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Hi, and welcome to the Safety Guru. Today, I’m very excited to have with me Professor Mark Young. He’s a human factor professional and a professor in transportation, University of South London, does a lot of work and research in this space. I’m very excited to have you with me, Mark. Tell me a little bit about your background and how you got started in this space.

Hi, Eric, and thanks so much for me on. It’s great to be here. Thank you for the introduction. I actually started out in psychology. My first degree was in a psychology department. As part of that, I started learning about cognitive psychology and how humans think and make decisions and perform and took a course in human factors during that time, which got me really interested in mixing my two interests of how people think and behave with technology stuff in the real world and how that applies to making the world better in terms of systems, interfaces, design of equipment, etc. I went on and did a PhD in that topic in the University of Southampton, using the driving simulator, looking at the impact of automation on driver mental workload and ultimately performance. The stuff that’s around now quite commonly in our car, so adaptive cruise controls, automatic steering, that thing. What that did in terms our attentional capacity, what that did in terms of mental overload. A lot of people have been concerned for a long time with things like overload, if you got too much to do and how that affects your performance, but there was less interest in the underload side of that equation, which can be just as bad for performance as overload.

That’s what I got interested in looking at using the simulator, looking at the effects of automation on drivers. I carried on in academia for some time, working at a partner in Southampton and then on to at Brunel University. Again, doing work in driver behavior, looking at things like eco-driving, looking at things like driver distractions from advertising, from meeting and drinking, that thing. And the more I got interested in I’ve got a performance in particularly safety critical systems, and I got interested in accidents, an accident investigation. Then an opportunity came up to work with the UK’s rail accident investigation branch. This is a bit like the NTSB in the States. They do independent investigations of accidents to improve safety. I’d like a job there and I was very fortunate to get it. I worked there for 11 years, which flew by. A very satisfactory time I had there working on a number of investigations across different areas of the railway, learned an awful lot about railway operations and applied my human factors experience to understanding what’s gone wrong in these accidents and how we can make recommendations to improve safety in the future. Although it sounds on the face of it a bit of a grim job, and it certainly had its moments, it was incredibly satisfying and was a great place to work.

But then about a year and a half ago, the opportunity came up to return to academia. In fact, to my original university back at Southampton with this role as professor of Human Factors in Transport within the Transportation Research Group. It was too good an opportunity to pass up, really. I went for that and again, was very fortunate to get it and have been back here now for about a year teaching and researching within… I’m actually in a School of Engineering, Department of Civil Engineering, even though I’m not an engineer. As I said, my original background was in psychology. But because human factors really breach all those disciplines. It’s a very interdisciplinary topic across engineering, design, psychology, behavior, all those things. It’s a very applicable place to be, and we’ve got great facilities here. Again, a much-upgraded simulator compared to the one I was using 25 years ago from PhD and interested in the vehicle and bicycle and that stuff. So great opportunities to carry on doing research in that area.  

We’ll talk shortly on the impact of automated transport on safety. But maybe First, let’s start on the human error side because we start most investigations looking at a degree of human error. Tell me a little bit about some of those elements and some of the work you did on the transport side.

Yeah, absolutely. It’s long been a bit of a bug bearer of mine, actually, that when you quite often see in popular media and reports when an accident happens, that so-called human error was to blame. Every time I see that, and it happens quite a lot, it always gets up my back a little bit, partly because obviously, looking at this area, you know quite a lot about it. But the reason being that, well, there’s a couple of things associated with that, really. You quite often see statistics that anything up to 80 or 90% of accidents are due to this notional human error. I take issue with that, partly because from my point of view, well, okay, you’re talking about the last person who touched it when you talk about those statistics, you’re talking about the driver, the signaler, the pilot, whoever that might be. That’s who people are typically referring to when they talk about this 80, 90% figure. From my point of view, I think about human factors from a socio-technical systems perspective. It’s not frontline performance. Yes, that’s an important part of it, and we absolutely do look at that. But in the accident investigations and with this socio-technical systems perspective, we dig beneath that.

