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Ergonomics Meets Human Factors: Building Safer, Smarter Workplaces with Dr. Era Poddar

Aug 6, 2026

Ergonomics Meets Human Factors: Building Safer, Smarter Workplaces with Dr. Era Poddar

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ABOUT THE EPISODE

In this week’s episode of The Safety Guru, we’re joined by Dr. Era Poddar, who shares her extensive expertise in ergonomics and human factors to explore what these principles are, why they matter, and how organizations can proactively integrate them into workplace design to transform safety outcomes, boost productivity, and build safer, smarter workplaces. She discusses the wide-ranging benefits of integrating these principles, including better decision-making, reduced cognitive load for employees, fewer errors, a lower risk of serious injuries and fatalities, and measurable returns on investment (ROI) through improvements in quality, productivity, and overall safety performance. This insightful discussion also highlights how leaders can champion ergonomic improvements, leverage emerging technologies that are reshaping workplace design, and foster a culture of continuous learning and improvement. Tune in to discover how ergonomics and human factors work together to build safer, healthier, and more productive organizations. Don’t miss this episode!

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Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and well-being of their people first. Great companies ubiquitously have safe yet productive operations. For those companies, safety is an investment, not a cost for the C-suite. It’s a real topic of daily focus. This is The Safety Guru with your host, Eric Michrowski, a globally recognized ops and safety guru, public speaker, and author. Are you ready to leave a safety legacy? Your legacy success story begins now.

Hi and welcome to The Safety Guru. Today, I’m very excited to have with me Dr. Era Poddar. She has a PhD in industrial ergonomics, an MBA from UBC, does a lot of consulting work in the ergonomic space, and is also an adjunct professor at the University of British Columbia. Era, so happy to have you with me today on the show.

Thank you, Eric, for the introduction. And I would like to just— mini-MBA.

Mini MBA?

Yeah, it’s not the full MBA at length, but I will reflect on that a little bit. Okay. Why I mentioned that. Yeah, thank you. I’m really glad to be talking to you today.

Absolutely. So, tell me a little bit about how you got started in ergonomics and the passion you’ve gotten for safety and ergo.

Right, it’s a very interesting question, and I, I have been asked about this for so many times. I remember talking to in one of the platforms in my previous employer, some people were talking about different epiphany happened to them, and that’s what they came. To be very honest, I never had such, such incidents, or I would say positive incidents, but what I had in the— I first, to, to be very honest, I learned about the subject when I went to the university to do my master’s program. And so, it’s a human physiology master’s from University of Calcutta. They had a specialization in ergonomics and human factors. So that’s where first I came across the subject. No one knew about this. I was pretty intrigued about the subject because it has direct implications on human life. Like, of course, industry to design and everything. So eventually, I got to love the subject, and I became passionate about it.

And it’s taking you all around the world. And so that gives you fairly unique perspectives as well in terms of how you’ve applied ergonomics in that space. Maybe let’s start with what is ergonomics and why is it so important?

Right. I should go back to a little bit because I had to also touch base on things which, which intrigued me to be part of this subject. One was like, I started my career in a design project, a mining scenario, and I thought that would be pretty interesting for the audience. So, this project ran for 1.5 years, and then we, we redeveloped or redesigned, uh, certain equipment’s, over 10 of them. And during that time, I realized this subject has a different application and we need to pursue more. That’s where I started doing PhD and all that, all the things. Uh, but as you know, life happens, things change, and I, I started my career in a university setting teaching after completing, uh, my PhD. So, while teaching, there are different design applications from physical product design to interaction design and all that. Stuff. So then, as usual, things change, uh, and I followed my husband to Middle East, and that’s where, uh, it’s a different, uh, scenario of ergonomics kind of came into my understanding because it’s a business side of it. That’s when I started my business because there was less scope of applying in the education domain.

Sure.

And before that, I lived a little, uh, time teaching in Nepal, one of the universities, medical school. So, all these things and, uh, kind of intrigued me to apply different domains of this area as well as leaving my comfort zone, I guess. So, in Dubai, we kind of, uh, what we did was, as I said, there’s less education apply— like application or courses. However, there was a scope, uh, to represent companies who had multiple offices across Middle East to help them in their ergonomics initiatives. So, you could call it a beginning of a mini-MBA for me, hands-on practice, and which I wouldn’t have done otherwise if I wouldn’t be leaving my secured career path. And that’s where it’s a different approach which, which is taken from there. And then onwards, I lived in the US and practiced, and then it came back to Canada at one point. So, through all this journey, which why I, I wanted to mention that I— it gathered to me, one is I understood the local practices, standards, and all that.

Sure.

It also did an interesting thing to me. I became more and more open and like it grew empathy to me more. And that is one of the key factors we practitioners in ergonomics do. And it’s really one of the key important factors to be successful in this field. Right. And coming back to your question, what is human factors and ergonomics? Is essentially reducing the mismatch between product or system and the user. So, in one word, however, there are several, um, definitions you could find. That is, it’s a science of work design, science of workplace design, and so on and so forth. But we always emphasize on one important aspect aspects of ergonomics and human factors, two different words. Yeah, coined together, they actually mean the same according to International Ergonomic Association. Uh, the overall— I mean, uh, the definition is, is like human factors or ergonomics is concerned with the understanding of interactions among humans and other elements of a and this profession applies theory, principle, data, and methods to design and optimize human well-being and overall system performance. So, we always focus into the system level, uh, changes so that it affects in an effective way for long term.

So yeah, in one word, it helps, uh, I think, reduce any mismatch between any system and product. And improve productivity.

And so why is it so important for businesses to look at that combination of ergonomics and human factors? And what’s the ROI that comes from it? 

It is a very interesting question. And we still, I mean, it’s proven, understood that it’s a business-friendly concept.

Sure.

Why? As I said, it reduces mismatch in very different ways. From building design to the product design, even for software design. So, there is a coin word called usability. That’s actually how you reduce the mismatch between human and the software or any interface design. So, over the years, it has been shown to be kind of helpful for the business. And why it is helpful? It reduces error, less time, and sometimes the processes are improved in, like we call them, ineffective time. How you reduce them? All this together, as well as a different reachability and use— usability, or ease of usage of any, any such product. Or given— I will just give you some examples.

Yeah, that would be good.

Yeah. Like for, uh, suppose a company who has a production line who produces certain products. Now if the workstations are higher compared to who are operating and there are a lot of reaches, like you move your hands pretty quickly and there’s long reaches. Now if we do it once or twice, that’s fine, right? And if you do it throughout 8-hour shift, sometime industry have 12-hour shift. To. Sure. So, these are the different aspects. One is size-wise, one, one is process-wise. And suppose you have kept certain products or so stored certain products in a different section. Now the employee has to go bring them. So, there are different touch points and different level of postures which is happening, which could have avoided with a better design.

Sure.

When the industry is built or when the workstation— yes, when the workstation was designed. So that’s where if we incorporate these issues, like how this whole process works, where, where people has to interact, and who will be the person who will be interacting. It is a range of people, not every— like, for even given, uh, different genders, there are sizes. And suppose, giving example, 95% percentile stature, people may not be having 95th percentile hand length or arm length, right?

Right.

So, all these challenges kind of available, or it is there within any workstation workplace setup. So, the more we kind of accommodate these requirements since the beginning, you definitely kind of benefit. And end of the day, product quality also improved. So, this whole span of activities, if we consider it effectively, we will save on time, we will reduce injuries, and the injuries will be less fatal, as well as there will be less error. As a result, you will get a product which is quality-wise better and more product. So, it’s an overall win-win for both employees and the employers in a way. I hope I understood.

No, no, absolutely. Yeah. So, and it’s something, as you talked about, it can mean how I design a plant for how the workers are going to work in. But I could also retroactively drive some improvements. So, there is less movement that’s unnecessary, less lifting, bending, stretching, overreach occurring throughout the day.

Also, less decision-making.

Sure.

Because more and more workplaces becoming automated.

Yeah.

And people are even in regular manufacturing settings; we see employees has to interact with machines where they have to put input and given that the cycle number and what is the output number and all that. So, these— all these interactions are happening at like simultaneously.

Sure.

So, there are cognitive demand as well as physical demand. I, I just gave you a very simple industrial scenario. So, there are complex scenarios like pilots interacting with machines, or we are driving a car. There are so many distractions these days, from external to internal to phone and displays and stuff. So yeah, it makes more sense to incorporate through the design at the beginning. However, it could be applied in every stage.

Sure. Yeah, to drive improvements, to improve the work practices, but also the cognitive load that you mentioned before in terms of the decision-making. I like your example of the car as well. So very, very beneficial. As you said, there’s a The ROI is really because it’s helping, one, the workers, but it’s also helping productivity directly. If you have less distractions, you have less complexity in your decision-making and less movement to complete the task. Is that fair?

