barriers to feedback 7. Eroding defences 8. Adaptations 9. Compromises & Trade-offs 10.Drift The fallacies of work as imagined | @stevenshorrock
34. The fallacies of work as imagined | @stevenshorrock
35. How we work How we design & implement How we think What happens Influence Influence The fallacies of work as imagined | @stevenshorrock
36. INTERVENTION FALLACIES § The fallacy of the magic bullet § The fallacy of command-and-controlism reminders | policies | overproceduralisation | formification | clumsy automation | targetology | inspection visits | unjust sanctions The fallacies of work as imagined | @stevenshorrock BRITTLE STRATEGIES
37. AFTER Photo: ResoluteSupportMedia CC BY 2.0 https://flic.kr/p/922V3P THE RUNWAY INCURSION
38. Image: Steven Shorrock CC BY-NC-SA 2.0 https://flic.kr/p/2bkA8HS
39. What is it about your work that others (outside of your profession) might find surprising, but that might be interesting or relevant to them? Or… What might you be reluctant to tell them? Tell me… steve.shorrock@gmail.com or @stevenshorrock
40. THE FALLACIES OF WORK-AS-IMAGINED § The fallacy of difference § The fallacy of the first story (human error-as-cause) § The mind projection fallacy (the ultimate WAI fallacy) § The fallacy of the system-as-designed § The fallacy of technical rationality § The fallacy of the magic bullet § The fallacy of command-and-controlism The fallacies of work as imagined | @stevenshorrock
41. HEALTHCARE EXAMPLES www.humanisticsystems.com bit.ly/TAOHW1
42. 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
44. or www.bit.ly/HindSightMagazine steve.shorrock@gmail.com @stevenshorrock Download Free at SKYbrary.aero HindSight 29 on Goal Conflicts & Trade-offs out Autumn 2019