Phillip Ragain discusses how views of human involvement in safety are evolving from seeing humans as a liability to seeing them as a potential stabilizing force in complex systems. Traditionally, human error was seen as the main cause of accidents, but now humans are recognized as elements within complex, interactive systems. The talk explores how complexity theory and human factors research show that human behavior emerges from contextual influences. Ragain argues that by understanding psychological factors like bystander effects, production pressures, and deference to authority, industries can design systems that better support human intervention and adaptation to enhance overall safety.

1. congress.nsc.org
Session # 57
Humans in the Machine:
Enhancing safety as operations
become more complex
Phillip Ragain

2. Humans in the Machine
Overview
‣ The Role of People: Evolving Frameworks
‣ A Linear View (Behavioral)
‣ A Systems View (Complexity & Human Factors)
‣ The Human Role in Complex Systems
‣ A Human Factors Analysis of Intervention
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

3. “88% of all accidents, injuries, and
illnesses are the result of man-failure.”
- Herbert William Heinrich (1931)
Evolving Frameworks
“The leading cause [of accidents and
injuries] is the at-risk behavior of
employees themselves.
- Watson, et al (2005)
A Linear View
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

4. Evolving Frameworks
BA
System of
Operations
Linear View
Sees behavior as affecting the safety of the system
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

5. Systems View
Sees people as part of the system
Evolving Frameworks
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

6. Systems View
Sees people as part of the system
Evolving Frameworks
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

7. Systems View
Two forces driving a “paradigm shift”
‣ Complexity Theory
‣ Human Factors
Evolving Frameworks
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

8. Complexity Theory
Evolving Frameworks

9. Complexity Theory
$
Evolving Frameworks

10. Human Factors
Evolving Frameworks

11. Human Factors
Evolving Frameworks
The study of how
people interact
with their physical,
technological,
organizational and
social environment
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

12. Human Factors
Evolving Frameworks
Cognition
occurring in a
specific context
is itself a
complex system.

13. Human Factors
Evolving Frameworks
Human behavior
is not the cause
of incidents.
It is part of a
larger system
failure.

14. A Stabilizing Force
The Reality
The production context
is . . .
‣ Complex
‣ Dynamic
‣ Unpredictable
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

15. ‣ Limited in Scope
‣ Slow to Change
‣ Necessary but Insufficient
The Problem
Mechanical and
administrative barriers
are . . .
A Stabilizing Force
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

16. A Stabilizing Force
The “Catch”
The more mechanical and
administrative barriers
introduced into the
system, the more
complex and difficult to
monitor things become.
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

17. The Solution
We need something
that is . . .
A Stabilizing Force
‣ Dynamic
‣ Creative
‣ Ubiquitous
(throughout the system)
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

18. The human body is an
analogue of other
complex systems.
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
A Stabilizing Force

19. While partially direct by
an executive function,
the system’s elements
are largely autonomous.
This can create
unintended or undesired
outcomes.
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
A Stabilizing Force

20. Because of the
interconnectedness of
different systems,
deterioration in one part
can spread throughout
the system.
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
A Stabilizing Force

21. The protections
integrated into this
system are similar to
what is needed in
industrial systems.
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
A Stabilizing Force

22. A Stabilizing Force
Linear View
Humans destabilize
systems that are
engineered to be
safe.
Systems View
Humans are uniquely
capable of stabilizing
complex systems.
System of
Operations

23. ‣ Awareness
‣ Risk Aversion
‣ Intervention
‣ Adaptation (Learning & Reporting)
Humans as a Stabilizing Force in
Complex Systems
A Stabilizing Force
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

24. ‣ Awareness
‣ Risk Aversion
‣ Intervention
‣ Adaptation (Learning & Reporting)
Humans as a Stabilizing Force in
Complex Systems
A Stabilizing Force
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

25. A Stabilizing Force
Most people take this
responsibility very seriously
and believe that they
would speak up.
But people intervene only
39% of the time.
Intervention.
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

26. A Stabilizing Force
We can use a human
factors approach to
understand why people
do not intervene.
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

27. A Stabilizing Force
The Context Effect
There are factors in the
production context that
often “override” people’s
belief that they should
intervene.
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

28. A Stabilizing Force
Inhibiting Forces:
Bystander Effect
The more people there are,
the less likely we are to
speak up.
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

29. A Stabilizing Force
Inhibiting Forces:
Production Pressure
It can change the way we
see the world.
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

30. A Stabilizing Force
Inhibiting Forces:
Deference to Authority
The presence of an authority
figure inhibits intervention.
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

31. A Stabilizing Force
Increasing
Intervention Rates
Simply being aware of
these inhibiting forces
decrease their influence.
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

32. ‣ Awareness
‣ Risk Aversion
‣ Intervention
‣ Adaptation (Learning & Reporting)
Humans as a Stabilizing Force in
Complex Systems
A Stabilizing Force
© 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.

33. congress.nsc.org
We rely on you to help evaluate Congress
sessions as we strive to increase
presentation and topic quality, so please
take the time to fill out the short survey.
Session # 57
Humans in the Machine:
Enhancing safety as operations
become more complex
Phillip Ragain