It is fair. And I should also add where it is, most of the time, the ergonomics or human factors concepts are applied towards later phase, like when you have an injury, right? And this is not that proactive, more reactive approach. Unfortunately, in— especially not even only in Canada, I have seen in the US or even in the Middle East, that’s where we are called as a practitioner. So, when everything is all set, you have a process set, you have a design set, and there are also different teams working together, not including one of, like, human factors or ergonomics professionals within. So, what it does is there’s always a gap remaining. So, end of the day, which we see, there is an incident, and most popular incident which relates to ergonomics, human factors, that’s musculoskeletal injuries.

Yep. 

And that’s where people think that’s what ergonomics is, which is not at all, uh, right directions. But that’s where most of the time we are called in. So as there also huge number of dollars are lost every year, if we see the recent statistics even through WorkSafe BC locally. It’s over $2 billion of cost. 

Sure.

And over the year, like recent years. So that is something has to be definitely seen as one of the ROI where we could control this cost.

And ideally done proactively, right? So, as you mentioned in the plant design, or even at a later stage to drive improvement.

Yeah, true. Unfortunately, that is not always done that way. 

Yeah, unfortunately not. Yes. Yeah, unfortunately, sometimes you need an event to realize it wasn’t designed the right way. So, one of the things I know when we first connected that you touched on, which I thought was very interesting, is around changing workplaces. And there’s a lot of changes in the current workplace. How does that impact the space of ergonomics and human factors.

This episode of the Safety Guru Podcast is brought to you by Propulo Consulting, the leading safety and safety culture advisory firm. Whether you are looking to assess your safety culture, develop strategies to level up your safety performance, introduce human performance capabilities, re-energize your BBS program, enhance supervisory safety capabilities, or introduce unique safety leadership training and talent solutions, Propulo has you covered. Visit us at propolo.com.

Few things we have to understand. Since World War II, when the subject evolved, many organizing factors, there’s very less understanding across other disciplines about the breadth an application of the subject. So, when, uh, the workplace changes considerations came into play, especially in Canada with the Inclusive Act and all that thing, uh, the concept remained pretty old. Like, it’s not that new, right? Uh, so the changing workplace has been— we see, just giving you an example, if we visit, even you come to any public place or any workplace, you will see different variations of populations coming from different cultures, background. So how does it affect the workplaces? Uh, one is size, like your anthropometric measurements. You have a different language spoken throughout like when growing up. So, you are learning a different language, you are getting instructions through different languages. As the same— at the same time, we have different, uh, equipment’s incorporated into the workplace, more like recent AI. And over the years, we have seen a lot of more automation happen. So, employees are interacting with various different as I mentioned earlier as well, the physical, like manual material handling to giving input to the machine to do a proper setup speed.

Sure. And the production. At the same time, you are getting information through your handle devices.

Yep.

And you are also interacting with some of those displays. And there’s a workplace changes happen through the age. We have older work curse, who has limited ability to interact with digital devices, right? So, these are a complex scenario where you have different, different genders, you have different background, you have different language, culturally different thinking. We don’t have enough time to talk about that stereotype things, but it is there. We think differently, we perform, understand differently. So, these vast and different sizes, as I mentioned, we incorporate this whole group of population within a particular workplace. Right. So, definitely there will be repercussion on that. Yeah. Unless it is really designed well or it is accommodating all this requirement. And at the same time, you have differently abled people who have limitation like moving or different level of cognitive abilities. So, there are so many different challenges within that place. So, when we say the accessible or universal design concept, so we, we talk about all of these people is welcome in that workplace or any space, and they can easily interact with all these different things. And how we make those things user-friendly for them. So that’s when we talk about different level of accessibility or universal design.

Which really means a lot more flexibility in terms of how you would interface with equipment, the technology, potentially very different sitting position, if in that scenario, you’re talking about, where there’s flexibility of adjusting depending on what’s right for that particular individual.

Yeah, I can provide you another simple example. Suppose you are accessing, uh, like an ATM machine, right? Right. So now, for people like you and me, I will go walk, park the car, go walk and access. It’s not a big deal. We know these are bigger buttons and everything. Now consider this person who cannot move, who is on the wheelchair.

Yeah.

Now there are different level of accessibility they need. So, he has to access the building first. There has to be certain ramp where they can access. And then there has to be certain reach so that they can see it, still see it, and interact with the machine, right? Not only physical buttons, but there are also digital buttons. 

Sure.

So, then there are all these requirements. So, you have a person who will operate this machine standing, there’s a person who may come on the wheelchair, there’s a person who may come in differently, other way of different, and there is person who cannot see. And also, the language-wise, so people may read English well, some may not, some may come from suppose Mandarin They speak Mandarin, reads Mandarin or Japanese.

Sure.

So, consider a world where all these people live together and interact with the machine. So that’s where the usable or universal design or accessibility come.

And bringing that to workplaces as well, because the same example, it’s how do I design a work environment, whatever that work environment might be, to have that flexibility in terms of interaction.

That’s right.

Excellent. And I know one of the themes we also touched on is around now that we’re hearing more and more about exoskeletons. How does that play into these human factors and ergonomics space?

That is another interesting area of time. Anytime we talk to colleagues, they come up with this question. So, I was recently listening to one of the webinars done by— I don’t remember the organization, but the person who was presenting, Dr. Christopher Reed from Boeing, he was reflecting on many such research and applied within the Boeing scenario. I will refer some of her— some of his topics. So, exoskeleton is, of course, related to ergonomics. It’s not like insects and others. So, it’s an external structure which helps us to support while working. 

Sure.

So, we call them industrial exoskeleton. And there are different types. Some are automated. I mean, they are more advanced these days. But essentially, it is built to support while working.

Right, sure.

So, few, a few different types. I’m very broadly, I’m touching this. One is made for postural assist system, like when someone is working within an environment or very concise space where you cannot do any engineering changes, where you cannot implement those changes. So that person has to work in a certain position, suppose electrician, in that space. You cannot bring in any other equipment. So continuous working within that space and having those shoulder and arm muscles in the, like, over above shoulder level. So that’s when this type of exoskeleton helps. Like, it’s a postural support where hands and shoulders and— sure, other, other part is supported. There is other type of where you have full body support, like especially doing manual material handling where any other engineering changes or equipment could be provided in such certain scenario. It seems that quite a few other companies, including Boeing, is using them while making the airplanes, not— I mean, after it is done, so before that part. So since employees are using them, I had also interacted with few local clients Sometimes, uh, some of the workers like it, some don’t.

Of course.

So, some of them— I, I was amazed to hear this— the— my contact person who was saying that 2 or 3 of them didn’t like it, so they never would wear them.

Sure.

So, there are 1 or 2, it happened that they wouldn’t open it. Without that, they cannot perform. So, there are different varied level of acceptance. Sure, there’s definitely different types of acceptance level as well as, uh, I mean, the type of work people does. Depending on that, this is effective. So, it’s always the first thing we as a professional suggest. If there is option, engineering changes is better options. In any day. However, there is no, I mean, opening to incorporate such changes, then explore this. Still, there’s a lot to— yeah, there is a lot of research has to go in. It’s still developing.

Yeah, absolutely. I think for me, the first example I saw of this was, I’m going to say it’s almost a decade ago, and it was in Japan with baggage handlers, and it was around how do we reduce the lifting and switching that’s happening when they’re moving bags, which sounded very interesting if you think about the repetitive motions and the— you don’t even know how heavy a particular bag is going to be, which adds a lot more risk as well to that equation.

Yeah, you’re right. And also, I remember mentioning I think 6, 7 years back, uh, still the COVID at the beginning of COVID or before that, there were, uh, we ordered some furniture’s and people came to deliver. Some of the company who was contracted to do that, so the employees, their employees were using those exoskeletons to move those furniture’s. Yeah, so I have seen, it’s interesting, few companies adopted them pretty well. And then sometimes, as I said, it’s, yeah, not always accepted.

And as you talk about change, I think one of the things that makes good sense to transition to is what’s the role of a leader in driving that change, right? So, they can— we talked about your role coming in and assessing, but how can a leader support change?

It’s a Very important and interesting topic, and that’s one of my other passion area these days— how to incorporate human factors ergonomic concept within the strategy, right? So, we all know this concept is old enough. However, it’s less accepted amongst the senior leadership.

Sure.

One main reason is the language we speak. So, language has to be such so it is acceptable to the senior leadership. And senior leadership, one and important part which I realized over the years is, of course, they have to be trained in certain aspects. So, we as a professional has to be able to speak that language which caters to that group. At the same time, leadership has to be a little bit open towards these new concepts coming in, right, which is beyond the conventional, okay, they have— there are standards, engineering standards, and we— sure, we have it, then it is all done. It is not always the case because at the end of the day, users are human, right, right. And or whoever is using it, they are the one who is manipulating with the system.

Right. 