We have to understand what led that person to make those decisions and actions at that point in time in that place. And there’s a whole bunch of stuff that can lead up to that from their training, from the systems they’re using, the equipment, the interfaces they’re faced with, the processes and procedures, right the way up to the culture of the organization, the regulatory framework. You can even take it up to government and national levels if you wanted to. So, there’s a whole bunch of other stuff that goes behind that so-called human error figure. Actually, when you think about it from that point of view, there are humans involved at every single step of this chain. Even what might be a technical failure, a wheel bearing that’s failed and caused a derailment or something like that, well, ultimately, why has that failed? Is it a design issue? Was there something wrong with something missed in maintenance, something like that? There are actually humans involved every step in this process. So, from that point of view, you could argue human error is a factor in 100% of accidents. So that’s one reason I have issue with that.

Fair? Yes. The other reason is this whole thing that as we’ve just discussed, it really is just the starting point. It puts the blame on the frontline operator. And like I was just saying, there’s so much more stuff behind that. So yes, if you go and investigate an accident, your starting point is what happened on the front line. How did we get to this point in time? And you will interview those people involved. You will try to understand what they were doing at that time. But then you dig so much further, you dig much more beneath that. That human error is just the starting point, and we dig beneath that. When we’re making recommendations, which is the end product of an investigation, we want to make stuff better. We want to improve safety in the future, make recommendations to plug those gaps that may have emerged in that system and stop this thing happening in the future. We make those recommendations so much further upstream. There’s no point making a recommendation saying, retrain this person or do something about what they were doing on that. Because all that’s doing is putting a sticking plaster on it.

All that’s doing is saying, we have fixed that one person’s activities at that specific location at that specific time. Sure. Another person could step into those shoes and do exactly the same thing on another day slightly different circumstances. If we go much further up the stream into the socio-technical system and make recommendations at a much higher level, we can stem that tide. If you think about it like the source of a river and loads of tributaries or something like that. If we stem the source, we can affect so much more, we can have much bigger impact to all those other people that might step into those shoes on that front line.

I think this is key because it’s one of the areas where transportation, I think, has gone much further, is in most other industries, it’s blamed the employee. It’s focused on the error, the person that made the mistake, as opposed to acknowledging that as humans, we all make mistakes, and none of us have not made a mistake in the last, probably hour or short period of time. We’re not fixing things. That’s, I think, the area where in aviation, but in transportation in general, there’s been the biggest shift is really understanding, recognizing that there’s a lot more to the chain, that if we want to fix it, if we want to prevent In an incident, we need to go much deeper.

100 %. And what you’ve just described there is exactly what I teach my students. We all make errors all the time. It’s all about the context in which these errors occur. So everyday errors and the psychological mechanisms behind our everyday errors are exactly the same, whether we are at home doing something quite inconsequential or on the flight deck of a of a major eyeliner. There’s a really good example, and it’s a fundamental error type that we all make, and it’s a mode error. And a really simple example of this is using a digital alarm clock and you’re trying to set the alarm, but it’s actually in time mode and you’re resetting the time on it instead. So, it’s an action that might be appropriate in one mode and you are unknowingly in a different mode and that becomes, by definition, an error. Sure. There have been examples of major airline disasters where these basic mode errors, like setting a particular altitude mode, descent mode, which the same numbers on the flight deck can relate to flight path angle or rate of descent. And one, if you put the same numbers in, it can be a much steeper descent in one mode than another. 

And that has, in the past, led to a major disaster. So, it’s exactly the same error type, but in the context of a safety critical system, it can lead to much greater consequences. So, you’re absolutely right. We shouldn’t just be thinking about the last person who touched it. And a lot of that, I got to be honest, is, and I’m not going to go into specific details, but some of that does come down to even geographical different cultures. You see certain cultures that are very, very quick and ready to pin blame, and even legally, even be charging people involved on the front line before any proper investigation has taken place.

