Saving Lives, Improving Mothers' Care: Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland. Confidential Enquiries into Maternal Deaths and Morbidity 2009-13

The issues being tackled within ergonomics problem spaces are shifting. Although existing paradigms appear relevant for modern day systems, it is worth questioning whether our methods are. This paper asks whether the complexities of systems thinking, a currently ubiquitous ergonomics paradigm, are outpacing the capabilities of our methodological toolkit. This is achieved through examining the contemporary ergonomics problem space and the extent to which ergonomics methods can meet the challenges posed. Specifically, five key areas within the ergonomics paradigm of systems thinking are focused on: normal performance as a cause of accidents, accident prediction, system migration, systems concepts and ergonomics in design. The methods available for pursuing each line of inquiry are discussed, along with their ability to respond to key requirements. In doing so, a series of new methodological requirements and capabilities are identified. It is argued that further methodological development is required to provide researchers and practitioners with appropriate tools to explore both contemporary and future problems. Practitioner Summary: Ergonomics methods are the cornerstone of our discipline. This paper examines whether our current methodological toolkit is fit for purpose given the changing nature of ergonomics problems. The findings provide key research and practice requirements for methodological development.

Fitting methods to paradigms: are ergonomics methods fit for systems thinking?

In examining the research literature on occupational health and safety (OHS), this paper argues that the growth in the number of specialists in OHS has resulted in an emphasis on policy and practice away from more scholastic concerns previously addressed by academics in the disciplines of psychology and sociology. A hiatus has occurred, and this is evidenced by the general absence of studies in management, even though OHS is increasingly seen as a key operational and strategic concern of business organizations. The authors call for OHS to be placed firmly on the research agenda of management scholars, and advocate the need for greater conceptual development, empirical study and theoretical reflection to complement existing pragmatic concerns of OHS specialists. In this review, the contributions of psychology, sociology, industrial relations and management studies are assessed, and five categories of specialist OHS literature are analysed, namely: prescriptive; systematic OHS management; success based; error and disaster based; and culture, climate and high-reliability studies. The conceptual and methodological limitations of this specialist focus are discussed, and future research opportunities are highlighted, for which the authors argue that management scholars embrace a range of methodological approaches. The authors advocate the value of extended case studies which examine OHS in context and over time in particular workplace settings. There remains considerable scope to develop this field further and, in conclusion, particular attention is drawn to the value of process-oriented contextual approaches for understanding OHS management in organizations.

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Occupational Health and Safety Management in Organizations: A Review

Global Drivers, Sustainable Manufacturing and Systems Ergonomics

The possible relations between resilience engineering and built environments are explored. Resilience engineering has been concerned with the safe and efficient functioning of large and small industrial systems. These may be described as built systems or artefacts. The resilience engineering approach argues that if the performance of systems is to be resilient, then they must be able to respond, monitor, learn and anticipate. The last ability in particular means that they must be able to consider themselves vis-a-vis their environment, i.e. be sentient and reflective systems. In practice, this means people individually or collectively can adjust what they do to match conditions, identify and overcome flaws and function glitches, recognize actual demands and make appropriate adjustments, detect when something goes wrong and intervene before the situation becomes serious. It is particularly important to understand the range of conditions about why and how the system functions in the ‘desired’ mode as well a...

Resilience engineering and the built environment

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From Safety-I to Safety-II: A White Paper

Human factors in safety is concerned with all those factors that influence people and their behaviour in safety-critical situations. In aviation these are, for example, environmental factors in the cockpit, organisational factors such as shift work, human characteristics such as ability and motivation of staff. Careful consideration of human factors is necessary to improve health and safety at work by optimising the interaction of humans with their technical and social (team, supervisor) work environment. This provides considerable benefits for business by increasing efficiency and by preventing incidents/accidents. The aim of this paper is to suggest management tools for this purpose. Management tools such as balanced scorecards (BSC) are widespread instruments and also well known in aviation organisations. Only a few aviation organisations utilise management tools for human factors although they are the most important conditions in the safety management systems of aviation organisations. One reason for this is that human factors are difficult to measure and therefore also difficult to manage. Studies in other domains, such as workplace health promotion, indicate that BSC-based tools are useful for human factor management. Their mission is to develop a set of indicators that are sensitive to organisational performance and help identify driving forces as well as bottlenecks. Another tool presented in this paper is the Human Resources Performance Model (HPM). HPM facilitates the integrative assessment of human factors programmes on the basis of a systematic performance analysis of the whole system. Cause-effect relationships between system elements are defined in process models in a first step and validated empirically in a second step. Thus, a specific representation of the performance processes is developed, which ranges from individual behaviour to system performance. HPM is more analytic than BSC-based tools because HPM also asks why a certain factor is facilitating or obstructing success. A significant need for research and development is seen here because human factors are of increasing importance for organisational success. This paper suggests integrating human factors in safety management of aviation businesses - a top-ranking partner of technology and finance - and managing it with professional tools. The tools HPM and BSC were identified as potentially useful for this purpose. They were successfully applied in case studies briefly presented in this paper. In terms of specific safety-steering tools in the aviation industry, further elaboration and empirical study is crucial. Statement of Relevance: The importance of human factors is recognised by operators at the sharp end of aviation, where flights are conducted or coordinated. At the blunt end, measurement tools are needed to manage operational resources.