So, the leadership’s main, I think, the initiative would be understanding, like keeping a little open mind, one. Second is putting a human factor economics concept as a strategy goal, which is actually part of their business decisions. Then if you have a budget, allocated already, then it’s much easier to implement at the design stage than at the level when an injury already happened.

It really touches the whole space of safety by design, even in terms of if you, if you do things right at the front end, and you’re putting in the time and the effort, you’ll be much better off later.

Exactly. And also, we always say this, you have as a company, every company has their standard operating procedure or SOPs. So, it is always smart to align the programs, including safety, ergonomics, and other programs, to that, right? It’s, it’s much— it makes a lot more sense. And if you remember, I touched upon briefly on a certain point that we have various departments within a company. Unfortunately, some of them, they don’t always interact, or there’s less, less scope, or whatever may be the reason, that interaction is very important. And leadership can bring in that interaction so that same things are simultaneously done but not applied effectively. I have seen that in my practice. That quality team had come up with an idea which is not fully applicable because of the other challenges, However, there was another department have developed a newer idea and applying them within the team which others didn’t know. So again, the communication, communication, and allowing this communication to happen free flowing among different departments without a bias. So that is another leadership role I, I think would be very helpful in such initiatives.

Sure, absolutely. And so, if somebody wants to get in touch with you, what’s the best way to do so? And maybe share a little bit about the type of work that you do to help organizations in this space. 

Right. So best way to reach me through LinkedIn. Also, we have our website, www.argoera.com. You can and definitely click to that website and see our services.

Yep. 

We do offer different types of services. We do offer the program support where the corporations can— an ergonomist like us or others can work together to come up with a plan or aligning their SOPs, which is more long-term. And I think we focus more into that. However, as I— excuse me— as I said, there are a lot more focus into risk assessment or management. So that’s where a lot of business come through that area. So, we do, of course, cover that risk assessment. It could be your industrial risk assessment to corporate. At the same time, we also do worker compensation. Kind of support. I mean, you do need that kind of risk assessment as well, and all, uh, different types of workshops, being it the executive workshops to strategy level workshops, and also participatory ergonomics.

Makes sense. Excellent. So, Era, thank you so much for joining me today. Appreciate your time.

Thank you so much.

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.

ABOUT THE GUEST

Dr. Era Poddar is a Canadian Certified Professional Ergonomist (CCPE) and safety specialist, with broad international experience across North America, the Middle East, and Asia. Her expertise covers industry, academia, corporate, and government sectors. She holds a Ph.D. in Industrial Ergonomics, a NEBOSH International General Certificate in Occupational Health and Safety (practical applications), and a mini-executive MBA from the Sauder School of Business, UBC.

With more than twenty years in consulting, coaching, training, and research related to ergonomics, human factors, workplace accommodation, and safety, Dr. Poddar helps organizations meet goals in health and safety, ergonomics, and MSI control. She currently sits on the Board of Directors for the Canadian College for the Certification of Professional Ergonomists (CCCPE) and actively contributes to the International Ergonomics Association (IEA) Health and Safety Technical Committee, where she leads a group advising on ISO 45001: Guidelines for Ergonomic Processes. Additionally, she is part of the Canadian Mirror Committee (CMC) to the ISO Ergonomics TC 159.

Era is the founder director of Ergoera Services Inc. (https://ergoera.com), which provides customized ergonomics and occupational health and safety services and training. She also serves as an Adjunct Professor at the University of British Columbia, guiding master’s students and professionals in industrial ergonomics, injury prevention, design ergonomics, human-centered design, and user research.

Known as an innovative entrepreneur, leader, and public speaker, Era balances her roles as consultant, educator, researcher, and mentor. She has successfully managed multicultural teams globally, including in North America, Asia, the Middle East, and India. Her work involves leading excellence initiatives, promoting accessibility and universal design, developing safety and ergonomics strategies, and implementing quality improvement programs. Throughout her career, Era has spearheaded ergonomics programs, risk assessments, participatory projects, gap analyses, and process improvements in sectors like manufacturing, mining, food processing, government, corporate environments, and healthcare. Her evidence-based, user-centered approach supports healthier, safer, more functional, and productive workplaces, reflecting her commitment to “Design for All.”

For more information: https://ergoera.com/

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Making Systems More Resilient: Elevating Situational Awareness and Critical Thinking with Craig Clapper

Jul 9, 2026

Making Systems More Resilient: Elevating Situational Awareness and Critical Thinking with Craig Clapper

LISTEN TO THE EPISODE: 

ABOUT THE EPISODE

Join us for this thought-provoking conversation with Craig Clapper, a seasoned systems engineer and founder of Reliability 4 Life, as he explores what it truly means to make systems more resilient. Craig explains why human error is an inevitable part of complex work and shares how organizations can strengthen situational awareness by helping people recognize where to focus their attention, identify the signals that matter most, and apply critical thinking in complex and safety-critical environments. Drawing on real-world examples from a variety of industries, including healthcare, Craig shares practical strategies for managing risk, improving recovery processes, and building organizational resilience. He also highlights the importance of fostering a culture of continuous learning to create safer, stronger workplaces. Don’t miss this insightful conversation and dive into how to build robust systems and elevate situational awareness and critical thinking within your organization. Tune in to learn more!

READ THE EPISODE

Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and wellbeing of their people first. Great companies ubiquitously have safe yet productive operations. For those companies, safety is an investment, not a cost for the C-suite. It’s a real topic of daily focus. This is The Safety Guru with your host, Eric Michrowski, a globally recognized ops and safety guru, public speaker, and author. Are you ready to leave a safety legacy? Your legacy success story begins now.

Hi and welcome to The Safety Guru. Today I’m very excited to have with me Craig Clapper. He’s a systems engineer, founder of Reliability for Life, or R4L, and we’re going to have a really interesting conversation today around systems, healthcare. It will be fascinating. So, Craig, welcome to the show. Very excited to have you with me.

Good. Thanks for having me with you today.

So, let’s get started with your background and how you got passionate about safety, because it was quite an interesting journey.

Excellent. Yeah, I got into this business as an engineer, and I was doing failure analysis work in nuclear power. And I noticed an interesting effect. We had a lot of repeat events, sometimes the same equipment failing for the same reasons.

Right. 

So, in an effort to improve reliability of nuclear power, is I got into this business, which is more about human reliability and systems. I didn’t know at the time, but it kind of took over my professional career. So, I worked in nuclear power, then power in general, transportation, manufacturing, and then for the last 25 years in healthcare.

And so, one of the things you’re looking at is, is essentially why would smart people repeat the same problems, right?

Yes, and repeat other people’s problems as well. I think both are important, us learning over time, but then the shared learning of learning from each other.

And so, tell me a little bit more about this theme around smart people making the same mistakes, or as you said, making some— the same mistake that somebody else did.

Excellent. Yeah, is that we know that, you know, people when they go to work or when they’re at home or at play, for that matter, is that their intent is always to do well.

Right.

Human error is a natural byproduct of people, and when we work in complex systems, that byproduct shows up even more frequently. Right. I think Jeff Raskin said it better than I. He said that everybody is human first and then either an expert or a novice second, but there is no such person that never experiences a mistake, or more accurately, an error.

Yes, an error, right? I think I only met one person who admitted in their mind they had never made a mistake. He was a tax accountant, but he was corrected by his CFO who questioned his assertion.

Yeah, so maybe even saying that was a mistake on his part.

That would be one of them for sure. And so, you talk about systems. Phil, so first, what are systems? We’ve talked about this topic quite a few times on this podcast. And why are they becoming so complex?

You bet. I think the fastest way to kind of smooth over the controversy is that when some people say process, they’re probably talking more about a work system. Sure. Systems are made up of everything, you know. So, when you talk about systems thinking, we say they’re made up of things. And together those things provide functions.

Right.

So, everything that we point to is a work system.

Mm-hmm.

So, we say aviation is a work system, nuclear power is a work system, a power plant is a work system, and then it gets even a little smaller and more granular.

Sure.

But I think what’s different is that it takes us away from processes, which makes us think everything’s linear, right, to thinking more about the nonlinear effect of real work. And over time, you know, technology becomes more complex. The needs of the system to perform become more complex. So, complexity is always increasing around us. And that makes it difficult for us as individuals because we can’t see everything that we’re doing. So, we’re reliant on other people and trying to grasp that situational awareness in the moment to see where we’ve been and where we’re headed.

Yeah, and I think your point is— so definitely there’s a sense that systems are getting more complex. You talk about technology. I remember I had an MIT professor join the podcast a little while back, and his analogy was talking— you might have heard about this one about Ford Mustang from the 1960s versus a Ford Mustang today, and how many engineers does it take because of the complexity of everything that’s engaged and involved. But even when you think about healthcare in terms of way back when, we didn’t have the fields of expertise to the degree we have now. And something like cancer treatment is no longer the domain of one doctor. It’s a domain of multiple different doctors that are essentially speaking different languages.