That also limits our ability to learn because now it’s immediately going to default, and people are going to start hiding some of the key facts.

100% indeed, yeah. These safety investigations are all about safety learning. The organization I used to work for and the NTSB and other similar organizations around the world, they’re all about safety learning. They It’s not going to go out for blame or liability or prosecution or anything like that. It’s got to be about safety learning. You’re absolutely right. If people believe that they are personally going to be at risk, they’re not going to share all of the facts. A really big part of that safety investigation is ensuring you get that trust in these people and ensure that you are getting all of the facts and on all of the learning so you can make those appropriate recommendations.

One topic we were also discussing initially is around fatigue and how fatigue plays out in often is a precursor of error, as we all, when we’re fatigued, are bound to make mistakes. Tell me a little bit more about fatigue and how different industries look at it.

Yeah, it’s a really good example of what we might call a performance-shaping factor. So, something that can affect us all, and as you just rightly said, affects our performance to a greater or lesser degree, depending on how fatigued we are. And the nature of transportation systems today, whether that be rail, aviation, whatever, 24/7 industries, they’re all going to be subject to fatigue to a certain extent because we are animals, we are human beings, we are animals, and we are circadian animals. We are designed to be up in a day and a sleep at night. If we mess with that in any way, trying to get people to work at night and sleep in the day, there’s always going to be an element of fatigue risk. You can never completely eliminate fatigue with a shiftwork-type industry, but you can do stuff to manage the risk of that fatigue, then translating into performance difficulties. Because if we’re fatigued, it can affect our reaction times, it can affect our decision making, it can affect our mood, and it can even have long term effects on our health, gut problems, heart problems, that thing, if we have chronic fatigue over a length of time.

It’s really important that we do manage this risk. And an aviation rail over the years have made great strides in trying to not just understand the causes and consequences of fatigue but put in place what they call fatigue risk management systems to try and mitigate the risks of that. And that’s not just about managing the hours of work. Yes, absolutely. Managing the shifts is a big part of managing fatigue, so not working too long, making sure people have got sufficient rest in between shifts. But it’s also got a qualitative angle. It includes things like fatigue reporting. Just as we were just talking about in terms of gaining trust from people in an investigation to report what’s happened so we can get the safety learning, it’s the same thing with fatigue. If people are tired for whatever reason, employers, managers would need to know about that. We don’t really want people in the cab of a train or the flight deck of an aircraft doing their job if they are fatigued. It’s really important to understand that and understand where that fatigue has come from so that we can then do something about it, because a lot of it is just about sleep and sleep opportunities.

The reason we talk a lot about managing work hours is because that’s the bit that organizations have control over. But really what they’re doing with that is providing people the opportunity for rest. It’s about making sure people have got adequate opportunity for sleep when they can regenerate and restore their abilities to come back fit for work the next day. The fit for work thing is, by the way, not just fit for work at the start of their shift, but all the way through to the end of it as well. Some of the accidents I was involved with in my previous post, we’ve seen accidents happen towards the end of a long night shift. People might have been turning up for work, fit for work. They do a fit for work check when they book on, and they might be fine then. But what are they going to be like 10, 11, 12 hours later? And that’s when you see these incidents tend to occur. So, it’s by no means solved. There’s a long way to go, and it’s the thing, as I say, you’re We’re going to completely eliminate fatigue in a shift work industry, but we can do a lot to manage and mitigate the risks associated with it.

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Are there some learnings from what’s being done in the transportation space that could be carried into other industries around the fatigue management side of the equation? Because obviously, shift work is a key component, and how you manage the shift and the hours of rust and so forth, but other things that could be brought forward to other industries.