Human factors in safety and business management

Contents: Introduction, Joachim Vogt and JA rg Leonhardt. Importance of CISM in modern air traffic management (ATM), Ralph Riedle Critical incident stress management in aviation: a strategic approach, Jeffrey T. Mitchell Critical incident, critical incident stress, post traumatic stress disorder - definitions and underlying neurobiological processes, JA rg Leonhardt and Joachim Vogt Critical incident stress management intervention methods JA rg Leonhardt A brief history of crisis intervention support services in aviation, Jeffrey T. Mitchell Critical incident stress management in air traffic control (ATC), JA rg Leonhardt Critical incident stress management in airlines, Johanna O'Flaherty Critical incident stress management at Frankfurt Airport (CISM Team FRAPORT), Walter Gaber and Annette Drozd Case study Lake Constance (A/berlingen), JA rg Leonhardt, Carol Minder, Sabine Zimmermann, Ralf Mersmann and Ralf Schultze Training in critical incident stress management - principles and standards, Victor Welzant and Amie Kolos Cost benefit analysis of a critical incident stress management program, Joachim Vogt and Stefan Pennig. Appendices. Index.

Critical Incident Stress Management in Aviation

This paper reports the implementation of the Critical Incident Stress Management (CISM) Program with the German Air Traffic Control Services (DFS). Particular attention is paid to the application of CISM services to a population of air traffic controllers. An extended economic efficiency evaluation was conducted for the European Organization for the Safety of Air Navigation (Eurocontrol) Brussels. Questionnaires and interviews were obtained from forty-seven air traffic controllers (ATCOs), thirteen CISM peers, and the program manager. The collected data describe the goals of the program and their achievement, program implementation, costs, and benefits. The results revealed that after five years the program's estimated fiscal benefits had exceeded the costs (break-even). Moreover, it had improved the safety culture within DFS in many ways. For this reason, controllers who never consulted a peer reported many benefits of the program. They believed that having the program was a good idea as a back-up support in case they would ever need it.

Economic evaluation of CISM--a pilot study.

Psychosocial factors play an important role in occupational health and safety. Stress is probably the most prevalent psychosocial problem and hence stress management ranks among the most promising health and safety promoters. This contribution deals with the stress of air traffic controllers (ATCOs) which results from workload on the one hand and the responsibility for air traffic safety on the other. Four steps in the stress management of German ATCOs will be described aiming at increasing air traffic safety and reducing stress: A current state analysis with 328 employees of the German Air Traffic Control Services (DFS) revealed a sufficient quantity and quality of safety instruments. In several field and simulation studies with 130 operational staff, the most important workload factors were identified and implemented in the work agreement. Now German controllers are paid and given breaks according to th eir workload measured as the number of aircraft under control, the probability of conflict situations between aircraft and pilot errors in the particular airspace, as well as the percentage of climbing/descending opposed to level flying aircraft. A simulation study with 40 air traffic controllers proved active relaxation to accelerate the recovery after work and to prevent safety problems . Controllers can experience critical incidents like separation losses between aircraft, near misses or accidents. A critical incident stress management (CISM) can support coping with these problems as a questionnaire survey with 60 air traffic controllers showed. This study was conducted for Eurocontrol, Brussels, and revealed also an improvement of safety culture by the DFS CISM programme. Moreover, an economic return on investment could be proven: Controllers reported a quicker and more sustainable recovery from critical incidents. In conclusion the DFS implemented a comprehensive safety and stress management which maintains the highest standard of air traffic safety and reduces work stress related problems. In the long run, these measures will pay off also economically.

Jörg Leonhardt

Papers

From Safety-I to Safety-II: A White Paper

Human factors in safety and business management

Critical Incident Stress Management in Aviation

Economic evaluation of CISM--a pilot study.

Increasing safety by stress management