Oh yeah, that’s an excellent point, both on the car and the healthcare analogy. And everybody becomes hyper-specialized to deal with all that complexity. And then there’s creases, the number of handoffs and the number of people involved. I really relate to the auto example. My first car was a 1970 Chevy Impala, and my dad taught me how to do a lot of the work on it. And now when I open the hood, it’s just— I might be looking for a UL code so I can call somebody that actually knows how to fix it. Right.

It’s impossible to— tweak it like you could way back when.

Yeah.

And so, you talk about the complexity that comes in, um, that brings— I like the expression you use, that, that systems become very brittle. Um, so tell me, what are some of those things that we can do to make systems more resilient?

You bet. Yeah, because, uh, resilient means they’re tough and can bounce back. And sometimes we use the word resilient to mean like after an event. But you can also talk about resiliency in the middle of event or even at the very beginning to prevent events outright. Sure. So, in complex systems, safety comes from resiliency. And I think the best thing to do when you start on this aspect of your safety journey is to think, you know, systems can be simple. Where the knowledge and skill and the tools kind of rule the reliability.

Sure.

But then they can be complicated, like assembling a jet aircraft.

Sure.

You know, a plane is a very complicated machine, yet we want it to be the same. So putting it together just requires standard work. So standard work is our best friend. 

Yep.

But when we get to complexity, is that things aren’t always the same and they’re not predictable, and some things that are unknown are unknowable. So, what makes reliability in complex systems work is our ability to think as an individual, but think together as our team, as a team. 

Sure. 

And then to extend that to resiliency is that you have to think, I believe situational awareness is the root of all resiliencies.

Sure.

Somebody realizes that something is different, and they can think together and then they have an adjustment that they could make. So, they make the adjustment and then they get back on track. In fact, David Woods, you know, from Ohio State, the cognitive psychologist, he had observed that we really don’t have safety events because people make mistakes. We have safety events because they don’t perceive the need to make an adjustment. So, they don’t adjust.

Sure.

And I paraphrase that. I’m sure his quote is better than that.

And so that makes a very interesting perspective as well, because it’s what you talk about, the situational awareness. You see it very regularly in terms of something changes in the environment, the conditions, but we’ve done the same routine work many, many times and we don’t notice. We may have a blind spot to changing conditions. We may not realize that a new risk is introduced or that new risk could be a small change that’s happening in the system. And so, when you talk about resilience, you also talk about this element of learning and bouncing back. And then there’s also this element of a better recovery. Tell me a little bit more about what that entails.

Sure. Yeah, it’s in Eric Hollnagel’s work in resiliency engineering. He includes learning as one aspect of resiliency. And I think that was very insightful. Is that, you know, we learn from our past experiences. So now we know what to look for. And when we perceive that, then the sensemaking is both faster and more accurate. Plus, we have ideas on what adjustment that we’ll want to make. Sure. So, I think that learning aspect, you know, is very important. And earlier when we touched on shared learning, I think it becomes even more important because I’ve also come to realize in doing this work is that we don’t have a lot of foresight. Usually what we call foresight is actually somebody else’s hindsight.

Yeah.

And we recognize that because we heard it from a colleague or we read about it in a report or we heard it on your podcast. Right. So suddenly why it’s novel, it hasn’t happened to us, is that we have some insight because we’ve learned from you, perhaps.

Right. And the element of better recovery. So, there’s the element of how we learn, but what about better recovery?

Yeah, I think the recovery aspect is both like traditional and well understood and still at the same time poorly understood. Remember that television show MacGyver? I think there’s even a reboot on MacGyver.

Yes. 

Yeah, so each generation can relate to MacGyver. And his recoveries were all improvisation, which is nothing what safe systems look like. Right. In safe systems, recovery is more preset. So, we’ve anticipated to this, we’ve written some instructions, we may be trained in simulators. So at least we have a plan B in place. So now when we perceive the need, we can invoke the plan, and we can perform reasonably well. But to kind of add to that is I’d worked with a physician. He was the chief medical officer. He was the ED physician who received the patients who came from the hotel, the Hyatt Regency Hotel in Kansas City, when their walkway collapsed. 

Oh, right. Yeah.

That was a very well-known event in the engineering world. And what Bill told me was none of our pre-planned stuff worked. You know, we had all of these things in place, and we had done the drills, but really what worked, what gave us that resiliency was getting people to the ED that knew both about the patients as well as the ED as well as how the hospital worked. There, the thinking together with the people, that’s what made the resiliency work in his mind. I believe that as well, because I’ve not been in the Technical Support Center on many real nuclear events. I was in one alert, but I’ve also been in many, many drills. The thing I remember most about the drills is the NRC people controlling the drills Nothing that we had ready to go ever worked because they wanted to test us. They wanted to test and see how resilient we were when our plan B didn’t work and what was our plan C as in Charlie and D as in Delta.

Interesting.

So, I’ve become a big believer in both is, you know, get prepped, be ready, have things to go, but then also be prepared to be there and make adjustments so that your adjustments work.

It’s very similar to pilot training. What you’re describing in terms of putting different scenarios where we know things have not go per plan and then having that complexities go into different additional scenarios to see how you respond to those events.

Yeah, that’s an excellent example. And, you know, not being a pilot is, you know, we get to see a lot more about aviation safety than I think other people get to see of things like nuclear safety or patient safety.

Sure.

But, you know, to your example, Eric, I think Al Haynes, who was the captain of that United flight that lost all their hydraulics and was able to land in Sioux City, a good example of with all the preparation work in air transportation, that was still something that was outside of their experience and training.

Correct.

Yeah. To circle back to our earlier point though, is after that event, you know, changes were made, both in procedures as well as training. And I think even there was some hardware changes that were made to give them additional capabilities when they lose hydraulics.

Yeah. The sad part on that particular one is from a system design standpoint, there was the engineer, one of the engineers that designed the hydraulic system for it, for the DC-10, allegedly. So he wrote a book afterwards, allegedly had Escalade raised the concern that there wasn’t a failover if the hydraulic line was cut, but it was ignored as a very low probability risk at the time, and struggled living with himself afterwards and trying to deal with the aftermath, knowing that he saw something, but whether he pushed far enough to drive the change.

Well, my, my hope is he came out okay. Yes, in the long run after that.

Exactly.

I think to touch on another aviation event, there was a large airliner for one of the Japanese carriers that they had a structural failure and lost their tail.

Oh yeah, yep, Japan Airlines.

And remember, the engineer who designed the repair actually took his own life, so he did not work through that.

He didn’t. It helped. Exactly. Yeah. So, so this element you touched on as well in terms of situational awareness. Is that something you can train, and how do you do it in a context like healthcare?

Yeah, that’s an excellent question. I follow the work of Micah Ensley quite closely on situational awareness. So oftentimes when I speak, I’m talking directly from the Ensley model. Remember that she was the chief scientist for the United States Air Force. When she developed that. If I was the chief scientist for the United States Air Force, I’d tell everybody. In fact, I would lead the podcast with that. But as 3 elements, there’s the perception first, and then there’s the sensemaking, and then there’s the projection part. And I think we really have to talk as we go and as we train and as we educate the new folks on what do we look for and why and what’s good and bad look like. And that’s part of that learning aspect. That you were touching on is that you can teach people what to look for. In fact, back to Hall Nagel, his first step of the 4 is knowing what to look for. So, I think that’s one of the overlooked parts of situational awareness is getting people to understand where they should be looking and what they should be looking for and what the good and bad look like.

But if you can get that first step, the perception, then you have a good chance to do that second step, which is that cognition, and think about, okay, what does that mean for us in the moment?

And so, in a scenario like this, because it assumes that the scenario is knowable, or is there ways of even sensing if you don’t know that the particular scenario could occur?

Yeah, yeah, a good point is that, you know, things that have happened before, we tend to have a little more collective insight into, but then we want to be prepared for things that we haven’t seen before. And I think to touch on another book, the Wyckoff and Sutcliffe book about high reliability organizing, they call it managing the unexpected. Sure. So, we have managing the expected Hey, this is a known event. But then we also need to be prepared for what happens when things look like they’re not known events, or maybe even it’s an event that’s unknown to everybody.

Sure.

So, in James Reason’s work, he talks about situational surprise. Hey, this happens. I just didn’t think it was going to happen today. Yep. But then there’s fundamental surprise where we never thought this would ever happen. And maybe in that United flight with the loss of hydraulics, they viewed that as a fundamental surprise. That one engineer mentioned that maybe we should prepare for this. And they said, oh, that hasn’t happened and will never happen because we have 3 independent and redundant hydraulic systems. You know, the probability that we would lose all of the hydraulics. Even though on that United flight, Their American Flight 191 had lost all hydraulics takeoff at Chicago’s O’Hare Airport.

Right.