Definitely. As I say, aviation, rail have gone great strides over the years to advance their fatigues management systems. Marine, to some extent, I guess, because of the nature of marine work, maybe hasn’t quite come as far as the other transportation modes, but they are starting to work on that. But one area where it’s really important, and this is an area that I’m getting into myself at the university, is healthcare. So, fatigue management in healthcare hasn’t really, certainly, I’m speaking for the UK now, hasn’t really gotten hold of this issue at all. I I wear another hat with my professional institute, the Chartered Institute of Ergonomics and Human Factors. I’m current President of the institute, and we published a white paper just a few months ago, actually, part of a… I don’t take full credit. It was part of a group effort but the white paper was on fatigue risk management in health care. Taking these lessons from other industries, primarily transport, and trying to apply those in the health care context. Because as you can imagine, some of these long and complex surgeries can go on for hours and hours and hours. There’s been, historically, this culture of powering through consultants and surgeons not feeling that they are susceptible to these issues.

But we’re all human at the end of the day. It doesn’t matter whether you’re a pilot, a driver, a train driver, or a surgeon. We all are subject to the whims of this circadian rhythm, this daily diurnal rhythm that we’re all susceptible to. It’s really important that we try and manage that and bring those lessons across. I’ve actually got a PhD student starting next month, actually, doing a project on this very topic, trying to understand fatigue in health care and how we can manage that.

It’s also an industry that has shifts that go through the night, particularly on the nursing, but the doctors, maybe not operations through the night, although there could be in emergencies, but high impacts.

Yeah, and look, that’s right. But the thing is, there are errors in health care, and there are consequences from that, but they are not on an individual level. They’re not on the same scale as a major airline disaster. But it’s a bit like road accidents, really. So, accidents tend to happen frequently, but a few people will be injured or killed on each individual occasion. So, they don’t tend to gain the public attention or hit the news in the same way as an airline going down with a couple of hundred people on it. So that would be very newsworthy. But actually, when you look at the data, that thing is happening regularly on the roads and in healthcare, just in ones or twos. It’s really important that we do get hold of these issues.

The last piece I really want to touch on is your work and your research around automated transport because there’s more and more instances of this automated transport, different vehicles. You talked about the cruise control and the adaptive cruise control. But we’re moving more and more towards vehicles that have high levels of automation, which for the most part should improve safety, but also introduces a lot of new risks. Tell me a little bit about the work you’ve done in this space.

Yeah, that’s right. It’s really interesting because as I mentioned at the top, this stuff I was doing 20, 25 years ago is almost more relevant now than ever. So, these systems are now live. They’re in our cars where many of us have probably experienced them and are using them. And the point we’re at now in terms of technology progression and legislative progression, too, and certainly I know a few states in the US, and we’re going to be doing that in the UK quite soon, is moving forward to this what they call Level 3 automation. I won’t go into detail about the different levels, but up till now, we’ve had bits of the driving task automated for us. You can automate speed with cruise control and adaptive cruise control. You can have some steering automation with lane keeping support and that thing. But we’re getting to a point now where we can automate an entire part of the driving task, but only in certain circumstances. So, you can actually technologically and legally take your attention away from the road, but only in a given context. So that might be on a highway under certain traffic conditions, that thing.

And you need to be ready to step in when the system needs you to. So, part of this whole thing will be the system monitoring the driver as well, understanding from things like eye movements and other behaviors, whether or not it thinks that you’re attentive and what they call fullback ready. You need to be ready to step in as a fallback user if the automation suddenly goes out of its design scope or some other technical issue. For me, from a human factor’s perspective, this is the really tricky phase. This is the troublesome adolescence, if you like, of automation going forward, because what we’re saying to people, drivers, not drivers, but the people behind the wheel, is that, yes, you We switch off now, but we need you to be able to step in. There’s a whole bunch of questions that are still… There’s still research going on in terms of how quickly people can step in. What warnings do they need? How do we ensure they maintain their attention that they are ready to step in? Because you can’t just say to people, Okay, you can sit there and watch a movie or do your emails or whatever, but as soon as I ring this bell, you need to be back in and driving.