So, they had a chance to realize that one assumption was poor and maybe even make some adjustments in those few years they had between the American flight and the United flight. Keep in mind, I’m not an aviation safety expert, but when you’re into the safety business like yourself, is you tend to look at aviation events and power events and bridge failures and dam failures. And here’s a traffic, you know, situation. And there’s a lot of commonalities in how and why we experience these safety events.

Yep. And I know when we spoke, you had some very powerful examples from healthcare, from some of the work from healthcare that illustrate systems, how they can be brittle, but also how you can increase resiliency. I’d love if you could share some of those stories and examples.

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Sure. Yeah, you know, so the system that’s brittle fails suddenly without warning. So, brittleness is the opposite of resiliency.

Sure.

So resilient systems are a little tougher. And if you like trees, you can say oak is a little more brilliant or brittle.

Yep.

And the palm tree is a little more resilient. It bends over in the wind.

Sure.

I actually prefer the candy analogy a little better. So, there’s the toffee, which snaps. It’s brittle, but the caramel, you know, is a little more resilient.

Yes.

And in healthcare, we need to be a lot more like the caramel.

Right.

And the idea is that They’re both made of the same basic ingredients, but the caramel is prepared at a different temperature. So, the sugar molecules are a lot longer and they’re more connected.

Sure.

And in healthcare, when we’re more connected with each other is that we team better and it makes us more resilient. And you know, that’s a good lesson. So, in healthcare, there’s many medication errors where it happens all at once and it’s over.

Right.

But then there’s also examples of where we have good second chances. If we monitor well after the patient receives the med, we realize they’re in distress and maybe there’s a reversal agent or maybe there’s some longer-term treatment. I think the best healthcare event to know in terms of resiliency happened in the Pacific Northwest. There’s actually an equipment failure a catheter malfunctioned in an open-heart procedure and burned a hole through this patient’s heart.

Oh wow.

And they realized, hey, this is trouble. How do we bounce back from this? So they, they kept him alive on a mechanical heart, an assistive device.

Sure.

And then they looked for a transplant, and they found a donor, and he received a heart transplant. And he wakes up weeks later at another medical center to hear quite a story about how they saved his life.

My goodness.

So that, that in my mind is like the Apollo 13 resiliency story showing up with our healthcare providers. 

And also, a failure that is likely not on the radar of the average surgeon that’s performing. You’re not expecting the equipment maybe to malfunction, but also then to burn, to cause a burn.

Definitely. So, so we don’t know if that was situational or fundamental surprise, but I’m positive that when they were doing their procedure, they weren’t thinking that, hey, this Swan-Ganz catheter is going to get hot as a firecracker and burn a hole right through this man’s heart. And then what would we do?

Right. 

And as far as I know, that, that was the first time that healthcare ever encountered something like that. So that was them managing the unexpected.

No kidding. Any other examples of the work that you do in terms of healthcare space to make the system more resilient?

Yeah, yeah. Our thinking is that, you know, if we practice good safety science, we should be able to reduce those harm events in healthcare by 80% every improvement cycle. So for big hospitals, that’s about every 2 years. Sure. In practice, most people see more of a 50% reduction.

Still substantial.

Still, still good enough. And we look for that both in patient safety as well as workforce safety. Mm-hmm. I think the difficulty in resilience engineering is that it’s not something that you can buy. It’s an emergent property of the work system.

Sure.

So, for systems to become more resilient, you have to get healthcare leaders to understand what makes us brittle, what makes us resilient, so they can jealously guard the things that they have while they work on adding more. So, you know, people who can think, like strong critical thinking skills, including questioning attitude.

Yep.

Getting response teams together. In healthcare, almost everybody has like a rapid response team or a medical response team.

Sure.

But then also, I think the untapped part is with technology and information systems. Can we use what we know in the electronic healthcare records to create more situational awareness among the caregivers and providers?

Sure.

Remember that show House? Another TV show. I have a kind of a TV show theme today. House seems to be the most opposite of all the healthcare television shows. Because they have one patient with a group of doctors that has nothing better to do but sit around and talk about their one patient. And in my experience is that it’s, there’s many patients and everybody has to split their time among many patients, but they’re never sitting around with their other doctors talking about one patient. Sure. But then the healthcare record, if we can use, uh, AI perhaps, or, or other, uh, more straightforward technologies to tell us what’s going on with our patients. So, I hold out a lot of hope for things like automated global trigger tools.

Sure.

And how the triggers can set situational awareness and maybe even create a central nervous system for a hospital where instead of having safety huddle for 15 minutes in the morning, we have more of a control room for the hospital, where we have people that can watch over populations of patients and do that perception in the Ensley model.

Interesting. When you were touching on that, you started out by talking about people becoming critical thinkers. How do you help people improve their critical thinking skills? Because it’s so important in the system view, right? 

Yeah, so important. I don’t think it matters which industry you look at, that the thinking errors are the single largest contribution to the severe loss events. In healthcare, it’s 40%. 40% of the acts leading to serious patient harm are critical thinking breakdowns. And then as you go to other industries, you know, the numbers can come up and come down, but it’s the single largest bit.

Sure.

The experts in talking about thinking are split. Some of them say that it’s a talent and others say, no, it’s a skill. And I’m firmly in the skill family. Is that not everybody can be great as a thinker, but everybody can become a little better. Sure. I think the best way to teach thinking is to create a vocabulary so you can talk about it. And then through the context of job experiences, share how you think and think differently. The nuclear power operators and the physicians I work with both say the same thing. In our training, there are a lot of technical details. We have to learn the right answers, but we also learn how to think differently. They’re a little more structured in their thinking. They have more discipline. They use logic more like the physician’s differential diagnosis. 

Sure.

In fact, if you want to get started, I’d recommend two well-known books, especially for your healthcare listeners. How Doctors Think by Jerome Groopman. He uses case study method and it’s an easy read. Better by a nurse, Gay Rubenfeld. Critical Thinking Tactics for Nurses. Now, she’s a nurse and a nurse educator and researcher, so she wrote it from a nursing perspective. She could have easily entitled her book Critical Thinking Tactics for Everybody on the Planet. She does a good job in saying, here’s what we mean when we say critical thinking, and here’s how to get started with some skills. But that might be the best answer, you know, to your question is that You know, human performance in general and culture and even the bigger picture, 3-step approach. Define a behavior as an expectation, something like questioning attitude.

Sure.

Then enable them with the knowledge and skills so they can do that if they choose. So now I have somebody that knows what to do and knows how to do it if they choose. And then step 3, that habit, that accountability is that big step where they actually practice that skill that they know as a habit. And that’ll give you that human reliability and to a large degree, that resiliency that you’re looking for.

And you touched on this element of questioning attitude and that struck me in any nuclear operation I’ve worked with. Is how embedded that mindset, or even the terminology around questioning attitude, is in everyone. And it turns into habits, rituals that occur daily. You would think that that’s something you can easily transpose in any environment as well.

Yeah, I think transpose, yes. And then when you said easily, that one didn’t strike me as strong, but that might be that questioning attitude that you talked about is that, you know, growing up in that environment, I was, I was 22 and right out of college when I worked in a nuclear power plant. So, I grew up in that environment, and it’s surprising how much, how sharply they think and then think with each other.

Yes.

So, in a nuclear power plant, you don’t make any bold assertions because now you have the entire room, you know, kind of picking apart your thinking, right? You get out into the rest of the, the world especially like on social media, is that the critical thinking not nearly as sharp. And people don’t question assumptions and they don’t really look for the logical fallacies. But I think you’re exactly right with those reactor operators, pilots on the flight deck, is those operators that are at the sharp end tend to have a very keen questioning attitude. Cause it might be, you know, the saying, which I heard it from a reactor operator, but maybe it was also a pilot saying, is that there’s old pilots and there’s bold pilots, but you don’t see too many old, bold pilots.

They haven’t made it. I think there’s an element as well to get to that questioning attitude. I’ve observed definitely within pilots, there’s a sense of once you’re in the air, it’s an unforgiving environment. So, you don’t want to be in that scenario, that situation. There’s also this, I call it a healthy paranoia. Others have created other terminology that’s probably more eloquent around it, but there’s a healthy degree of expecting something could go wrong. And I see very similar characteristics in nuclear because the consequence is huge, you know, it’s unforgiving. And so, there’s this paranoia, healthy paranoia, which supports questioning attitude. You expect things to not go necessarily per the plan.

Yeah, yeah, excellent point. I would probably frame that around the preoccupation with failure, which is one of those 5 Wyckoff and Sutcliffe HRO principles, is, you know, that to have a preoccupation with failure is you have a very healthy skepticism and you attend to all of the little things that you need to go right in an effort to have nothing go wrong. Maybe what James Reason called the dynamic non-event. So, I think preoccupation with failure is very misunderstood, especially in healthcare. They make it sound like we just sit around with this anxiety that things are going to go horribly, horribly wrong. But no, no, it’s that you know that you have to be focused on a lot of important details to give yourself some assurance that it’s okay. So, it can add up to success.

Correct.

And, and so the way you had framed that, I think, is, is very accurate and very helpful in advancing that in the positive about what we should be doing.

Yeah, because if you assume, if you have an overconfidence bias, assume a positive outcome, you’re more likely to miss some of those early warning signs that something is happening in the system.

Exactly. Yeah, now to add to that point is, you know, in a nuclear power plant, the one that I worked in most recently was worth $4.5 billion. And if we made a mistake, we could turn a $4.5 billion asset into a $500 million liability.

Right.

Plus, we all would lose our jobs and maybe we would spread radioactive contamination apart. Across the eastern United States. That, that could all happen, right? But I thought in healthcare, where there was a living person in your hand and you had the ability to either make them better or to harm them and maybe take their life away, that seemed to be even a closer link to safety in my mind.

You think so? Yeah.

So, I’ve talked to some of my clinician colleagues about this, and they said, “No, I still think that the airline pilot and the nuclear power operator have a bigger responsibility.” But having worked in those industries, I wonder if it’s back maybe into the caregivers and providers in healthcare. I think like a perfusionist who is running a machine that has the blood from their patients circulating and becoming oxygenated. Right. They are literally controlling the life of that patient. Absolutely. And it’s not like being on the flight deck of a 787 to say like, well, if this happens, then this might happen. And then if this goes bad and we don’t recover here and you go through like 8 things, is then we can have an event. I mean, I think it’s a more direct linkage. Sure. I would maintain that everybody’s job and safety is important. Absolutely. And I think it’s an element of how you see your role and the ownership you take in that direct call. Yeah, yeah.

Especially that idea of that risk sensitivity, that what you’re doing at the moment is, is very important. And if it goes wrong, here’s what happens. And then how do we know that it’s go wrong? Because there’s usually a story behind it. Sure. Where here’s what happens.

And Craig, you’ve authored books, um, and you help organizations improve the resilience of their system. Um, tell me about your books and tell me a little bit about how somebody can reach out to you if they want, um, your to carry this conversation forward, or also think about how I could make my system more resilient.

Exactly. Well, thanks. Yeah, I think the best way to read about our work in healthcare is through Zero Harm. Sure. So, it talks about safety management systems in healthcare and improving both patient safety and workforce safety. If you wanted a more compact form, I wrote a chapter with our chief executive officer, who’s a nurse, Tammy Strong. And that shows up in the Healthcare Quality book. It’s Chapter 5 on safety science and high reliability organizing. So given the opportunity, read a whole book or read a chapter. I think a lot of people go for the chapter. And I admire that, you know. But I like to talk to leaders, especially who are safety minded. And the easiest way to get a hold of us at Reliability for Life is through our website. Or we have a strong LinkedIn presence, and you could either look for the company Reliability for Life, or you can look for me, Craig Clapper, PE.

Excellent. Well, thank you so much, Craig, for joining me today and sharing your thoughts around systems, uh, how we can make them more resilient, how individuals can become better critical thinkers and, and surface, uh, potential brittle systems. Or items within a brittle system. Excellent.

Thank you for having me. Excellent.

Thank you so much. Take care.

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.

ABOUT THE GUEST

Craig Clapper is a founder and the chief knowledge officer of Reliability 4 Life, a consulting group specializing in improving human performance in complex systems using evidence-based methods derived from high-reliability organizations. Craig has more than 30 years of experience improving reliability in power, transportation, manufacturing, and healthcare. His expertise includes failure analysis, event analysis, systems thinking, system reliability improvement, and safety culture transformation. Craig has led safety culture and high-reliability organizing (HRO) transformations for Duke Energy, the US Department of Energy, ABB, Westinghouse, Framatome ANP, Sentara Healthcare, Sharp Healthcare, Banner Health, and many others. Prior to Reliability 4 Life, Craig was the Chief Knowledge Officer of Healthcare Performance Improvement (HPI), the Chief Operating Officer of HPI, the Chief Operating Officer of Performance Improvement International, Vice President of Failure Prevention Inc (FPI), Systems Engineering Manager for Hope Creek Nuclear Generating Station, and Systems Engineering Manager for Palo Verde Nuclear Generation Station.

For more Information: https://reliability4life.com/

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Why Systems Thinking Matters for Safety with Dr Paul Salmon

Jul 10, 2025

Why Systems Thinking Matters for Safety with Dr. Paul Salmon

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Join us on The Safety Guru for a thought-provoking conversation with Dr Paul Salmon, professor and seasoned expert in applied human factors and systems science research. In this insightful episode, Paul breaks down how interconnected systems and both direct and indirect decision-making impact safety outcomes, and how every individual plays a role. He also explains the difference between the old and new views of safety, sharing real-world examples to deepen our understanding of complex systems. Discover why systems thinking matters for safety and learn how to apply it across your organization with practical, actionable strategies. Don’t miss this powerful episode!

READ THE EPISODE

Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and well-being of their people first. Great companies ubiquitously have safe, yet productive operations. For those companies, safety is an investment, not a cost for the C-suite. It’s a real topic of daily focus. This is the Safety Guru with your host, Eric Michrowski, a globally recognized ops and safety guru, public speaker and author. Are you ready to leave a safety legacy? Your legacy success story begins now. 

Hi, and welcome to the Safety Guru. Today, I’m very excited to have with me Professor Paul Sammon. He’s from the University of Sunshine Coast. Paul, welcome to the show. Very excited to have you with me.

Hi, Eric. It’s great to be here. Thanks for having me.

Why don’t we get started with how you got into safety and some of your background because it’s quite fascinating.

Yeah, sure. It’s quite an interesting journey to where I am now. I’m a professor of human factors at the moment who doing a lot of safety work, but I actually started out life as a sports scientist. I did an undergraduate degree in sports science. During my studies there, I had access to things like Anthropometrics, and I became interested in football boot design. I knew about physical ergonomics and things that. And at the end of the degree, I saw a master’s degree in applied Ergonomics being advertised. I’d heard of ergonomics, and I was quite interested in doing further studies. I thought that would be interesting. So, I applied for that. And on that master’s degree, there was a module around accident causation investigation. And so, we did a case study. I remember it very clearly. It was on the Herald of Free enterprise, the Brugger disaster, where a roll-on-roll-off ferry capsized just after leaving Port and killing a number of people and crew. And we did a case study on that. We were exposed to reasons, Swiss cheese model, and I just I’m completely fascinated in accident causation and disasters and went from there, really. So that’s where it all started for me.

From sports science, football boot design through to major incidents.

Quite diverse set A lot of experiences, but it is the whole Swiss cheese and all that is incredibly fascinating from a safety standpoint. Which gets me to speak about one of the most critical parts that we’re starting to finally embrace in safety is really the systems thinking. Can you tell me a little bit more around why systems thinking is so critical to safety and maybe how you move to that perspective? 

Yeah, I mean, look, I think the movement to that perspective is another interesting story, so maybe I’ll talk about that first. Sure. After the master’s degree, I worked on a project with Professor Neville Stanton and Professor Don Harris, Brunell University and Cranfield University at the time. We were developing a human error, what’s called a human error identification technique. It was specifically for identifying potential pilot errors in cockpit certification processes. Sure. Through that, I was to things like reasons, generic error modeling system, Barry Kerwin’s work on human error identification, Sydney Decker’s work on the old and new views, and then methods like Sherpa, Tracer, and CREEM. So, I was I was working in the space of human error. I guess reading around all of that work, I became exposed to different models of error, different models of failure, and things like Rasmussen’s Risk Management Framework, Perro’s Normal Accident Theory, and so on. And I started, towards the end of that project, I started to get this idea that focusing on errors alone is actually quite misleading. And I became interested in what Factors are actually influencing people to make errors. And so, I started to really look at those systems issues.

But the real incident that really got me firmly into systems I was thinking was that I then was working in defense research. And so, I was asked to look at an incident which was a fratricide or blue on blue or friendly fire incident that you might call it, where UK tank had fired upon one of its own tanks, killing two crew members, and I think severely injuring another two. And what I found really interesting in this case was that no matter how you looked at the incident or no matter what analysis method you used, the decision to fire at the target always made sense. So, I couldn’t find any errors. The system was actually behaving exactly as it should, given the circumstances. And so, I started to question, is human Is there actually a real thing, or is it just a label that we’ve put on performance variability where factors across the system are interacting to influence behavior? And from then, I just really immerse myself in the models, the methods, and started applying them in all different contexts.

Interesting.

Yeah. And I think the reason why it is so critical as an approach is that it lets you actually understand what is driving behavior Rather than just looking at a behavior in of itself or a behavioral issue like human error or loss of situation awareness, it lets you understand all of the things across a broader socio-technical system that interacted to create that behavior. I think when you do that, you really get a very different understanding of why something happened in the way that it did.