People don’t work like that. We need to regain our situation awareness. We need to think, Okay, what’s going on? What are you telling me? What is the automation doing? What’s going on all around me now? How am I supposed to get back into the loop on this thing? What you said about the automation introducing all sorts of new problems, that’s absolutely true. We’ve seen that in aviation, too. We learned a lot of lessons from automation and aviation in terms of translating that across to automotive. Because yes, okay, fundamentally, there probably will be fewer accidents on the main with automation than with human drivers. I think the jury is still out on that to some extent. But I think it’s probably fair to say that that will be true. But what we will get is a whole bunch of new categories of incidents and accidents, because what that involves now is not just being aware of the driving task and what’s around you, but also managing this relationship with the system. You’ve got another layer, if you like, of a driving task there. What’s this system doing? How do I know what it’s coping with? What do I need to do?

It becomes an issue of communication. It’s almost like driving with a co- driver, a human co- driver, and that analogy has been drawn. This system now is becoming part of a team. Human automation teaming is a real big area of research at the moment. How do we actually work together? How do we communicate and coordinate our actions for the ultimate good of the system performance. We want to be able to get from A to B safely and as efficiently as we possibly can, and we need to work together to do that. We can learn lessons from human teamwork. How would I work with another human co- driver? We’d be talking to each other all the time. We’d be saying, Okay, there’s something weird going on here. I need your help here to cope with this. The thing is with automated systems, they tend not to communicate like that, and we need to get better at that. We need to be able to design these systems to work better with their human counterparts. And that’s a two-way thing. We need to work so that the humans can talk to the automation and the automation can talk to the humans.

Otherwise, I think we will see a whole bunch of new problems going forward. And that causes all sorts of sticky legislative and ethical and moral issues because, okay, society, I’m not saying this is right, but society might well accept people crashing or having incidents on their own back. But now what’s happening is, well, who’s now responsible? This system has maybe caused this accident. So, who’s responsible for that? Is it the driver for not paying attention? Is it the manufacturer of the vehicle or the provider of the automated system? Where does that responsibility now lie? And these are all questions that are still open for debate.

And we’ve certainly seen, you brought up aviation. We’ve certainly seen in aviation, a lot of incidents where the autopilot kicks off and there’s a warning that comes in. The amount of time for the pilots who are highly trained to really recognize what’s happened, in some cases, like the 737 max, where systems kicked in automatically because they interpreted data in a way that they shouldn’t have. The pilots weren’t even able to overcome and take over control of the flight.

That’s right, because they weren’t aware of what was going on with the system. There’s a whole bunch of stuff behind that. 737 is one of these incidents that really illustrates this system’s view, because there were all sorts of even organizational stuff going on there about not providing the flight crew with appropriate training and understanding of what that system should be doing. But, yeah, fundamentally, it came down to communication. The system actually informing the flight crew about what’s going on, what they need them to do, and that communication breakdown. It’s the same thing with the Air France 447 accident. Same thing happened there. Workload comes into play again with that one. It’s in the cruise phase of flight over the Atlantic, very low workload phase. Then the system started getting screwy readings from the Pepto tube for the airspeed. Then it’s I’ll cut long story short and oversimplifying, it got to a point where it basically said, I can’t cope with this anymore. I need you to take over, and gave this back to the flight crew, at which point the flight crew go, Wait, what’s going on here? Because they’d never seen that situation before.

They’re highly trained. Nothing wrong with their training or what they did. It has been said in research that these kinds of situations, again, coming back to that point about human error, you could very easily say, well, it was the pilot’s fault because they should have taken over flying. But no, there’s an alternative perspective on this where actually the pilots just weren’t able to save the situation. It wasn’t the pilots that caused it, they just weren’t able to save it because actually what happened was, they were faced with a situation that was a surprise to them, a fundamental surprise. I’m not just talking like a birthday surprise. This was something that they were completely unprepared for and not expecting in the slightest and were unable to cope in that particular situation, unable to diagnose and resolve the situation in the limited time they had available to them. You can’t really put that on the flight crew. It is a socio-technical systems issue.