Are you able to expand on why those decisions in that incident you mentioned all made sense? To give a bit of an illustration of… Because I think most people think there’s obviously somebody who made a mistake, and so it’s very easy to get to that. I don’t know if you’re able to share a little bit about the background that provides context where these decisions made sense.

Yeah, sure. In the circumstance, if we look at the decision to fire upon the target, I think there was a thermal signature that was representative of an enemy coming out of a weapons bunker. So, the signals being provided by the technology were that it was enemy. I think in the planning of the incident, there was no information given to the people involved that there would be other friendly forces in that area of the boundary. So, there was no prior communication around that. So, they were basically going through a process that had been gone through many times. They were getting the information that was telling them that there’s enemy, and the response to that in that circumstance was to fire upon the enemy. So whatever way you look at that, you can say the decision to fire is an error in hindsight. But actually, at the point in time, the decision to fire made perfect sense to the person who made it, given all of the information, all of the training, all of the planning, all of the things in the system that were present, that actually made sense to the individual. I think that’s one of the key aspects of systems thinking is rather than try to label something as a mistake or an error, what you’re actually doing is you’re saying, Well, why did this action make sense to the person that made it at the time?

Often you find that actually it’s not an error. They’re actually doing what is expected.

I think that ties in to touched on it a little bit before, but the view, old view versus new view of safety. Can you share a little bit more in terms of what it means, I think, to a lot of safety professionals, very common language, but it’s still fairly new in some circles in terms of the points of difference between this old view and new view?

Yeah, sure. The old view really is this idea that when systems fail, it’s typically caused by humans that have made an error or a mistake of some sort. It’s a view really that systems are really well designed. They fail because of unreliable or erratic human beings who make some error. Really the way to make systems safe is to use things like training, procedures, or appraisals to restrict human behavior so that they don’t make any errors. It takes this view, this interesting view that systems are really well designed, and its only unreliable people that break them. And the new view is very different. So, the new view actually says that actually systems are highly complex. They comprise humans interacting with things and technologies. They’re very brutal. They’re very prone to failure. Actually, humans are the glue that are keeping these systems together. And so when systems do fail, what instead we should be doing is going, what Sydney Decker says, go up and out into the broader system rather than down and in to the human in the decision and go up and out into the broader system and try and understand how all of the components interacted to get to the point of an error.

So why did the decision that we’re calling an error with hindsight makes sense to the person who made it at the time. Sure. Then in response to that, rather than these ideas of restricting human behavior through procedures, which paradoxically make the system far more complex and even more prone to failure, we need to understand what leverage points there are in the system. What is actually influencing behavior and what leverage points can we target with interventions that will actually influence behavior in a positive way? 

When you mentioned in the old view, you bring up basically systems are well-designed, but those systems are well-designed by humans that have been themselves in an area imperfect. That’s right. You can’t design a system that’s perfect.

Absolutely. I think everybody can reflect on their own occupations and say that systems are just not well-designed. They’re complex. They’re layered with processes that don’t work together. I think we’ve all experienced systems that don’t work particularly well.

I think there’s also quite a bit of arguments to say that systems have become much more complex as you start layering technologies, as you start layering specialization. The examples I’ve heard was even if you go back in history, for a doctor, you will need one specialist for a particular operation. Now, you need a whole team of experts. If it’s, for example, cancer treatment, even when you’re building a used to be a very simple design, but now you have lots of specialized expertise that are building it that all speak different languages.

That’s right. That’s absolutely right. I was presenting only the other day on AI safety and Liz Anne Bainbridge’s paper on the Ironies of Automation, which is, I think, was published in 1983. She talked about how introducing advanced technologies basically makes systems far more complex and brutal and more prone to failure. We’ve known about this for many years, and we can see it happening right now with AI, for example.

I think even I’m going to touch on aviation when you touch on the elements. If you think about the Air France crashes many moons ago, you had a system that was sending all sorts of alerts. You’re on autopilot, so you’re expecting things to be normal, and suddenly things go wrong. Even the 737 max, you have the system failing, and you’re hoping this human can figure a solution to something they’ve not been trained to.

Yeah, Air France 447 is a really great example of system syncing, and we use that a lot in our teachings and lecturing’s, just about the idea around why the action made sense to the individuals at the time. There are points in that unfolding scenario where the pilots, I think, don’t even know if they’re going up or down. The messages that they’re getting from the system are just not assisting them in any way, really.

You’ve got seconds to make decisions, and you’ve not been trained for the system failing around you. Same with the 737 max, where the autopilot was kicking and doing things that nobody could understand how to take off.

That’s right.

Absolutely. This view of systems thinking, I think, is one thing to understand the impact. I think more and more people are starting to realize the impact of the system and starting to bring a lot. But it’s a lot more complex in many ways because it’s very easy to blame the person who made a mistake. When you’re trying to do it proactively from a systems thinking standpoint, there’s a lot of decisions people that are, in some cases, unrelated to the work being performed that are in head offices that make decisions that ultimately impact the system. What are some of the ways that an organization can start looking at really driving this shift towards systems thinking?

Yeah, that’s a really interesting question. I think based on the experiences we’ve had. The first thing is there’s really an education piece. I think there’s an education piece where you have stakeholders from across whatever system you’re working in and you’re educating them on the philosophy, the principles, the approaches. I think one of the interesting things is often there’s an assumption that all we’re really trying to do is shift blame higher up into higher levels of the system. So, from the frontline workers to more people in managers and things like that. I think there’s an education piece about what it’s about, what its power is, and certainly in the work we’ve done, we’ve always had what we call our industry champions who are in the sector who are preaching and communicating the principles of system sinking. I think once the education piece starts to gain traction, I think then it’s really about the methods that are used for safety management. I lose count about the times when we’ve been doing work in sectors and the methods that they use just are not going to enable a shift towards systems thinking. I’m thinking about things like incident reporting and learning systems that would only let you report one cause of an incident that you’re reporting.

And so that just limits what you can learn. Or an accident investigation Delegation method that doesn’t look at contribute factors across the system and doesn’t look at interactions between contribute factors. So, it’s about then, I think, developing appropriate safety management methods and all of the training piece around that and implementing the methods and evaluating them to show that they actually are beneficial. I think the methods part is really critical because what we do see in most sectors is a significant research practice gap where the methods that are being used by researchers in our ivory towers all the time in the world to do this analysis, they haven’t really been effectively translated in practice. So, you have organizations who really are willing to embrace a system-sinking approach, but they just don’t have the methods to do it, which is a challenge. Sure.

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It is, and I’d say the other part I’m also seeing in many organizations is it shifts from safety is the role of operations and safety to the entire organization really impacts the system. We haven’t necessarily educated in organizations for somebody in finance, as an example, to understand how you impact safety. But if you look at Deepwater Horizon as an example, or even Texas City, both traces back to financial decisions that were made and how they were interpreted by other decision-makers at the end of the day. I think there was a dollar called Every Dollar Counts. I have a program that was called Every Dollar Counts. My point, usually want to bring that up, is other oil and gas supermajors have also had cost-saving programs but didn’t have the same impact in the decision-making that came as a follow-on.

Yeah, absolutely. That’s really interesting because we We’ve written some pieces around this, and my view is systems thinking should be taught in schools. Because I think there’s an argument. I can’t remember who makes the argument, one of the prominent figures, I forget the name. But they say that we start life out as systems thinkers, and it’s actually driven out of us through the education system that we go through. It’s interesting to me that we could be teaching this very early on, and people could be coming out naturally as systems thinkers, and whatever role they’re in within organization, they’re able to apply that thinking.

That’s a really good observation because at the end of the day, systems thinking has a huge impact on safety. But it has impact on P&L. I remember even some executive I was talking about that was complaining about how somebody had cut some budget in marketing, and it reduced certain print materials, and it passed the dollars, magnified them by to the next group in the organization. You saved maybe a million dollars, and you created $2 millions of cost somewhere else.

Yeah, that’s right. A lot of the work that we do in the center, for example, applying systems thinking in sport, yes, we’ve been doing it, looking at injury management and things like that. But a key part of that is that it’s about performance optimization. So, you’re getting safety benefits, but you’re really getting benefits It’s across the board in terms of performance, cost saving, efficiencies, and things like that. I think it’s definitely a good skill to have.

I love your point about increasing awareness, about introducing even training or awareness around systems thinking. What are some of the approaches that organizations can look at to mitigate risk? And are there some things that could be done from a risk assessment standpoint that are more proactive? Because it’s easy after an event, and aviation has done very well in terms of doing really detailed investigations following an event that are not single-handedly laying blame in one place but also has pushed to see a lot more in your miss reporting overall. But that’s not something that’s common across all industry.

Yeah, no, that’s another great question. I think there’s no doubt that when I mentioned the research practice gap, prospective risk assessment methods are a very good example for that. You have whichever, I guess, domain you look in. We have very limited risk assessment methods currently being used where it’s based heavily on experience. We identify the risks that we’ve seen happen before, often brainstorming or a checklist or something like that. But really, a really good risk assessment method has some key parts to it that really not many have currently. And a good example of that is, you’re basing the risk assessment on a description of the work system. And it’s really interesting to me how few methods do that. So, if I think of something like, for example, Nancy Leveson’s stamp, SPA, prospective risk assessment or the networked hazard analysis risk management system that we’ve developed with myself, Claire Dalet and a few others. These methods, really, the first step in those approaches are to develop a model of the socio-technical system that understands, that describes and understands all of the interactions going on in that system. I think if you have a risk assessment method that doesn’t do that, you can’t get any handle on the likely risks that are going to emerge in that system.

I think that’s the first point. I think adopting these methods to actually build a model of the work system first is critical. I think then the most important thing is that the methods that you’re using, they look across the work system for risk. You could argue that we’ve got a very good understanding of the risks that might emerge in a cockpit, in a control room, in a train cabin. What these methods don’t do really is understand risks in the broader socio-technical system. They don’t look, for example, at risks that happen at the work design stage, risks that are present in policies and procedures, risks in training programs. They’re really missing a big part of the picture. A lot of the work we’ve done has shown that by looking at these broader socio-technical systems risks and how they interact, you really get a much better handle on what potentially can go wrong at the sharp end or whatever you want to call it. I think methods that do that are really important. Again, those are methods like stamp, STPA, net harms, and things like that. There are very few methods that do that, though.

Can you really wrap your head around the full system in the age of complexity we’re in? I’m thinking many organizations don’t even have a process map that tells them how the work is being done. Or the process map is outdated by 10 years.

That’s right.

The system can be incredibly complex.

That’s right. When I say a description of the full work system, I acknowledge that we’re never really describing the full system or getting a full handle on it. But I think at least you need to base your risk assessment on some model of the broader socio-technical system and how work is actually designed, planned, and then undertaken. I like the idea, for example, that organizations can have living, breathing models of the work system, and when they implement change, they can then update their models. We’ve looked at doing that thing like Nancy Leveson’s stamp control structure. I do acknowledge that that’s a big undertaking and you never fully getting to grips with what’s actually going on in the system. But I think at least some model of that allows you to get a better sense of all of these different risks that you need to manage.

Are there some additional pieces from a risk assessment standpoint in terms of, if I think about from a safety management system, management of change, trying to understand as you make decisions, how could it be layering in? There could be more steps where we’re forcing people to understand. I saw in one organization, they introduce a language, planning red flags whenever they’re introducing risk. Because in the Swiss cheese part, it’s the layering of the risk as well. So, one risk on its own may be a necessary evil of running business but understanding where we’re planning risk in a particular decision-making process.

Yeah. So, I think there’s more that people can do. And I think some of that, trying to understand about things that are being introduced and what potential unwanted consequences might emerge from that. It is a really good process for organizations to go through. And I think as we get more sophisticated with dynamic modeling tools, we can become better at that. So, we can become better at understanding how if we’re introducing a certain policy or a new procedure or new technology, what the knock-on effects of that are across the broader system. Some of the work that we’re doing at the minute, for example, is we’re using things like computational modeling to try and simulate the behavior of a system over time and see what happens when we introduce different interventions. Does it solve the problem we’re trying to solve, but does it also create unwanted effects elsewhere in the system? And that’s a very academic, again, ivory tower exercise. But as we get more advanced software programs and tools, I would think that would be something that organizations can start to do themselves.

I think, as you said, the first step is to understand that there is a system impact and understand, getting people to better understand how they impact indirectly decision making, where the rubber hits the road and start understanding, having the conversations around it to then be able to identify the risks that we’re introducing.

That’s right. A good example. I’ve mentioned Claire Dalet’s work, who was a PhD student of mine. Her work was in the space of led outdoor activities. Basically, when kids are taken on school camps and there’s an educational component, but they’re led by an instructor. We’ve done a lot of work in that sector. Her work involved developing the net harms prospective risk assessment method. But I think the most powerful piece of her PhD was actually she did what we call a hierarchical task analysis of how an organization sets up, plans, organizes, and delivers. I think it was a five-day hike for a school, a bunch of school kids, right? Sure. I think the most powerful part of her PhD was to say, look, there’s this whole system of work, and actually there are, I think, five times more risks in the planning and organization phase of the work than actually delivering the hike on the ground out in the wilderness. And that was such an education piece for the sector because it was really saying, yes, we can dynamically manage risks as they occur during the hike, and we have a good experience and knowledge of what those are.

But actually, all of the more powerful and difficult risks are in there before we even get out there. They’re in the organization when we’re planning and organizing this hike. So that was really a really powerful piece of work, I think, for that reason.

Another thought is, is there anything that can be done as well in terms of how we train, educate those that are in the field? Because there’s a system part. But if I think about the flight deck as an environment, a lot of it is really how do we get better decision making, how do we communicate in those circumstances versus what you mentioned before, the procedures tend to get you to think in a very linear way in a very complex system.

Yeah, I mean, absolutely. I think dynamic risk assessment, obviously, is something we can train. But I think really, I’m always reticent to fall back on the training argument because I’ve seen it as a solution proposed so many times to cover up problems in the design of the work and the design of the technologies that the people are using. So, I think really the key is joint optimization. If we’re really thinking about jointly optimizing humans, procedures, and technologies from the get-go, we’re not going to really need to step in with additional training programs to manage things. We’re going to be sorting these issues out through the design of the work and the technologies.

I think where it’s going is more the if I expect you to be a problem solver as opposed to following a procedure, then you may be more aware of the risk in front of you.

Absolutely.

But I agree, it’s not the end-all be-all solution because I’ve seen that as well, where something goes wrong and it’s retrained irrespective of what happened. Paul, thank you so much for joining me. Really insightful thoughts in terms of pushing people to really think about the system and how you can have events that really made sense to everyone at the time, and that we need to really start thinking organizationally in terms of, really, how do we start moving towards more of a systems thinking perspective? How do we get everybody realizing how they impact the system through their decision making?

It’s been great to chat, Eric, and there’s really interesting questions. Thank you for having me.

If somebody wants to get in touch with you, What’s the best way to do that?

You can flick me an email, [email protected] or just flick me a message on LinkedIn. You’ll find me on there as well.

Excellent. Thank you so much for joining me today, Paul.

Thanks, Eric.

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.

ABOUT THE GUEST

Dr Paul Salmon is a professor of Human Factors and creator of the Centre for Human Factors and Sociotechnical Systems at the University of the Sunshine Coast. He has almost 25 years’ experience of applied Human Factors and systems science research in a diverse set of domains. Paul has co-authored 23 books and over 300 peer-reviewed journal articles. His current research interests are focused on the application of Human Factors and systems science to manage societal and global risks. Paul has received several prestigious awards from the International, Australian, US, and UK Human Factors and Ergonomics societies, and for the past 5 years, The Australian has identified him as Australia’s field leader in the area of quality and reliability.

For more information: https://www.usc.edu.au/staff/professor-paul-salmon#research

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Looking Beyond Human Error to Improve Safety with Dr. Mark Young

Oct 3, 2024

Looking Beyond Human Error to Improve Safety

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ABOUT THE EPISODE

We all make errors all the time. Join us for a fascinating conversation on looking beyond human error to improve safety, featuring special guest Dr. Mark Young. With profound insights into human factors and backed by solid research, Dr. Young shares the psychological mechanisms behind errors and emphasizes the importance of fostering a learning culture to enhance safety. The conversation also covers the impact of vehicle automation on safety and the critical role of fatigue risk management in safety-critical industries. Don’t miss this engaging episode!

READ THE EPISODE

Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and well-being of their people first. Great companies ubiquitously have safe, yet productive operations. For those companies, safety is an investment, not a cost for the C-suite. It’s a real topic of daily focus. This is the Safety Guru with your host, Eric Michrowski, a globally recognized ops and safety guru, public speaker and author. Are you ready to leave a safety legacy? Your legacy success story begins now.

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.  

ABOUT THE GUEST

Professor Mark Young is a professor of human factors in transport within the Transportation Research Group at the University of Southampton and is currently the president of the Chartered Institute of Ergonomics and Human Factors (CIEHF). Mark has nearly 30 years’ experience working in human factors across transport modes in both academia and industry. Before joining the University of Southampton in June 2023, Mark spent 11 years working as an Inspector at the Rail Accident Investigation Branch, applying his human factors expertise to the investigation of railway incidents and accidents. Mark has written over 70 peer-reviewed journal papers and five books, he is a Chartered Ergonomist and a Fellow of the CIEHF.

For more information: https://www.southampton.ac.uk/people/62gmgv/professor-mark-young

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