You’re also dealing with an industry where the level of training is significantly higher than the typical driver.

Wow, yeah, seriously.

Then the driver does doesn’t have the simulations, all the various training components that happen every year, and suddenly they have to deal with the technology in front of them.

That is so true. Some people say, well, aviation must be more complicated because you’re moving in three dimensions and all of that. But no, there’s a prevailing perspective that no, driving is way more complicated because it’s so much more random. You’ve got all sorts of stuff that could… Okay, it’s only in two dimensions, but you get all sorts of stuff that could happen. These rogue other road users, you don’t know what other drivers are going to be doing. What’s that pedestrian going to do? Is that cyclist going to ride out in front of me? And again, another point about this intermediary space until we get to full automation at some point in the future, probably decades away, to be fair. But it’s not just about this intermediate automation inside one vehicle. We’re going to have a mixed fleet on the road. We’re going to have some cars that are human-driven, some cars that are partially automated. How are they all going to interact with each other? How are they going to interact with other road users, pedestrian cyclists, vulnerable road users? And that thing? Actually, I wrote a book and a paper on this myself last year with a slightly contentious perspective on it, but deliberately provocative, suggesting that You know what?

We should just wait. We should just wait until we are ready to fully automate and then jump off that cliff and just say, Right, okay, we’ll hold back, let people drive their cars up. Yes, we can use the technology to help them. Yes, we can provide safety systems, the stuff that we’ve already got, like antelope, braking systems, traction control roll systems, collision, the stuff that’s like a safety net for drivers. For sure, use those systems to help people do what they normally do. But until we can fully and completely automate the entire task, and I can just get in my car on the driveway here and it can take me to my office or wherever I need to go without any intervention from me, then maybe we need to think again about that relationship with the automation.

Yeah, I think provocative Statement, but I think there’s a lot of merit in it in that if you look at aviation, there’s so much more training, so much more guardrails around dealing with the automation. And yes, we talked about the Air France, and the Boeing 737 max, both illustrations were technology and humans were trying to figure out how to interact with each other.

Yeah, that’s right, indeed. And as you rightly point out, drivers on the road get barely any training in comparison. And That’s another question. Will we need to train people to use the automation? Again, using the UK as an example, we have a different level of driving license for using automatic transmission, automatic Gearbox in our cars. If you train and pass a test on an automatic transmission, you can’t use a manual or stick shift until you’ve taken another test. Will we need to think about that for more levels of automation in our vehicles? Is that something that we need to be able to manage the system as well as driving the car? But yeah, I’ve always said that driver training really just tells you how to operate the car. It doesn’t really tell you how to drive properly. It’s a lot more stuff going on there. As you say, in comparison to what flight crew gets, it’s a world apart. Yeah.

Mark, thank you very much for joining me today. A fascinating topic. I think the main takeaway for industries in general is really to think about how I can bring some of these topics from the transportation space. We talked about fatigue, but also, we talked on just the element that humans are going to make mistakes. We are bound to make errors. How do we create a system that reduces the consequences as opposed to blaming the individual at the end? Thank you so much for joining me today.

Thank you for having me. It’s a pleasure.

Thank you for listening to The Safety Guru on C-suite Radio. Leave a legacy. Distinguish yourself from the past. Grow your success. Capture the hearts and minds of your teams. Elevate your safety. Like every successful athlete, top leaders continuously invest in their safety leadership with an expert coach to boost safety performance. Begin your journey at execsafetycoach.com. Come back in two weeks for the next episode with your host, Eric Michrowski. This podcast is powered by Propulo Consulting.